Perceptions of evaluation in longitudinal versus traditional clerkships

Medical Education 2011: 45 : 464–470 Objectives Methods for evaluating student performance in clerkships traditionally suffer shortcomings, partly as a result of clerkship structure. The purpose of this study was to compare preceptors’ and students’ perceptions of student evaluation in block clerkships and longitudinal integrated clerkships (LICs). Methods From 2007 to 2009, preceptors who taught on both block clerkships and an LIC were surveyed on their perceptions of clerkship evaluation. Year 3 students were surveyed on their perceptions of clerkship evaluation at the year end. Responses from preceptors who completed both block clerkship and LIC surveys were compared using paired‐samples t‐test; student responses were compared using independent‐samples t‐test. Results Overall, 66% (67/102) of block clerkship and 75% (77/102) of LIC preceptors responded; 44% of preceptors (45/102) completed both block and LIC surveys. In total, 62% (68/110) of block clerkship and 83% (19/23) of LIC students responded. Both preceptors and students favoured evaluation in the LIC on three factors (p ≤ 0.01): validity of evaluation process, quality of clinical skill evaluation, and willingness to provide constructive feedback. Conclusions Preceptors and students perceived evaluation in an LIC more favourably than evaluation on block clerkships. For educators working to improve student evaluation, further examination of the LIC structure and evaluation processes that seem to enhance both formative assessment and summative evaluation may be useful to improve the quality of evaluation and feedback.     

Growth of analytical thinking skills over time as measured with the MATCH test

Context Ber’s Comprehensive Integrative Puzzle aims to assess analytical clinical thinking in medical students. We developed a paediatric version, the MATCH test, in which we added two irrelevant options to each question in order to reduce guessing behaviour. We tested its construct validity and studied the development of integrative skills over time. Methods We administered a test (MATCH 1) to subjects from two universities, both with a 6‐year medical training course. Subjects included 30 students from university 1 who had completed a paediatric clerkship in Year 4, 23 students from university 2 who had completed a paediatric clerkship in Year 5, 13 students from both universities who had completed an advanced paediatric clerkship in Year 6, 28 paediatric residents and 17 paediatricians. We repeated this procedure using a second test with different domains in a new, comparable group of subjects (MATCH 2). Results Mean MATCH 1 scores for the respective groups were: Year 4 students: 61.2% (standard deviation [SD] 1.3); Year 5 students: 71.3% (SD 1.6); Year 6 students: 76.2% (SD 1.5); paediatric residents: 88.5% (SD 0.7), and paediatricians: 92.2% (SD 1.1) (one‐way anova F = 104.00, P < 0.0001). Students of both universities had comparable scores. MATCH 1 and 2 scores were comparable. Cronbach’s α‐values in MATCH 1 and 2 were 0.92 and 0.91, respectively, for all subjects, and 0.82 and 0.87, respectively, for all students. Conclusions Analytical clinical thinking develops over time, independently of the factual content of the course. This implies that shortened medical training programmes could produce less skilled graduates.     

Use of a structured interview to assess portfolio-based learning

Context Portfolio‐based learning is a popular educational tool usually examined by document review which is sometimes accompanied by an oral examination. This labour‐intensive assessment method prohibits its use in the resource‐constrained settings typical of developing countries. Objectives We aimed to determine the feasibility and internal consistency of a portfolio‐based structured interview and its impact on student learning behaviour. Methods Year 4 medical students (n = 181) recorded 25 patient encounters during a 14‐week medical clerkship. Portfolios were examined in a 30‐minute, single‐examiner interview in which four randomly selected cases were discussed. Six standard questions were used to guide examiners in determining the ability of candidates to interpret and synthesise clinical data gathered during patient encounters. Examiners were trained to score responses using a global rating scale. Pearson’s correlation co‐efficient, Cronbach’s α coefficient and the standard error of measurement (SEM) of the assessment tool were determined. The number of students completing more than the required number of portfolio entries was also recorded. Results The mean (± standard deviation [SD], 95% confidence interval [CI]) interview score was 67.5% (SD ± 10.5, 95% CI 66.0–69.1). The correlation coefficients for the interview compared with other component examinations of the assessment process were: multiple‐choice question (MCQ) examination 0.42; clinical case‐based examination 0.37; in‐course global rating 0.08, and overall final score 0.54. Cronbach’s α coefficient was 0.88 and the SEM was 3.6. Of 181 students, 45.3% completed more than 25 portfolio entries. Conclusions Portfolio assessment using a 30‐minute structured interview is a feasible, internally consistent assessment method that requires less examination time per candidate relative to methods described in published work and which may encourage desirable student learning behaviour.     

