How to choose your advanced skills in rural generalism 

Choosing an advanced skill is one of the biggest decisions a Rural Generalist registrar makes. It shapes where you can work, what your week looks like, which services your community can offer, and in some cases whether the local hospital keeps its theatre or birthing suite open. It is also a decision people agonise over more than they need to, partly because it feels permanent and partly because the sheer number of options makes it hard to know where to start. 

Here is a practical guide to working through it. 

What Advanced Specialised Training involves 

Advanced Specialised Training, or AST, is the component of the four-year ACRRM Fellowship where you stop broadening and start going deep. It runs for a minimum of one year and sits alongside three years of Core Generalist Training. Every registrar completes one AST to achieve Fellowship, choosing from twelve disciplines that span both procedural and non-procedural practice. 

A few practicalities are worth knowing before you start weighing up disciplines. Most ASTs run for 12 months full-time, with Surgery the exception at 24 months. You can generally undertake your AST at any time after your first year of training, and registrars who are already at PGY3 or above may even commence training with an AST rather than starting with core training. Posts must be in MM2 to MM7 locations, although a semi-urban post is sometimes approved where that is the only way to get the necessary scope for a particular discipline. 

Navigating the twelve AST options 

The full list of AST disciplines is broader than most people expect, and it is worth reading past the obvious procedural choices: 

•  Aboriginal and Torres Strait Islander Health: addresses the intertwined health disparities and ensures they have access to culturally safe and responsive healthcare •  Academic Practice: teaching, medical education, and research skills 

•  Adult Internal Medicine: diagnose and manage an extended range of adult internal medical conditions•  Anaesthesia: the skill that keeps an operating theatre and a maternity service viable 

•  Emergency Medicine: resuscitation, trauma, and retrieval decision-making 

•  Mental Health: acute and chronic mental health care where services are thin 

•  Obstetrics and Gynaecology: keeping birthing services in the community 

•  Paediatrics: sick children, developmental care, and paediatric emergencies 

•  Palliative Care: provide compassionate end-of-life care and make a meaningful impact 

•  Population Health: prevention, screening, and community-wide health improvement 

•  Remote Medicine: practice at the far end of the resource spectrum 

•  Surgery: the only 24-month AST, covering Rural Generalist surgical scope 

Each discipline has its own page setting out what the training involves, and the Rural Generalist Curriculum and Fellowship Training Handbook detail the specific training, education, and assessment requirements. If you are seriously considering two or three, reading their curriculum requirements side by side is the fastest way to understand what you would be signing up for. 

The benefits of specialising in rural practice 

An AST is not simply a year of extra study. It changes your scope, how you are recognised and your renumeration.  

ACRRM describes an AST as expanding your professional scope, and that plays out in three ways: it can support clinical privileging in hospitals, it gives access to additional Medicare Benefits Schedule item numbers, and it expands the pool of medical services available in rural and remote communities. That last point is the one that matters most locally. An advanced skill is often the difference between a service existing in town and not existing at all. 

There is targeted financial support attached to procedural skills, too. The Rural Procedural Grants Program lets Rural Generalists practising in surgery, anaesthetics or obstetrics claim up to $20,000 per fiscal year toward maintaining those skills, with up to $6,000 per year for those practising emergency medicine and an additional component for participants registered under the emergency mental health component. The General Practitioner Procedural Training Support Program offers $40,000 to help Fellows gain anaesthetics skills. Browsing the College’s grants and subsidies early is sensible, because eligibility often depends on registering before you undertake an activity. 

Non-procedural disciplines carry their own advantages. ACRRM encourages registrars to work toward a related academic qualification alongside their AST, such as a graduate certificate, graduate diploma or master’s degree, and specifically flags this for Population Health, Remote Medicine, Aboriginal and Torres Strait Islander Health, Academic Practice and Mental Health. Finishing your AST with a postgraduate qualification as well as a Fellowship is a strong position to be in. 

All of this now sits inside a bigger shift. With Rural Generalist Medicine recognised as a field of specialty practice, advanced skills are increasingly the visible marker of what distinguishes Rural Generalist practice from general practice in a rural location. 

How to choose 

Start with what your community needs 

This is the question experienced Rural Generalists tend to put first, and it is the one most likely to make your working life satisfying. A town losing its birthing service needs obstetrics. A community with an ageing population and no local palliative care needs something different again. If you already know roughly where you want to practise, ask what that health service is missing and what it is at risk of losing. Choosing into a genuine gap means your skills get used, valued, and maintained. 

Be honest about what you enjoy and can sustain 

Community need matters, but so does the shape of the life attached to each discipline. Procedural skills can come with rosters, on-call, and a real obligation to keep your numbers and credentialing current. If the thought of being called in at 2am for a caesarean is energising, obstetrics may be perfect. If it is a source of dread, that is useful information, and a non-procedural AST may serve both you and your community far better than a procedural skill you quietly avoid using. 

Use core training as a test drive 

Core Generalist Training already gives you structured exposure to primary, emergency, and secondary care, with specific experience in anaesthetics, paediatrics, and obstetrics. Treat those rotations as data. Notice which works you find yourself volunteering for, which cases you read about afterwards, and which parts of the day you would happily do more of. That pattern is usually more reliable than an abstract ranking of disciplines. 

Talk to people doing the job 

Supervisors, medical educators, and you regional training team have watched many registrars make this decision, and they know which posts are well supported, and which disciplines are in demand in your region. The College’s registrar support team can help with the process, and the Fellowship FAQs answer many of the practical questions that come up first. 

Check the practicalities early 

Availability is a real consideration. AST posts must be accredited by ACRRM for the relevant discipline before you start, and some disciplines can have limited positions in any given region, so it pays to search accredited posts and lodge your preferences. The Australian Government’s Advanced Skills Training Posts program, administered by ACRRM, has funded 15 new AST posts a year across 55 locations, which has widened the options in places that previously had none. If you are an international medical graduate with substantial overseas experience in a discipline, whether that counts toward an AST depends on comparability, recency and accreditation requirements, assessed under the College’s recognition of prior learning policy. 

Remember, it is not a one-way door 

Much of the anxiety around this decision comes from treating it as irreversible. It is not. Fellows can complete an AST outside of training to add a second advanced skill later, which means a registrar choosing emergency medicine now is not permanently closed off from palliative care or anaesthetics in ten years. Careers in Rural Generalism tend to accumulate skills over decades, and the community you serve in your forties may need something quite different from the one you started in. 

Choosing well 

The best AST choice usually sits where three things overlap: what your community needs, what you find genuinely interesting, and what you can sustain for the long haul. Get those three lined up and the year of training stops feeling like a hurdle and starts looking like the point of the whole pathway. 

Explore all twelve options on ACRRM’s Advanced Specialised Training pages, check the requirements in the Fellowship Training Handbook, and browse the College’s courses to start building skills in an area you are curious about. For candid conversations with rural doctors about training and career decisions, the RG Life Hacks podcast is also worth a listen.