Learning professional values
The World Federation for Medical Education emphasizes the need to balance the academic capacities and the behaviour of medical students. It is aimed for them to undertake life-long learning and demonstrate their professionalism in the different roles of a doctor . Professionalism includes respect for confidentiality of patients, constituting one of the basic skills that they have to develop and maintain both as undergraduate medical students and as doctors in their professional career .
88.6% of the respondents were aware that the obligation of confidentiality affected the most intimate physical and mental health data, also considering those contents in CHs (90.6%) (test results, genetic data...). It also includes any information assigned to a physical person for health purposes that identifies them univocally . Although it had a majority response, it was not so frequently selected by the students (85.7%). Recently some deficiencies have been described related to the knowledge of the obligation of confidentiality [5, 15, 16]. Other authors mention final-year students who show little respect for the patients’ confidentiality compared to other obligations, this being more marked in male students . In this work the women also responded more correctly to the concept of confidentiality although with no statistical significance. The need to reinforce the competency-based education  in study plans has been proposed, as well as implementing measures oriented towards developing the study of Medical Ethics. This subject presents some differentiated characteristics, so that it would be necessary to go deeper into the analysis of the professional conduct guides . A theoretical training is recommended, which is based on the analysis of clinical cases in which problems related to confidentiality arising in clinical practice are posed, as well as a direct exposure to situations in which the patient’s intimacy is questioned [19, 20].
Requirements of action to be followed during attendance of the patient
Medical students endorse their obligation to respect the human dignity, freedom of choice and intimacy of the patient  by signing a commitment to confidentiality at the beginning of the practice exercise period in the healthcare institution. The Faculties of Medicine should inform the healthcare institution about the students who are going to do practice exercises. Most of the participants had done so although a non-negligible percentage admitted that they had not (17.1%).
The direct intervention of the student on the patient is a key element. Thus it would be vital for both the patients and the rest of the healthcare professionals to be aware of the presence of persons in training during patient attendance, so that the institution has to take on the responsibility of giving the student a card/tag permitting their identification . Patients confer great importance on knowing who is participating in the medical process  and this study shows that only approximately a half were always suitably identified, and a large number of them who did not wear the tag (90.2%) did not refer to any negative reactions from their tutor. The presence of students may also be a conditioning factor, and this raises different positions. Some professionals contend that patients cannot refuse their intervention in an educational institution like a university teaching hospital, whereas others believe that there is a direct presumption of patient’s consent if the latter does not actively oppose it. The Protocol demands that express consent should be obtained authorizing their presence during medical attendance, and that their number should be limited in attending one same patient . Most of the patients usually accept the participation of students , although, in certain specialist treatment, the patient’s response could be conditioned by their sex . This study did not permit to make that inference, but 64.5% declared that the patients usually expressly knew their condition of being a student and this was significantly related to wearing a tag.
In order to ensure the fulfillment of all the requirements described the healthcare institution itself will designate a tutor, who will be the person of reference whom the student should address . Despite the circumstances in the healthcare system not always being favourable, the figure of the tutor is considered to be highly relevant , not only as a supervisor but for the feedback and assessment work with the student when acquiring practical skills in a safe and thoughtful atmosphere [24, 25]. 75.9% of the participants usually knew who the tutor in charge during the practice exercises, which was especially positive.
Guarantees in accessing Clinical History
The Protocol expressly prohibits EMR access to students . The reasons could be based on the fact that in CHs on paper it is not possible to look for the records of different patients at the same time, or several medical attendance episodes of one same individual, or easily duplicate or edit the data . These results contrasted significantly with the legal precepts, since over half the participants assured that they accessed the CH of patients on some occasion (59.2%) without the patients’ express consent (77.2%).
In countries like Germany some hospitals have facilitated the use of the CH to final-year students . Similarly, in the United Kingdom the team in charge of attending the patient including the students, can access the CH without the patient’s express consent [27, 29]. In the United States, its use has been permitted for years  and it increased to 96% of the centres in 2016. Guimarães et al.  made various proposals for encouraging the use of the CH among students in Portugal. In countries in which standard access is authorized, it is generally considered as an advantageous tool for the learning process [32, 33]. It permits making a long-term follow-up of patients from diagnosis up to the treatment, even once the direct relationship is over. However, this post-control has caused some ethical reactions related to the duty of training students in the right to intimacy and autonomy of patients [34–36]. Students need to access the CH to develop their abilities in its use and maintenance, as well to understand the nuances of the EMR itself during a medical consultation . Besides, the handling of the CH is analogous to learning based on clinical cases, so that, in addition to promoting good professional conduct, it permits a more active participation of the student in their training by directly applying theoretical knowledge on real cases [38–40]. Although the advantages are obvious, other authors have pointed out that this type of action may be potentially harmful for the patient, so that their interests would have to be prioritized in the absence of an additional benefit to the educational objectives of the student [41, 42].
Restricting complete access to the whole evolution of the patient and assigning levels according to the year of the student’s training  have been proposed for establishing some limits guaranteeing the educational finality. However, these premises should, in turn, safeguard the patient’s autonomy [38, 43]. Therefore, rather than directly constrain the access, the ultimate solution to the problem could be the same as in the countries where it is permitted, i.e. to request the patient’s consent.
One notable aspect in this study previously described, is that students accessed the patient’s CH by employing the authentification mechanism of a health professional . It clearly emphasizes the vulnerability of the health system, which is becoming increasingly more complex and fragmented, and in which the quality and safety in attending patients have become the principal foci of attention . Spanish legislation does not even contemplate student access to them, so that neither does it propose solutions to these problematic types of situations. In the United Kingdom, a similar phenomenon was described in primary medical care attention, so that, it was proposed to assign to each student a unique digital identity, that leaves an indelible and identifiable mark and is therefore susceptible to being traced . To counteract the above-described conduct, it is esteemed to be a priority for the healthcare institutions to apply educational and even motivational measures  to take responsibility for the risks and ethical and legal problems arising from their employment by students [44, 47, 48].
The law is somewhat more flexible with regard to the records kept on paper. Present data reveal the high frequency with which most of the students (71.9%) could reach the CHs without the personal and clinical data of the patients being previously dissociated, something that is contrary to what has been pre-established. The aim is to preserve anonymity unless the patients themselves have expressly consented to it, which would seem to be the definitive solution so that the student’s training is not undermined. If the use of this information has a teaching finality, the anonymization of the CH is also mandatory, although only a 49.3% alleged that they received anonymized clinical data of patients to do their FYP .
Around 43.3% of the students disposed of copies of non-anonymized CH reports of patients outside the healthcare sphere, without in most cases obtaining the patients’ consent (82.1%). The frequency of this phenomenon did not agree with the fact that a very high percentage (90.6%) of them were aware of the obligation of confidentiality that protected those data. Although copies were probably supplied by the doctor in charge of the patient, the students accessed that material outside the healthcare institution. The fact that they took part in such situations could be the cause of the students having a greater tendency to consider certain unprofessional acts as being acceptable behaviour after their practice work . Hence, the importance of the hidden curriculum throughout pre-degree training can be deduced, in order that the students incorporate modes of behaviour taken from those of their professors/tutors beyond the contents of the formal curriculum.