Clinical clerkships: students can structure their own learning

In clinical clerkships, student learning is often unstructured and diverse. Even when curriculum objectives are explicit, they are seldom used by students to guide their learning. Student-determined learning objectives may help students to structure their learning. This study aimed to assess whether students can use this method to meet widely differing learning needs within the general practice clerkship and considered the relationship of student objectives to overall curriculum objectives. Students allocated a 5-week clerkship in general practice from April 2000 to April 2001 were required to set and meet personal learning objectives within a supportive learning environment. They recorded the strategies they used, how well objectives were met and which curriculum objectives they met. Objectives were categorised using a hierarchical system. A total of 143 (85%) students recorded 1549 objectives. Four categories accounted for 1092 (70%) of objectives: Consultation Skills; Study of Diseases; Practical Procedures, and Therapeutics. Otherwise the range of objectives set was wide, encompassing all curriculum objectives. A total of 1043 objectives were rated as satisfactorily or highly satisfactorily met and 185 (12%) were not met at all. Strategies that students used to meet objectives included clinical experience with doctors but also with practice-based nurses. Students were able to use student-determined learning objectives to meet a diverse range of learning needs within the general practice clerkship. The objectives set reflected the breadth of curriculum objectives. This method allows students to address gaps in their knowledge in a clerkship where teaching is largely based on opportunistic contact.     

Spaced education improves the retention of clinical knowledge by medical students: a randomised controlled trial

Purpose Medical knowledge learned by trainees is often quickly forgotten. How can the educational process be tailored to shift learning into longer‐term memory? We investigated whether ‘spaced education’, consisting of weekly e‐mailed case scenarios and clinical questions, could improve the retention of students' learning. Methods During the 2004–5 surgery clerkships, 3rd‐year students completed a mandatory 1‐week clinical rotation in urology and validated web‐based teaching programme on 4 core urology topics. Spaced educational e‐mails were constructed on all 4 topics based on a validated urology curriculum. Each consisted of a short clinically relevant question or clinical case scenario in multiple‐choice question format, followed by the answer, teaching point summary and explanations of the answers. Students were randomised to receive weekly e‐mailed case scenarios in only 2 of the 4 urology topics upon completion of their urology rotation. Students completed a validated 28‐item test (Cronbach's α = 0.76) on all 4 topics prior to and after the rotation and at the end of the academic year. Results A total of 95 of 133 students (71%) completed the end‐of‐year test. There were no significant differences in baseline characteristics between randomised cohorts. Spaced education significantly improved composite end‐of‐year test scores (P < 0.001, paired t‐test). The impact of the spaced educational e‐mails was largest for those students who completed their urology education 6–8 and 9–11 months previously (Cohen's effect sizes of 1.01 and 0.73, respectively). Conclusion Spaced education consisting of clinical scenarios and questions distributed weekly via e‐mail can significantly improve students' retention of medical knowledge.     

