Editor,Depending on the speciality choice you have made you may spend anywhere between zero and one hundred percent of your direct clinical contact time in an outpatient setting. The UK Patient charter, now designated the NHS Constitution, sets out the standards of care that patients can expect including the maximum waiting time for a routine outpatient appointment which currently stands at 18 weeks in the United Kingdom1. Within Otorhinolaryngology outpatient referrals have increased year on year. With increasing referral numbers and fixed waiting times outpatient clinics are at risk of being overloaded with decreasing time available for patients to spend with their doctor and potential decreases in the quality of care that they may obtain.ENT UK have drawn up guidelines for safe patient numbers at clinics for consultants, registrars, SAS and junior trainees2. No such guidelines are present for other specialities. Mention is made in the ENT UK guidelines with regards to reducing clinic numbers for consultants supervising trainees, however no mention is made with regards to medical student teaching for either consultant or registrar grades.In 1845 the number of students studying medicine at Queens University was 55, while today the number of fulltime students is approximately 12003. This is a substantial increase and is common across all Universities in the UK. Interestingly a review into admission rates to Medical and Dental Schools in the UK has shown that admissions have exceeded recommendations for at least the past five years and the government have recommended a 2 per cent reduction in intakes from next year4.This increasing number of medical students will all engage in clinical tuition to some extent throughout their undergraduate career with a proportion of this occurring in the outpatient setting. A study in 1999 suggested that medical student satisfaction is higher when they have the opportunity to both sit in on consultations and get an opportunity to take histories and certainly this is a key aspect of medical training5. The slow erosion of supporting profession activities (SPA) sessions is resulting in the relocation of medical student teaching from non clinical sessions into clinical time. Unfortunately this places additional demands on the supervising doctors in these clinics to provide both high quality patient care and tuition and one would question whether this well versed form of teaching is sustainable. In addition medical school admissions are increasingly competitive as are foundation job placements which has led to increased student expectations and demand for a greater duration of higher quality teaching.Increasingly teaching is being diluted in our teaching hospitals to allow the prioritization of service provision. In an era of increasing litigation, time pressure and patient demand we need to ensure that our clinics are productive, safe, sustainable and provide adequate learning opportunities for medical students and junior doctors. This may mean that patients numbers at outpatient clinics need to be reduced to ensure successive doctors remain competent to treat them.