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Community Affairs References Committee
Health services and medical professionals in rural areas

NICHOLSON, Professor Geoffrey Charles, Head and Director of Research, Rural Clinical School, The University of Queensland School of Medicine, Rural Clinical School


CHAIR: Welcome. I have an official bit I have to do. I understand information on parliamentary privilege and the protection of witnesses and evidence has been provided to you.

Prof. Nicholson : Yes.

CHAIR: I invite you to make an opening statement, and then we will ask you some questions.

Prof. Nicholson : I was not quite sure how long or short 'brief' is, so I have a short and a longer version.

Senator MOORE: How about the longer one? Get everything you want to say on record. I think it is more important that we hear what you have to tell us. If we then have questions, we can ask them, but I would like to hear you. I think that is the best thing to do.


Prof. Nicholson : Okay. I am trying to appear as a scientist rather than an advocate, so there is probably an excessive amount of statistics and data.

CHAIR: We love statistics in this committee.

Prof. Nicholson : Yes, I gathered that from this morning's session! So, if there is a problem along the way, please interrupt.

I am sure that the committee knows about the RCTS program, which commenced in 2002. It had broad aims. One was to increase the rural medical workforce essentially by increasing the proportion of graduates of medical schools who went and worked rurally. The other was involved with Indigenous health and the recruitment of Indigenous students. I will focus on the first one because that seems to be the main topic at the moment.

For background, the University of Queensland School of Medicine is the largest in Australia, as you probably know. It is important to understand there are two entry pathways. One is an undergraduate, or provisional school leaver pathway where students who have done very well at the end of high school get provisional entry, provided they keep their marks during the undergraduate program provided they keep their marks, to the medical school. The other entry pathway is graduate entry. Initially, the University of Queensland was entirely graduate, but about five years ago they started to introduce the undergraduate program. It started with quite small numbers but then ballooned to become the majority of the entrants. That explains some of the other data I am going to present to you.

As a result of UQ School of Medicine itself being the largest and the rural clinical school one of the largest, we have four teaching sites that go from Rockhampton down to Toowoomba. They are major regional sites. We have more than 80 teaching sites across central and south-west Queensland. So it covers a very large area. The number of students has tripled from 36 in 2002 to 117 this year, and I estimate it will be about 136 next year. In 2012 33 per cent will complete two years rather than one year. You are probably aware that the parameter is that 25 per cent of students have to do one year. We are pushing up towards the majority doing two years. Next year this percentage may be as high as 67 per cent of our cohort doing two years.

I am sure the committee is also aware of the factors that influence the likelihood of rural practice, and most of them start with 'rural'. We have rural background, rural schooling, rural clinical school attendance, having a rural partner, having a general preference towards rural, doing a rural internship and doing rural postgraduate training and extended longitudinal placements. There are other vague terms of having rewarding rural experiences and also having random life events which we obviously cannot do much about. Postgraduate training opportunities are probably quite important. So some of these factors are independent and some are not, and they may confound each other and interact.

You have already been talking this afternoon about rural background, and that is one of the parameters of the funding of the rural clinical schools. The federal government has mandated with medical schools with a rural clinical school must recruit at least 25 per cent of their students from rural backgrounds. Prior to 2011 this was an aspirational target rather than a mandated target. The review panel report of 2010 into medical training stated that six medical schools had not achieved the 25 per cent rural background target and that for the University of Queensland it was 7.5 per cent. This hit the press and has caused a great deal of difficulty. This data is incorrect but has been used by some to advocate for changes in the funding model, so I think it is quite important that I set the record straight. I do not know where the 7.5 per cent came from and neither does anybody at the school of medicine, but presumably it came from information provided to MDANZ, which is Medical Deans Australia and New Zealand, by central UQ administration. But the actual situation in 2010 was that we had 25.7 per cent of 138 graduate entry students who had a rural background and there had been a quota in place for a number of years. But the rural background amongst the majority of 178 undergraduate entry students was unknown. So we had a denominator of X and a numerator of Y and ended up with 11.4 per cent, which was technically correct, not 7.5 per cent. But I will be able to produce some data that corrects that.