Applying multimedia design principles enhances learning in medical education

Medical Education 2011: 45 : 818–826 Context The Association of American Medical Colleges’ Institute for Improving Medical Education’s report entitled ‘Effective Use of Educational Technology’ called on researchers to study the effectiveness of multimedia design principles. These principles were empirically shown to result in superior learning when used with college students in laboratory studies, but have not been studied with undergraduate medical students as participants. Methods A pre‐test/post‐test control group design was used, in which the traditional‐learning group received a lecture on shock using traditionally designed slides and the modified‐design group received the same lecture using slides modified in accord with Mayer’s principles of multimedia design. Participants included Year 3 medical students at a private, midwestern medical school progressing through their surgery clerkship during the academic year 2009–2010. The medical school divides students into four groups; each group attends the surgery clerkship during one of the four quarters of the academic year. Students in the second and third quarters served as the modified‐design group (n = 91) and students in the fourth‐quarter clerkship served as the traditional‐design group (n = 39). Results Both student cohorts had similar levels of pre‐lecture knowledge. Both groups showed significant improvements in retention (p < 0.0001), transfer (p < 0.05) and total scores (p < 0.0001) between the pre‐ and post‐tests. Repeated‐measures anova analysis showed statistically significant greater improvements in retention (F = 10.2, p = 0.0016) and total scores (F = 7.13, p = 0.0081) for those students instructed using principles of multimedia design compared with those instructed using the traditional design. Conclusions Multimedia design principles are easy to implement and result in improved short‐term retention among medical students, but empirical research is still needed to determine how these principles affect transfer of learning. Further research on applying the principles of multimedia design to medical education is needed to verify the impact it has on the long‐term learning of medical students, as well as its impact on other forms of multimedia instructional programmes used in the education of medical students.     

Techniques for teaching electrocardiogram interpretation: self-directed learning is less effective than a workshop or lecture

Medical Education 2011: 45 : 347–353 Context Teaching 12‐lead electrocardiogram (ECG) interpretation to students and residents is a challenge for medical educators. To date, few studies have compared the effectiveness of different techniques used for ECG teaching. Objectives This study aimed to determine if common teaching techniques, such as those involving workshops, lectures and self‐directed learning (SDL), increase medical students’ ability to correctly interpret ECGs. It also aimed to compare the effectiveness of these formats. Methods This was a prospective randomised study conducted over a 28‐month period. Year 4 medical students were randomised to receive teaching in ECG interpretation using one of three teaching formats: workshop, lecture or SDL. All three formats covered the same content. Students were administered three tests: a pre‐test (before teaching); a post‐test (immediately after teaching), and a retention test (1 week after teaching). Each tested the same content using 25 questions worth 1 point each. A mixed‐model repeated‐measures analysis of variance (anova ) with least squares post hoc analysis was conducted to determine if differences in test scores between the formats were statistically significant. Results Of the 223 students for whom data were analysed, 79 were randomised to a workshop, 82 to a lecture‐based format and 62 to SDL. All three teaching formats resulted in a statistically significant improvement in individual test scores (p < 0.001). Comparison of the lecture‐ and workshop‐based formats demonstrated no difference in test scores (marginal mean [MM] for both formats = 12.4, 95% confidence interval [95% CI] 11.7–13.2]; p = 0.99). Test scores of students using SDL (MM = 10.7, 95% CI 9.8–11.5) were lower than those of students in the workshop (p = 0.003) and lecture (p = 0.002) groups. Conclusions Compared with those taught using workshop‐ and lecture‐based formats, medical students learning ECG interpretation by SDL had lower test scores.     

