THE ability of medical students to gain experience by exposure to patients was discussed recently in the ODT (15 and 19.5.26).

A threat to education in our medical schools is apparent. The quality and success of medical care depend on sound ethical and educational principles.

The shortage of medical professionals is of concern to all Kiwis. Foreign graduates in NZ currently make up the highest proportion of medical workforce amongst OECD countries (43.3%).

Financial, cultural and educational factors make overseas recruitment increasingly difficult in a strongly competitive international environment.

A relatively small minority of foreign trained professionals remain after 10 years. More home-grown practitioners are required.

Medical student numbers have increased at both Otago and Auckland Medical Schools. The government has controversially announced launching the Waikato Medical School focusing on training general practitioners.

Learning from experience with patients is essential to master clinical skills. The distinguished physician, Sir William Osler, stated that trying to learn medicine without contact with patients is like trying to become a mariner without ever going to sea.

Workshops, tutorials, mannequins, books, internet aids, and even lectures all have their place but that knowledge needs application to real patient experience to gain clinical validity.

Adequately funded training is required for teaching and learning. Time and dedicated effort is required, especially in this age of rapidly develop scientific advances.

The art of learning to deal with intensely personal patient issues in a compassionate manner with

appropriate awareness of cultural factors affecting clinical practice in Aotearoa is not learned overnight. Logistical planning must ensure that students have an adequate a variety of student-patient interactions essential for valid clinical teaching programmes.

For many years, medical student teaching was based almost entirely in teaching hospitals. During my professional career, there has been a well-directed, gradually increasing shift to learning in general practice and multiple other health-related disciplines in both urban and rural settings.

This has allowed students to gain vital experience in areas of greatest needs.

Suitably qualified tutors are needed to guide and encourage students through this challenging process. This requires time and patience as speed and aptitude to learning clinical skills varies greatly.

Working in a team setting amongst multiple disciplines has become an essential part of modern practice.

Informed patient consent is mandatory for all practitioners. This sometimes includes students who are part of the care team.

In teaching hospitals, patients are traditionally under the care of a team comprised of consultant, registrar, house-doctor, nurses, and perhaps other health professionals.

Any additional staff introduce themselves as a member of that team.

Patient choice and autonomy must nevertheless be respected as part of informed consent. Actions and decisions can be questioned at any time.

Similar principles apply to post-graduate students training to become specialists. They are at serious risk of falling behind international standards if they are denied access to patients with rare disorders excluded from care in New Zealand public hospitals.

Overseas experience may become mandatory for them to gain experience with rare conditions required of a specialist.

How students learn from patients who are unconscious or lacking cognitive capacity is a problem. The dreadful past when students not part of the team examined patients under anaesthesia without consent must never recur.

Informed pre-anaesthetic consent is essential. Exceptions will occur, eg cardiopulmonary resuscitation or resuscitation of an unconscious accident victim. Those who lack capacity, as in all other aspects of their care, rely on high clinical and ethical standards of their carers.

As I have experienced personally during recent hospital admissions, I was informed that students would be part of the team responsible for my care. I had the right to question that at any time.

In general practice, patients pay for a consultation where they may have a precious 15 minutes to explain their concerns and then agree on management. Students attend as observers in the practice team.

The more involved students become, the better the learning experience.

Who pays for the extra time taken by the students to gain this experience? The student has already paid for their education, and GPs take responsibility for patient management as well as running a business.

How will the already overburdened and under remunerated GP practices survive with the influx of students requiring time and effort to learn their craft in already overloaded general practices?

The time-consuming and complex task of assessing students’ clinical competence is an elephant in the room. The process must be fair and equitable to enable graduates to be regarded fit to practice medicine in a competent and compassionate manner.

Time and educational expertise are essential.

Personal choice is an important patient right. However, do we as patients and members of the community carry responsibility to support educating tomorrow’s doctors?

The awful abuses of the past cannot be allowed to recur, neither should we toss out the baby with the bathwater and sacrifice the quality of clinical care and learning. Those in charge must lead by example, and set the clinical and ethical standards for both patients and professionals.

The Hippocratic Oath or Declaration of Geneva has been avowed by all New Zealand doctors. All medical professionals, including students, must be seen to live by those standards.

Gil Barbezat is an emeritus professor of medicine.