For many years, medical students at the University of Sydney undertook their clinical clerkships in traditional metropolitan teaching hospitals, which were regarded as the 'gold standard' for clinical training. In 2001 the university established a rural clinical school at which increasing numbers of students now complete a significant proportion of their medical education. The aim of the study reported here is to examine students' perceptions of what facilitates their learning in clinical settings and to compare their perceptions across rural and metropolitan settings. Focus groups were conducted to collect students' views on their experiences of learning in clinical settings. The findings were used to generate a questionnaire with items designed directly from focus-group data ensuring content validity. The questionnaire was sent to all students in the 2004 cohort. Exploratory factor analysis was used to provide evidence of construct validity. The internal consistency reliability of the questionnaire was assessed using Cronbach's alpha. Factor scores were computed to compare students' perceptions across the two settings. Four factors were extracted: (1) clinical teachers' orientation to teaching; (2) opportunities to develop clinical skills; (3) supportiveness of the clinical setting; and (4) student confidence and sense of self-efficacy. Students rated the rural experience more highly and positively than the metropolitan hospital experience with regard to all four factors. This study highlights the positive role that rural attachments can play in providing an educationally sound learning experience. The findings are important in the context of both the drive, among medical programs worldwide, to seek out additional and alternative settings for clinical education and the national agenda to foster student interest in rural careers through positive rural training experiences.