Clinical competence understood through the construct validity of three clerkship assessments

Medical Education 2011: 45 : 849–857 Objectives This study examined the construct validity of three commonly used clerkship performance assessments, including preceptors’ evaluations, objective structured clinical examination (OSCE)‐type clinical performance measures, and the National Board of Medical Examiners (NBME) medicine subject examination, in order to better understand their conceptual structures and utility in the explanation of clinical competence. Methods A total of 686 students who took an in‐patient medicine clerkship during the period 2003 to 2007 participated in the study. Exploratory and confirmatory factor analyses using structural equation modelling were adopted to examine the latent domains underlying various indicators assessed by these three measures and the pattern of indicator–domain relationships. Results Factor analyses found three latent constructs, labelled Clinical Performance, Interpersonal Skills and Clinical Knowledge, underlying the observed measures. The three domains were modestly correlated with one another (inter‐factor correlation coefficients ranged from 0.39 to 0.54). They also tapped a common higher‐order construct, Clinical Competence, in varying degrees of magnitude (0.73, 0.74, 0.53, respectively). Conclusions The study demonstrated that although the three commonly used tools for assessing clerkship performance contributed uniquely to the understanding of clinical performance, they also attested to a shared domain of clinical competence in their assessment. The study confirmed the need for a multiple‐methods approach to clinical performance assessment. Findings also revealed that clerkship preceptors need to differentiate their evaluation of students’ performances, and that the OSCE did not assess a single domain of clinical competence.     

Attitudes towards the doctor-patient relationship: a prospective study in an Asian medical school

Context Patient‐centredness is an accepted guiding principle for health system reform, patient care and medical education. Although these attitudes are strongly linked with cultural values, few studies have examined attitudes towards patient‐centredness in a cross‐cultural setting. Objectives This prospective study evaluated attitudes towards patient‐centredness in a cohort of Asian medical students and examined changes in these attitudes in the same students on completion of their junior clinical clerkships. Methods The study was conducted in a cohort of 228 medical students entering Year 3 in medical school. The Patient–Practitioner Orientation Scale (PPOS), a validated instrument which scores an individual’s level of patient‐centredness, was used. Results Being female and having personal experience of continuing care were significantly associated with higher scores. Students in the USA were previously reported to have similar ‘caring’ but higher ‘sharing’ scores on the same scale. At the end of the junior clinical clerkship, there were improvements in the ‘caring’ subscale, but no change or a reduction in ‘sharing’. Students who did not have previous personal experience with continuing care experienced a greater increase in overall PPOS score. Conclusions When compared with students in the USA, the students in our study appear to have a lower propensity to view the doctor–patient relationship as a partnership. This may be a reflection of differences in cultural norms and expectations of doctor–patient interaction in different societies. Our finding that attitudes towards patient‐centredness did not decline over the course of the year, which contrasts with findings of other studies, may be attributed to various factors and warrants further study.     

Changes in students'' attitudes and values during medicine versus surgery clerkships

A prospective study of students' attitudes and values was conducted during medicine and surgery clerkships over the first clinical year. Students who finished the surgery clerkship first were more cynical and intolerant of ambiguity than the medicine students. Surgery students also felt they lacked self-confidence and had stronger feelings of being victimized. Cynicism and attitudes towards ambiguous situations improved during the medicine clerkship. Feeling victimized was strongly correlated with their problems with self-confidence, with cynicism, and a feeling of having to submit to authority figures. The findings of this study suggest that the clerkship order significantly affects the development of students' attitudes. Students also became more punitive and less confident as the first clinical year progressed. The implications of these changes in attitude on educational planning are discussed.     

What do students actually do on an internal medicine clerkship? A log diary study