Historically we were able to achieve the target because we had predominantly graduate entry. It slowly slipped down without anybody noticing it. It was a very complex management going from an all-graduate to mixed-entry program, and I think the administrative processes fell down.

So what is the current situation at the University of Queensland School of Medicine? After this information came out I initiated a survey of the entire year 1 and year 2 cohorts. That is 609 students. We had a very high response rate of 93.2 per cent. If we look at the rural background by MBBS year, 22 per cent of year 1 and 21 per cent of year 2 students reported having a rural background. This is based on the standard criteria of RA2 to 5 for at least five years since beginning primary school. I am very happy to table that report if the committee would like that.

In addition we have surveyed all students in the undergraduate pre-med course and consistently find around 13 per cent of those have a rural background. There is a clear difference between the proportion with rural background in the undergraduate versus the postgraduate program, but I would like to say very clearly that we are absolutely committed to achieving the 25 per cent target. Quotas will be in place next year for both streams, and we will ensure that the 25 per cent is met or exceeded. Very senior management has taken responsibility for this.

That is the background data, but what is really important is the outcomes. Are we producing more rural doctors? We have three lines of evidence that we are. One is in regional internships. Over the years between 2006 and 2011, between 60 and 100 per cent of our fourth-year graduates are doing their internship in a regional teaching hospital. In 2011, for example, it was 77 per cent. So the vast majority of our graduates are doing rural internship. A number of years ago the school started a rural tracking project where we surveyed the students every couple of years to find out where they are and get their ideas about why they are there and all that sort of stuff. A paper was recently published based on 2009 data by a colleague of mine, Dr Eley. That reported that 40 per cent of our graduates were practising rurally. More recently we have gone up-market a bit from survey into data linkage techniques. We have surveyed a large cohort of over 1,500 graduates of the University of Queensland School of Medicine who graduated between 2003 and 2008. Fifteen per cent of those had spent at least one year in the rural clinical school and 88 per cent of them were able to link their data to the AHPRA database—that is the Australian Health Professional Regulation Authority. Every practitioner has to register each year with a new address, so the data we have was within one year. It would come out in the wash, actually, because some people would come and some would go.

We found that 33.5 per cent of our rural clinical school graduates and 18 per cent of the non-rural clinical school graduates are currently practising in rural areas. The rural clinical school graduates are 2.25 times more likely to be registered in rural practice but 3.6 times more likely to be registered in a remote practice—that is RA to 5. The other question is the dose effect; students have done one year or two years. Students who have done two years are 2.4 times more likely than non-RCS graduates to practise in a rural area and five times more likely to practise in a remote area. Each year of placement in the rural clinical school increases the odds of rural practice by 1.6 times and of remote practice by 2.22 times. So clearly rural clinical school placement is an independent predictor of rural practice. We think that this RCS effect will increase as our numbers increase and the proportion of the school that is doing the rural clinical school increases. There is a significant dose effect. But I will add that these data are not adjusted for confounders. As I will discuss in a moment, is it rural background that matters, rural clinical school that matters or both?

We know that about 31 per cent of the Australian population live outside metropolitan areas, so to achieve this 31 per cent we need to improve the success rate of the rural clinical schools and/or increase the proportion of medical students attending rural clinical schools. To improve the success rate of rural clinical schools we really need to have a lot more robust data about what works and what does not work. There is evidence for the long list I read out at the beginning, but it is often done in small studies that have not adjusted for confounders.

So does rural background plus rural clinical school placement have additive or synergistic effect? Is one year of the rural clinical school enough or should it be more? If it is one year, should it be in the middle of the course or the last year, for example? Other things that I have not discussed so far include: what is the effect of increasing the rural postgraduate training opportunities? As I said, most of our students do internship; but, if they want to do any specialist training apart from things like the rural generalist program or general practice, they basically have to go back to the city. So I think clearly one of the most important things we could do is increase specialist training. We have Toowoomba Base Hospital, for instance. It is a very large hospital, but there are very limited specialist training opportunities. Probably almost certainly they need to be generalist specialists, if you like, so general physicians, general surgeons and the like.

