1. Learning trajectories in longitudinal
rural medical school placements
Cathy Owen, Amanda Barnard and Jill
Bestic, Rural Clinical School,
Australian National University
Medical School, Canberra, Australia
MUSTER 2014

2. Hard working rural stream students

3. Our setting
• longitudinal clinical placement for 40 weeks in
a rural setting (on average 120 kms from main
campus largely in towns <10,000 people)
• Learning opportunities are both structured
(e.g. with planned teaching sessions) and
opportunistic, with progressively entrusted
activities in GP and rural hospitals
• Student placements differ in patient mix, load
and opportunity for independent practice

4. Other learning signposts
• End of placement learning goals
• Portfolio of required learning activities
• Little structured guidance on performance
expectation at points along an extended
program
• End of year assessment

5. What is a learning trajectory?
• Contextual map to guide a learning pathway
• Shouldn’t assume all students learn in the
same way
• Should offer sufficient flexibility to be adapted
to individual student-supervisor needs
• Should adapt to the developing student
supervisor relationship

6. Why use a learning trajectory?
• To maximise learning opportunities
• To “hit the ground running” in a strange
learning environment
• To support the lost student or for that matter
the “lost” supervisor
• To reference the notion of adequate
performance on placement assisting feedback

7. How did we make one?
• Ethics approval
• Emailed requests for
students and
supervisors to
document key
learning
achievements at
quarter half and full
time in key areas:
– skills development
– knowledge acquisition
– professional
experiences
– level of responsibility
• Workshopped at
supervisor meetings

8. Response

9. Response
Students
• n = 23
• Early 11
– Skills focused
• Mid 11
– Confidence & sensitive
communication
• Late 8
– Exams focused
Supervisors
• n =25
• Early 5
– History taking & behaviour
focused
• Mid 5
– High expectations of useful
well integrated care
• Late 1

10. Feedback
Students
• Given draft at end of year to
review – items not
commonly achieved
removed
• Important but not universal
items retained e.g.
independent practice, with
explanatory notes
Supervisors
• Discussed at supervisor
meetings: some concern
about “lowest common
denominator effect”
• Most found useful for
orientation and feedback

12. Examples
Skills you aim to develop Taking a good focussed history
for a range of common
conditions.
Getting confident in basic
system examinations. Writing in
medical records.
Basic skills e.g. aseptic
technique, hand washing,
venepuncture and cannulation
Becoming more methodical at
focused history and physical
examinations. Presenting long
cases in a more professional &
problem-based manner
Increased confidence in basic
skills plus new skills e.g.
spirometry
Doing all histories,
examinations, consultations,
procedures and case
presentations with a better
order/flow and confidence. All
skills in the 3rd year portfolio
completed with supervisor
feedback
Content knowledge you aim to
be able to answer a written
exam question on
Case based questions, with a
history, provisional and
differential diagnosis,
examination, investigations and
management for common
disorders e.g. acute abdomen,
diabetes, asthma
Common surgical and medical
scenarios covered in structured
teaching session so far
Deeper understanding of
common presentations in
General Practice, indications and
complications of common
surgeries and identifying the
unwell child and other important
conditions in paediatrics. Have
practised and become more
confident writing sample exam
questions

13. Professional experiences you
aim to have undertaken
Familiarising self with the
everyday running of rural
hospitals and general practices.
Basic general practice
consultations. Some
independent consulting (history
and examination) with
supervisor review. Contributing
to discussions about patient
care and consulting other health
professionals (e.g. pharmacists
& radiographers) regarding
patient care
Better able to consult in terms
of time management, talking
about preventative health
issues and ability to discuss
basic management plans with
patients, before bringing the
supervising doctor into the
consultation. To write discharge
summaries using the clinical
notes. To assist in surgical
procedures performing
excisions/biopsies etc. To
contribute to health
professional teaching sessions
In consultations able to initiate
investigations, suggest lifestyle
modification, write referral
letters for patients (all under
supervisor guidance). Assist in
theatre, on call and can help
workup patients in emergency.
The level of responsibility you
may have in your practice
setting
Observe consultations in various
practice settings. Start to see
patients initially alone on wards
rounds and in the GP setting and
then review with supervisor.
Undertake basic investigations
or management within level of
teaching.
Observe procedures
Increased confidence in
discussing management options
with patients with supervisor
approval. Responsible for note
taking.
Expected to take a history, do an
examination and formulate a
management plan in GP and ED
settings, then execute plan with
supervisor approval. Assistant in
GP procedures and theatre

14. Helpful thoughts from previous
rural stream students
At this stage in the year I was
able to take histories off
patients but I felt a bit shy
talking to patients as they were
'real' and I was really conscious
of trying not to 'mess things up'
and was self-conscious about
taking a history
I felt much more comfortable at
this stage doing GP consults at
my own - I felt confident calling
out patients names in the
waiting room and felt confident
introducing myself to doctors at
the hospital and surgeons. I felt
part of the team
.
I felt better skilled at talking
with patients about their
treatment including when drugs
were not required. Wrote better
quality referral letters. I felt
most confident answering exam
questions on medical conditions
or scenarios I have witnessed
throughout the year as I tend to
remember these better than just
rote learning lecture material

15. Three key learning objectives
• Three key learning objectives
• Existing students and supervisors on
longitudinal learning placements can identify
key incremental learning goals by time to
display as a learning trajectory
• Variations in medical practices means that
timing of learning goals may vary
• The developed learning trajectory is useful for
student and new supervisor orientation