BACKGROUND: There are limited data on the amount of time students spend on teaching and learning while on internal medicine clerkships, and existing data suggest a wide international variation. Community-based teaching of internal medicine is now widespread; but its strengths and weaknesses compared to traditional hospital based teaching are still unclear. AIM: To determine the proportion of time students spend on different activities on an internal medicine clerkship, and to determine whether this differs in general practice and in hospital. In addition we aimed to determine students' views on the educational value and enjoyment of various activities. METHODS: Prospective completion of log diaries recording student activities. Each student was asked to complete the diary for two separate weeks of their internal medicine clerkship: one week of general practice-based teaching and one week of hospital-based teaching. RESULTS: The response rate was 68% (88/130). Students spent approximately 5.5 h per day on teaching and learning activities in both environments, with more time (50 min vs. 30 min, P = 0.007) on unsupervised interaction with patients in hospital than in general practice, and more time (53 min vs. 21 min, P < 0.001) undergoingassessment in general practice than in hospital. Standard deviations were wide, demonstrating the heterogeneous nature of the data. Students perceived supervised interaction with patients and teaching by doctors as the most educational activities in both environments, but found it even more educationally valuable and enjoyable in general practice than in hospital (mean score for educational value: 4.27 in general practice, 3.88 in hospital, P = 0.048; mean score for enjoyment 4.13 in general practice, 3.66 in hospital, P = 0.03). CONCLUSIONS: Students greatly value interactions with patients, perceiving these as both educational and enjoyable. Curriculum planners must continue to place patient-based learning at the centre of undergraduate medical education. The heterogeneity of the data suggests that individual students have very different experiences, despite apparently similar timetables.     

Simulation in undergraduate medical education: bridging the gap between theory and practice

OBJECTIVE: To evaluate the use of simulation-based teaching in the medical undergraduate curriculum in the context of management of medical emergencies, using a medium fidelity simulator. DESIGN: Small groups of medical students attended a simulation workshop on management of medical emergencies. The workshop was evaluated in a post-course questionnaire. SUBJECTS: All Year 4 medical students allocated to the resuscitation rotation during the first half of 2002. MAIN OUTCOME MEASURES: Student perceptions of learning outcomes, the value of the simulation in the undergraduate curriculum and their self-assessed improved mastery of workshop material. RESULTS: A total of 33 students attended the workshop and all completed questionnaires. Students rated the workshop highly and found it a valuable learning experience. In all, 21 (64%) students identified teamwork skills as key learning points; 11 (33%) felt they had learnt how to approach a problem better, particularly in terms of using a systematic approach, and 12 (36%) felt they had learnt how to apply their theoretical knowledge in a clinical setting better. All 33 students were positive about the use of simulation in their training; 14 students wrote that simulation should be used more or should be mandatory in training; 5 students commented positively on the realism of the learning experience and a further 5 said they valued the opportunity to learn new skills in a safe environment. CONCLUSION: This study demonstrates that medical students value simulation-based learning highly. In particular, they value the opportunity to apply their theoretical knowledge in a safe and realistic setting, to develop teamwork skills and to develop a systematic approach to a problem. A medium fidelity simulator is a valuable educational tool in medical undergraduate education.     

In-training assessment: qualitative study of effects on supervision and feedback in an undergraduate clinical rotation

BACKGROUND: Supervision and feedback are essential factors that contribute to the learning environment in the context of workplace learning and their frequency and quality can be improved. Assessment is a powerful tool with which to influence students' learning and supervisors' teaching and thus the learning environment. OBJECTIVE: To investigate an in-training assessment (ITA) programme in action and to explore its effects on supervision and feedback. DESIGN: A qualitative study using individual, semistructured interviews. SUBJECTS AND SETTING: Eight students and 17 assessors (9 members of staff and 8 residents) in the internal medicine undergraduate clerkship at Vrije Universiteit Medical Centre, Amsterdam, the Netherlands. RESULTS: The ITA programme in action differed from the intended programme. Assessors provided hardly any follow-up on supervision and feedback given during assessments. Although students wanted more supervision and feedback, they rarely asked for it. Students and assessors failed to integrate the whole range of competencies included in the ITA programme into their respective learning and supervision and feedback. When giving feedback, assessors rarely gave borderline or fail judgements. DISCUSSION AND CONCLUSION: If an ITA programme in action is to be congruent with the intended programme, the implementation of the programme must be monitored. It is also necessary to provide full information about the programme and to ensure this information is given repeatedly. Introducing an ITA programme that includes the assessment of several competencies does not automatically lead to more attention being paid to these competencies in terms of supervision and feedback. Measures that facilitate change in the learning environment seem to be a prerequisite for enabling the assessment programme to steer the learning environment.     