The other element is: what is the effect of having the whole pipeline, as Dr Lennox was talking about, with students coming from high school into a medical school that is a rural clinical school, staying in that right through, going into internship in a regional environment and then doing their training? It is very likely that that pipeline will have a multiplier effect, but we do not really know. We need to collect robust data.

I think it is time for us to get a lot more sophisticated about the data collection. It actually has been quite difficult to find out where students are. For example, when they graduate they disperse all over the country and notoriously do not respond to surveys. I guess not many of us do respond to surveys. I think we need to have a mandated tracking process so that we know where all Australian medical graduates go so we can actually answer these questions. We need very comprehensive baseline data and then very robust outcome data so we can link the two and determine what the determinants are of eventual rural practice. The medical school's outcomes database will help, but I will add that that is a voluntary process. There has been very high participation early on, but I am quite sure that, as the graduates get further out, they are going to respond less and less often.

I think the other really important thing is that we should not make any changes unless we can measure what effect that change has. The worrying thing is that people will decide we should do this or we should do that. I think we need to find out what is happening now in great detail and then be very careful that we can measure what we do. Thank you very much.

CHAIR: Thank you.

Senator MOORE: You said 80-something locations for training across training? Is that right?

Prof. Nicholson : Yes. That is the short-term placement.

Senator MOORE: That is where they have a couple of weeks or whatever?

Prof. Nicholson : Our students do six weeks. There is one week of orientation; then they do six weeks and one week where they reflect on what has happened and get some additional training.

Senator MOORE: That is with MDs, rural practice or hospitals? Where do they go? You mentioned the two biggies: Toowoomba and Rockie. They are big, established hospitals.

Prof. Nicholson : Yes. The other two are Hervey Bay and Bundaberg.

Senator MOORE: Right. They are the bigger campuses. But they go out to places like Dalby or Gundi?

Prof. Nicholson : Yes. Basically there are between 80 and 100 sites.

Senator MOORE: Are they all hospitals?

Prof. Nicholson : No. Some of them are general practices. Some of them are rural hospitals where they do both. In some sites they go to the general practice and to the hospital.

Senator MOORE: A lot of practitioners in country towns actually do both, don't they? They also do hospital service.

Prof. Nicholson : Yes. That is probably one of the best models. We also have a couple of other models. That is the long look program, where students spend an entire year at one of those remote communities. The other one is called back to back, where they do the general practice and the rural and remote rotations sequentially, so they get four months at one of these sites.

Senator MOORE: Okay. Does anyone who is studying standard medicine do the short-term process of the six weeks but have to choose to be in the rural stream to do the longer placement?

Prof. Nicholson : That is correct. It is mandated for 100 per cent, so we have 300-plus students doing that short-term rotation.

Senator MOORE: A logistical nightmare.

Prof. Nicholson : Yes.

Senator MOORE: What happens with these kids when they go out in terms of accommodation? I say 'kids' even though I know there are mature-age students, but what is the responsibility for accommodation when they go out to these regions?

Prof. Nicholson : Part of our funding requirements is that the students are not disadvantaged, so there are a number of models. There is a rental subsidy. We do home stay. They could be put up in Queensland Health facilities. In a few places like Roma we have our own facilities.

Senator MOORE: There are not many of them left.

Prof. Nicholson : No. We do have our own accommodation in Roma. At all the other sites the 120-odd students are essentially given free accommodation for the year or two years.

Senator MOORE: You heard the evidence, and I know you work with state health for your stream at UQ. For a trainee doctor who is thinking about going through and then going into rural specialisation, is there anything special they do through their normal training to identify that that is what they want to do?

Prof. Nicholson : Into a specialty?

