Longitudinal integrated clerkships are now recognised as representing credible and effective pedagogical alternatives to TBRs in medical education.

In this paper we are challenging six traditional notions about assessment that are unhelpful when designing 'assessment for learning'-programmes for competency-based education. We are arguing for the following: Reductionism is not the only way to assure rigour in high-stakes assessment; holistic judgements can be equally rigorous. Combining results of assessment parts only because they are of the same format (like different stations in an OSCE) is often not defensible; instead there must be a logically justifiable combination. Numbers describe the quality of the assessment. Therefore, manipulating the numbers is usually not the best way to improve its quality. Not every assessment moment needs to be a decision moment, disconnecting both makes combining summative and formative functions of assessment easier. Standardisation is not the only route to equity. Especially with diverse student groups tailoring is more equitable than standardisation. The most important element to standardise is the quality of the process and not the process itself. Finally, most assessment is too much focussed on detecting deficiencies and not on valuing individual student differences. In competency-based education--especially with a focus on learner orientation--this 'deficiency-model' is not as well aligned as a 'differences-model'.

Rural community-based medical education programmes are seen as academically acceptable and can facilitate symbiotic relationships among students, rural clinicians, patients and community stakeholders. These relationships can influence students' clinical competency and professional identity, increase graduates' interest in rural careers, and potentially improve rural health service stability. Formal prospective stakeholder consultations should be published in the literature.

Gaining clinical experience for an extended period of time in teaching hospitals is one of the enduring strengths of medical education. Teaching hospitals have recently faced significant challenges, with increasing specialisation of services and workload pressures reducing clinical learning opportunities. New clinical teaching environments have been established in Australia, particularly in rural and regional areas; these are proving to be ideal contexts for student learning. The new clinical teaching environments have shown the importance of developing symbiotic relationships between universities and health services. Symbiotic clinical learning is built around longitudinal, patient-based learning emphasising priority health concerns. The symbiotic framework provides a basis for reconstructing clinical teaching in teaching hospitals so th@they continue to play a vital role in Australian medical education, with additional clinical experience provided by primary care and community, rural and regional hospitals.

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