Unintentional failure to assess for experience in senior undergraduate OSCE scoring

Context One goal of undergraduate assessment is to test students’ (future) performance. In the area of skills testing, the objective structured clinical examination (OSCE) has been of great value as a tool with which to test a number of skills in a limited time, with bias reduction and improved reliability. But can OSCEs measure undergraduate internship expertise in basic clinical skills? Methods Undergraduate students (n = 32) were given a questionnaire listing 182 basic clinical skills. We asked them to score the number of times they had performed each skill during their internships (a 12‐month period in Year 6). We assessed the students at the end of Year 5 (before the start of their internships) and again at the start of Year 7 (undergraduate training takes 7 years in Belgium, with internships during Year 6), using a 14‐station OSCE assessing basic clinical skills. Global ratings were used to score performance. The relationship between internship experience and the OSCE Year 7 score was analysed using a linear regression model, controlling for variation in OSCE scores from Year 5. A multi‐level analysis was performed considering students as level‐1 units and stations as level‐2 units. Results Year 7 OSCE scores (post‐internships) were not affected by the number of times that students practised basic medical skills during their internships. Discussion Scores on OSCEs do not seem to reflect clinical expertise acquired during internships. Other more integrated assessment methods may prove to be more valid for testing final undergraduate skills levels.     

Authenticity of instruction and student performance: a prospective randomised trial

Medical Education 2011: 45 : 807–817 Objectives This study aimed to investigate the relationship between the authenticity of instructional formats and outcome measures within a pre‐clerkship clinical reasoning course. Methods We conducted a randomised, prospective, crossover study with Year 2 medical students taking a pre‐clerkship clinical reasoning course. Students were randomised to small groups and exposed to three formats of differing instructional authenticity (paper case, DVD presentation, standardised patient [SP] presentation) across three subject areas (abdominal pain, anaemia, polyuria). Three student cohorts were taught using one instructional format per subject area so that each cohort received a different instructional format for each of the three subject areas. Outcome measures (objective structured clinical examination, video quiz, written examination) were selected to determine the effect of each instructional format on the clinical reasoning of students. Results Increasingly authentic instructional formats did not significantly improve clinical reasoning performance across all outcome measures and subject areas. However, the results of the video quiz showed significant differences in the anaemia subject area between students who had been instructed using the paper case and live SP‐based formats (scores of 47.4 and 57.6, respectively; p = 0.01) and in the abdominal pain subject area, in which students instructed using the DVD format scored higher than students instructed using either the paper case or SP‐based formats (scores of 41.6, 34.9 and 31.2, respectively; p = 0.002). Conclusions Increasing the authenticity of instructional formats does not appear to significantly improve clinical reasoning performance in a pre‐clerkship course. Medical educators should balance increases in authenticity with factors such as cognitive load, subject area and learner experience when designing new instructional formats.     

From rural beginnings to statewide roll‐out: Evaluation of facilitator training for a group‐based diabetes prevention program

Objective: To evaluate the approach used to train facilitators for a large‐scale group‐based diabetes prevention program developed from a rural implementation research project. Participants: Orientation day was attended by 224 health professionals; 188 submitted the self‐learning task; 175 achieved the satisfactory standard for the self‐learning task and attended the workshop; 156 completed the pre‐ and post‐training questionnaires. Main outcome measures: Two pre‐ and post‐training scales were developed to assess knowledge and confidence in group‐based diabetes prevention program facilitation. Principal component analysis found four factors for measuring training effectiveness: knowledge of diabetes prevention, knowledge of group facilitation, confidence to facilitate a group to improve health literacy and confidence in diabetes prevention program facilitation. Self‐learning task scores, training discontinuation rates and satisfaction scores were also assessed. Results: There was significant improvement in all four knowledge and confidence factors from pre‐ to post‐training (P < 0.001). The self‐learning task mean test score was 88.7/100 (SD = 7.7), and mean assignment score was 72.8/100 (SD = 16.1). Satisfaction with training scores were positive and ‘previous training’ interacted with ‘change in knowledge of diabetes prevention program facilitation’ but not with change in ‘confidence to facilitate.’ Conclusions: The training program was effective when analysed by change in facilitator knowledge and confidence and the positive mean satisfaction score. Learning task scores suggest tasks were manageable and the requirement contributed to facilitator self‐selection. Improvement in confidence scores in facilitating a group‐based diabetes prevention program, irrespective of previous training and experience, show that program‐specific skill development activities are necessary in curriculum design.     