Senator MOORE: Into the rural specialty that Queensland Health has and that we just had the evidence about. In the evidence from Dr Lennox from Queensland Health he was saying that he felt it was a pathway and that the kinds of people who were interested in getting involved in that regional specialty were the ones who showed interest from school, through university into that program. How do doctors who are studying through the University of Queensland get access to that pathway? Are there information sessions? Does Queensland Health come out and say, 'We've got an offer for you'? The way I see it now, young doctors have this huge smorgasbord of options in front of them and every specialty has shortages. I do not think there is an oversupply of any single specialty in medicine in Australia at the moment. There are a whole lot of competing demands.

Prof. Nicholson : Certainly in training programs there are. I am an endocrinologist. The endocrine training program is oversubscribed by two or three times.

Senator MOORE: That is right; they love it.

Prof. Nicholson : To be an orthopaedic surgeon there is a waiting list, and only a small percentage get in.

Senator MOORE: And psychiatry.

Prof. Nicholson : Yes. And it is increasingly becoming so because the number of graduates is getting much larger. But the rural clinical school basically has the standard curriculum that they all do and then extra stuff for the rural clinical school students. The whole plan is to make them more work-ready. We do a lot more procedural and skills based training, scenario training and interprofessional learning. At these sites we teach medical students with nursing students, and they do scenarios. So a lot of that extra stuff is done essentially extracurricular—sometimes on weekends—to give them extra skills. We are hoping that that will make them more able to get into those specialist programs such as the rural generalist program.

In the longer term, of course, we know that they will need those skills. Probably a graduate of most universities these days does not come out with the full skill set to be able to deal with a motor vehicle accident on the side of the road or a birth in a remote hospital, for example, so extra training is needed.

Senator MOORE: The interest around the data that was put out in the department's figures about UQ only having seven per cent of the 25 per cent aspirational quota really seemed to focus people for a few months. Certainly we had evidence at a previous hearing where it was drawn to our attention by people from another area who were saying that large universities—they quoted the University of Queensland, but there were others—

Prof. Nicholson : I have read the transcript, yes.

Senator MOORE: You saw they raised that point to say that the larger medical schools in particular were 'paying scant attention'—I think that was a direct quote—to their responsibilities to train people from a rural background. What have we done to say that that I wrong from UQ's basis? Being a Queenslander, when we got that evidence I was quite miffed that they could point to this figure. Have the figures now been through the university process? Have they been corrected and the reputation of UQ ensured?

Prof. Nicholson : Yes indeed. You can imagine the student data management system is immensely complicated, and it was basically a glitch in that. It is certainly not true. The rural clinical school is the largest clinical school at UQ, which is the largest university. The head of school is an ex-rural GP, and he recruited me. We have a very strong motivation to make the rural clinical school successful. That goes right through the university. I have had a lot of discussions with senior people following this event and a lot of support from them to remedy it. Next year the graduate quota will go up well above 25 per cent in order to compensate.

Senator MOORE: The data we have in the department's submission, which I was going to question before I heard your statement, says on page 17 that they still have the data from the University of Queensland as 7.5 per cent. The other one that was referred to—you know in the evidence that you have read—was the University of Sydney, with 13 per cent.

Prof. Nicholson : Which department are you talking about? DoHA?

Senator MOORE: This is DoHA's evidence that they have given us in their table marked 'Commencing domestic medical students with a rural background by state/territory, 2010'.

Prof. Nicholson : They must have taken that from the medical training report, because I reported to them 11.something per cent.

Senator MOORE: We will question where this came from, but it is what they have put in their standard.

Prof. Nicholson : The 7.5 per cent—as I said, I have no idea where that came from, and nobody at the University of Queensland does. We reported 11 per cent, because I did not know the number but we now know the number and percentage is 21.5 per cent.

Senator McKENZIE: Have you let the department know that?

Prof. Nicholson : Yes.

Senator McKENZIE: And when did you let the department know that?

Prof. Nicholson : A couple of weeks ago.

Senator MOORE: This would have been before that.

Prof. Nicholson : Yes—I just do not understand the 7.5.

