To the Editor:

In 2014, the mandatory clinical attachment for fifth-year medical students at Copenhagen University (UCPH) Medical School was reduced from 4 to 3 weeks. As the performance of the mental status examination (MSE) is considered a difficult part of the course objectives, the time reduction spurred the development of a collection of short video recordings of authentic patients, interviewed only for educational purposes and only for the training of MSE. Video demonstrations of patients or simulated patients are regularly used in psychiatry lectures [1], but we deemed it important that the students had access to the video vignettes whenever they had time to spare at the wards. Consequently, we set out to make a video library as a supplementary educational resource accessible across the 12 general psychiatric hospitals that are part of UCPH Medical School. The use of authentic patients was deemed relevant, as the video vignettes were to be used to describe varieties of real phenomena [2]. The project was approved by the Ethics Board of Faculty of Health, Copenhagen University after thorough consideration of the ethical aspects of using authentic patient videos for the described educational and research purpose.

Patients were recruited at a general psychiatric hospital with four integrated wards and an emergency unit, with a total of 80 beds and several outpatient clinics. We passed information leaflets about the project around the wards with a call for all clinicians to recruit patients for the project. A senior resident worked full time on the project and went on recruitment rounds 2–3 times a week, where she talked to patients who showed an initial interest in the project. One in five patients agreed to participate in the project, and the number of recruitments per week varied from 0 to 4. If a patient agreed to participate, their decision was immediate. No patient who initially hesitated ended up agreeing to participate.

The resident informed the patients about the project and secured signed consent, which was always confirmed a week after the video was recorded. One patient withdrew consent at the confirmation request. The videos were recorded at the wards or in the adjacent Research Unit. Two video cameras were used at every recording; the camera with highest resolution (Sony PXW-X70) and audio input (Sony Microports, URX P03, and UTX B03) was focused on the patient with medium close-up, and the smaller camera (Sony Handycam HDR-CX740) recorded the total interview situation, including the whole-body patient and interviewer. The interview started out with questions about recent or present mental problems and continued with screening for affective disorder and psychosis symptoms and risk of self-harm. Recordings lasted between 8 and 20 min. The raw recordings were imported into a clipboard (Adobe Premiere Pro, version 2015), where they were compiled into one multi-camera sequence from which it was possible to switch between camera views and cut out sequences irrelevant to MSE. However, we avoided extensive cutting and extensive switching between camera views in order to maintain phenomena continuity. The final video vignettes were 8–12 min long, as recommended by Dong and Goh [3] and were downsized from full HD 1080 25p, H264 to HD 720 25p, H264, as size became an issue for the video library server placement.

Apart from the vignettes, the library also entailed an expert MSE upshot of each video. First, a professor in psychiatry (RH) undertook the task of writing the MSE upshot of all videos in the traditional narrative fashion of Danish medical records. Pending feedback from the students, who were confused about the details of these freestyle MSEs, we modified this component of the library. We entered the texts into a MSE template and then two specialists (SMA and EBH) entered their MSE in the same template and RH extracted a simplified structured MSE, which represented the new MSE upshot. In accordance with previous efficiency findings [4], the provision of the MSE template and the structured MSE upshot were reported to be helpful by the students.

We received permission for the handling and storage of the videos under Region Zealand’s Health Research Data Protection Approval (REG-96-2015) under the auspices of the Danish Data Protection Agency. The permission includes storage of the videos on a secured Microsoft SharePoint on-premises server, only accessible with a regional student ID from a PC in Region Zealand Health Service. Student access is given individually after a confidentiality agreement is signed. The website contains folders of numbered videos and corresponding numbered documents with a brief 4–8 line case summary, without diagnoses, and a guideline about the recommended way to use the video vignettes (i.e., see the video, write down MSE, see the expert MSE upshot). As we also aimed for dissemination of the video library to UCHP students with clinical attachment in the Capital Region, an agreement was made between Region Zealand and the UCPH Faculty of Health, which describes the framework for video data transfer and continuous protection. However, it has so far not been possible, to store and handle the videos securely within the university’s IT system.

Presently, the video library contains 23 video vignettes that are 8–12 min long. The library is accessible on the hospital intranet for invited students at the three hospitals in one (Region Zealand) of the two regions covered by UCPH Medical School. It seems to makes sense for the students to use the video library, and issues of confidentiality and data security have been solved within one health care system IT. Solving the confidentiality issue by using a secure site within the University would make the video library accessible for students at UCPH Capital Region Hospitals. Furthermore, it would be possible to apply for permission from the Danish Data Security Agency to make the library a national educational database available in all of the four Danish medical schools. We believe that supplementing the clinical attachment with access to the library will add to MSE precision among doctors and perhaps increase standardization of the MSE vocabulary. Presently, we plan to investigate the training effects in a case-control design, where we compare the MSE skills of the students with access to those without access at the end of their attachment. It is also necessary to explore how students use the library and the extent of integration of the library with bedside teaching and clinical tutorials, which it was not planned to replace.