Students’ experiences and perceptions of the use of portfolios in UK preregistration dietetic placements: a questionnaire‐based study

Background: Reflective portfolios were introduced to dietetic practice placements in 2005, providing evidence for learning outcomes achieved and acting as a summative assessment tool. Portfolios may measure clinical competence more effectively than conventional examinations, but can be time consuming and subjective. The present study investigated current dietetic students’ experiences and perceptions of the use and effectiveness of portfolio based learning and assessment during practice placements. Methods: Current UK dietetic students, who had completed a B or B and C placement, were invited to participate, via University course leaders, in an online questionnaire exploring opinions and experiences of portfolio preparation, generation, assessment, and personal and professional development and reflection. Results: One hundred and fourteen students from 11 Universities participated. Seventy‐seven percent would have liked more information about portfolio construction prior to placement. Eighty percent of students believed that reflection helped monitor their strengths and weaknesses. Perceived reflective skills were significantly positively correlated with students’ perceived writing skills (P < 0.0005) and academic ability (P = 0.002). Of the respondents, 92% agreed the portfolio was a valuable learning experience; however, 76% agreed that the amount of paperwork involved was excessive and 67% felt there were inconsistencies in portfolio assessment by different supervisors. Conclusions: Portfolio weaknesses identified are not specific to dietetics but are inherent to portfolio assessment across many professions. The introduction of national standardised assessment processes, practices, tools and training for assessors may help improve inter‐departmental and inter‐rater reliability, respectively.     

Student perceptions of assessment and feedback in longitudinal integrated clerkships

Objectives This study was conducted to elucidate how the learning environment and the student–preceptor relationship influence student experiences of being assessed and receiving feedback on performance. Thus, we examined how long‐term clinical clerkship placements influence students’ experiences of and views about assessment and feedback. Methods We took a constructivist grounded approach, using authentic assessment and communities of practice as sensitising concepts. We recruited and interviewed 13 students studying in longitudinal integrated clerkships across two medical schools and six settings, using a semi‐structured interview framework. We used an iterative coding process to code the data and arrive at a coding framework and themes. Results Students valued the unstructured assessment and informal feedback that arose from clinical supervision, and the sense of progress derived from their increasing responsibility for patients and acceptance into the health care community. Three themes emerged from the data. Firstly, students characterised their assessment and feedback as integrated, developmental and longitudinal. They reported authenticity in the monitoring and feedback that arose from the day‐to‐day delivery of patient care with their preceptors. Secondly, students described supportive and caring relationships and a sense of safety. These enabled them to reflect on their strengths and weaknesses and to interpret critical feedback as supportive. Students developed similar relationships across the health care team. Thirdly, the long‐term placement provided for multiple indicators of progress for students. Patient outcomes were perceived as representing direct feedback about students’ development as doctors. Taking increasing responsibility for patients over time is an indicator to students of their increasing competence and contributes to the developing of a doctor identity. Conclusions Clerkship students studying for extended periods in one environment with one preceptor perceive assessment and feedback as authentic because they are embedded in daily patient care, useful because they are developmental and longitudinal, and constructive because they occur in the context of a supportive learning environment and relationship.