Senator MOORE: Professor, we have got 21.5 in 2011. This particular expectation that 25 per cent would be students from rural backgrounds—when did that come in?

Prof. Nicholson : The last reporting round—I think it was the 2010 entry.

Senator MOORE: So it is only that recent, so there is no history.

Prof. Nicholson : University of Queensland was achieving 25 per cent or more until 2009 when it started to dip but that data I have collected retrospectively. It was not apparent at the time.

Senator MOORE: You would have seen this model. They all seem to be up high, and the ones we would expect to be high are Newcastle and James Cook with a special focus. The Western Australians do not do magically either, but I am pleased that that particular thing has been put to bed. I will be asking the department about that as well because, when people make statements impugning the program and the fact that larger organisations like UQ are not fulfilling their responsibilities, it is a fairly serious thing to have on the public record.

Prof. Nicholson : Apart from the rural clinical schools, in those years I have mentioned, the University of Queensland has put 250 doctors into rural practice and that is only in a relatively limited period. Many of the doctors that have been there historically and who are preceptors for our students are University of Queensland. I think it is a bit unfair for a university, particularly one that does not have a medical school, to say we are not doing the job.

Senator MOORE: Does not have a medical school yet. The other point is all about the importance and the competitive nature of doing medicine. This inquiry has been looking at much more than medicine; we are looking at the health workforce. The kind of stuff that you are telling us about the University of Queensland for their medical school—and I know you do not do nursing but you do do the various therapies. For many years you were the only university in Queensland that did the range of medically focused therapies. Do you know whether within that wider health area within the university they are looking at the same kind of focus on rural health—in occupational therapy, physiotherapy, dentistry and those other things that UQ in this medical scheme? Do they have a rural focus as well?

Prof. Nicholson : I cannot answer that question. I suspect strongly that they do but that is a faculty of health sciences question.

Senator MOORE: You operate separately; you don't share knowledge or experience?

Prof. Nicholson : I share less because I am based in Toowoomba and my interaction is—

Senator MOORE: That is a very fortunate place to be based, because that is my home town, Professor.

Prof. Nicholson : I live on the top of Mount Lofty, and so I am in the clouds most of the time.

Senator MOORE: Is that a university location?

Prof. Nicholson : No, that is where I live.

Senator MOORE: You work out of the general.

Prof. Nicholson : Next door to the base hospital University of Queensland have a teaching and learning centre.

Senator MOORE: It is very large and it always has been because of the nature of the cross-references. I have only got one more question, apart from stating the obvious predilection for Toowoomba. You said earlier about the fact that people would go into a generalist process rather than a specialist process when they are working in regional hospitals. If you are going to a regional hospital such as Toowoomba or Rockhampton, because of the large number of specialists that work in those areas, do people who are doing a specialty in orthopaedics or emergency medicine go to the regional areas to do that or is it always focused in Brisbane?

Prof. Nicholson : No, we do the whole lot. The entire clinical program, which is years 3 and 4, is done in the Rural Clinical School—and, to my mind, actually done better. Our marks are as good or better in all subjects, but I think they get a broader and more practical experience. The patient-student ratios are much higher. The teacher ratios are higher. There are many advantages. There is certainly no trouble getting access to patients.

Senator MOORE: Which is what students want to do: they want to be with patients.

Prof. Nicholson : Yes.

Senator MOORE: Lovely.

Prof. Nicholson : Hands-on stuff.

Senator MOORE: Thanks very much.

Senator McKENZIE: Given that there will be quite a significant jump in students from a rural background, I am just wondering how you are planning to make that happen. You have the aspirational quota that will be changing.

Prof. Nicholson : It is actually mandated now.

Senator McKENZIE: So what sort of strategy is there? How are you going to make that happen?

Prof. Nicholson : We will do what we have been doing in the graduate program for some time: we have a quota.

Senator McKENZIE: Yes, I know you have the—

Prof. Nicholson : A subquota.

Senator McKENZIE: Right. So how do you think that will be reflected in the selection process? Will there be different entry requirements?

