You Get What You Reward: A Qualitative Study Exploring Medical Student Engagement in 2 Different Assessment Systems.

Purpose: Educational impact is dependent on student engagement. Assessment design can provide a scaffold for student engagement to determine the focus of student efforts. Little is known about how medical students engage with assessment. Therefore, we asked the following research question: How do medical students engage with the process of assessment and their assessment data in 2 clinical assessment systems?

Method: This multi-institutional, cross-sectional constructivist grounded theory study of fourth-year undergraduate medical students at the University of Washington and Cleveland Clinic Lerner College of Medicine assessed 2 different assessment systems: traditional tiered grading, in which clerkship grades were summative, and programmatic assessment, in which students received low-stake, narrative feedback across clerkships with progress based on aggregated performance data in student portfolios. All fourth-year students were invited to participate in one-on-one semistructured interviews guided by student engagement theory between September 2022 and January 2023. Verbatim transcripts underwent iterative, qualitative analysis.

Results: Twenty-two medical students were interviewed, 13 from a traditional grading assessment system and 9 from a programmatic assessment system. Three major ways in which assessment systems affected how students engaged with their assessments were categorized into the affective, cognitive, and behavioral domains of engagement: as a sociocultural statement of value, as the cognitive load associated with the assessment system and practices themselves, and as the locus of power and control in learning and authentic practice.

Conclusions: Medical students' beliefs about assessment goals, cognitive burden of assessment, and relationships with others significantly affected their engagement with their assessments. In assessment systems that reward grading and an archetypal way of being, students report engaging by prioritizing image over learning. In programmatic assessment systems, students describe more fully and authentically engaging in their assessment for and as learning. Systems of assessment communicate what is rewarded, and you get what you reward.