Prof. Nicholson : Yes, most likely. Basically we have two streams. All the students fill out a stat dec where they declare whether they are rural or not. By the way, I think one of the reasons that our reported percentage may have been lower was that the students who are GPA 7 do not bother to do the stat dec because they do not need to to get in.

Senator MOORE: Do they just get straight in?

Prof. Nicholson : Yes. That is what I am saying: we need robust data across the board for all students. We will know whether any student has a rural background—yes or no—and then—

Senator McKENZIE: Yes, but you have a quota to increase it. I am just wondering how you see that that will make an impact on the selection process.

Senator MOORE: Discriminating against kids who live up in Brisbane.

Senator McKENZIE: Yes—or will the level at which they can get in be lower? How is this going to play out in actual fact in your undergraduate program?

Prof. Nicholson : If the student has a rural background, they will not be competing with students with a metropolitan background; they will be competing with students from a rural background. So 25 per cent of our intake of 320—

Senator MOORE: Will be quarantined.

Prof. Nicholson : will be from a rural background—end of story.

Senator McKENZIE: Okay. I would love to know your opinion of the ATAR. What is the Queensland word for your entrance score at the end of your higher school certificate.

Senator MOORE: How do you get your 7?

Prof. Nicholson : OP.

Senator MOORE: OP—that is right.

Senator McKENZIE: Okay. What is your opinion of that as a measure or indicator of being a good doctor?

Prof. Nicholson : I do not think anybody really knows.

Senator McKENZIE: Here we are happy if they are from rural. Obviously it will be a different level of score for those 25 per cent, but we are confident they will be good practitioners.

Prof. Nicholson : My personal opinion is that one does not have to have an OP 1 to be a good doctor, by any means.

Senator McKENZIE: I wanted your personal opinion.

Prof. Nicholson : The University of Queensland is the No. 2 or No. 3 research university in a very competitive space, and it likes to recruit the next Nobel prizewinner. I do not think the medical school particularly needs to do that, and this will be a compromise.

Senator MOORE: Professor, do you think we are advantaged in Queensland—I am sorry to jump in—because we have such a decentralised state? When we say that someone has a rural background, and our definition of 'rural' is anything that is outside—

Prof. Nicholson : Advantaged in Queensland?

Senator MOORE: We are advantaged because we have more students who are coming through. If you were in Perth and you had similar thing—

Senator McKENZIE: It is a decentralised population.

Senator MOORE: We have a decentralised population, so that I believe we would have more students who would be able to identify that they have five years in a regional area in their schooling in the past number of years than Western Australia, just because of the percentage of the population.

Prof. Nicholson : I think Western Australia and maybe South Australia are extremes, but the whole of Tasmania is rural. JCU, and obviously Newcastle and the regional schools, have an advantage. Queensland is probably in the middle of that. I do not think advantage to the university is the point; we need to recruit rural students—

Senator MOORE: It is an advantage to service delivery.

Prof. Nicholson : who are capable of doing the medical course and being good doctors. That is an advantage for the system.

Senator McKENZIE: One of the influencing factors was the length of practicum conducted in a rural area. I am wondering whether we measure whether or not that has been a positive experience for students. Senator Moore asked some questions around accommodation options et cetera. It is all well and good to go out to a rural area, but do we ascertain whether or not the students have had positive experiences there?

Prof. Nicholson : Yes, we do a lot of that, and we have been doing that for a long time. I was trying to make the point that that does not really matter—what matters is the outcome. I think the fact that most of our fourth year graduates—most of whom do two years in a rural hospital—choose to stay on at a regional hospital proves that they like it. We do survey them about their aspirations and desires, but I do not think that is as important as the actual outcome.

Senator McKENZIE: In terms of the specialists that are not in the rural medical school—the postgraduates training to be specialists but not in rural practice—what are the expectations within the profession that part of their work will include working in a hospital outside of Brisbane, for instance, as part of their public service, if you like?

Prof. Nicholson : Sorry; you've lost me.

Senator McKENZIE: I am based in regional Victoria, and whenever we need a specialist in X we will have a visiting specialist at our local hospital with a small surgery there et cetera. I am just wondering if it is an expectation within the profession that after graduation, when you are out in the field, even if your main practice is in Melbourne, you will also do some work outside of Melbourne.

Prof. Nicholson : In the Rural Clinical School—

Senator McKENZIE: No, your graduates.

Prof. Nicholson : In a lot of areas the workforce does come from a metropolitan area and there are FIFO doctors and locums that provide this service. Our aim is to get our graduates into rural practice. We have talked quite a lot about rural generalism and general practice but it is just as important that we produce rural and regional specialists. That is why we need the opportunities to train them in regional hospitals.

I was previously with the University of Melbourne. Twenty-odd years ago I moved to Geelong and became the first endocrinologist—a hormone and diabetes specialist—outside of metropolitan Melbourne in the entire state of Victoria. We essentially did home-grown training. We gave up recruiting people from Melbourne because they just went back there, and recruited people from elsewhere or trained our own junior doctors to become specialists. When I left, most of them were trained there. So we were building the regional workforce endocrinology, which is an important area because diabetes is growing exponentially. I think that that is the sort of model that we need in Queensland.

Senator McKENZIE: You mentioned the waiting lists for specialists in response to Senator Moore. How can we address those waiting lists? Is it a lack of financial resources for universities?

Prof. Nicholson : No. Unfortunately—and use that word advisedly—postgraduate training is not done by the universities; it is done by the colleges and they basically rely on the state teaching hospitals. There need to be positions in the hospitals that are fully funded for training. Going back to my experience in Geelong, there was no position. I established the position where essentially the senior doctors paid the salary of the registrar in order to get somebody through, you needed to use innovative schemes. It was not considered reasonable or proper to train somebody in a regional hospital. I am sure that you will find that the vast majority of training positions in all states, including Queensland, are situated in metropolitan teaching hospitals.

Senator McKENZIE: Do you think some of the cultural issue you are talking about—the status, if you like, of being trained in a regional hospital—is being addressed by the industrial changes made in the Queensland space?

Prof. Nicholson : No, I do not think it is industrial at all. It is complicated. One of the factors is that students are afraid to get out of the system. If someone is trying to get into, say, the Royal Brisbane, they get known by all the right people and they are seen around and then they are accepted in the training program. It is hard for outsiders to get in. One of the drivers is that some students want to work rurally but want to train in surgery, so they hang about metropolitan teaching hospitals. Then they get married, get a mortgage and that is the end of it.

Senator MOORE: In your rural planning, is there any work done on palliative care?

Prof. Nicholson : We have a course—a rotation in palliative care. That is about all I can say. That is not done by the Rural Clinical School.

Senator MOORE: So that is part of the standard UQ curriculum?

Prof. Nicholson : Yes. It is an elective, actually.

Senator MOORE: That is what I thought as well—I thought it was an elective; that it was not core business but some students choose to do it.

Prof. Nicholson : Yes. We do have other electives where people can do that if they are interested.

CHAIR: Thank you very much. We very much appreciate it. I do not think we gave you any questions on notice. Sometimes we give homework—questions on notice—but we did not give you any. Thank you very much.

Prof. Nicholson : That would not have made it easier.

Senator McKENZIE: I have a question on notice about sharing data. Obviously all the Sandstone medical schools are having the same issues. Are you collaboratively looking at sharing the data at a more global level to address the problem of rural and regional students' access to Sandstone medical schools?

Prof. Nicholson : We have a club called FRAME, with all the rural clinical schools. That is a very close club. We meet regularly and everybody is on the same side. They are all rural.

Senator McKENZIE: That is good.

Prof. Nicholson : Even different universities.

CHAIR: What does FRAME stand for?

Prof. Nicholson : It is the Federation of Rural Australian Medical Educators.

CHAIR: Thank you very much.

Proceedings suspended from 15:19 to 15:37