DETERMINANTS OF PRIMARY-CARE SPECIALTY CHOICE - A NONSTATISTICAL METAANALYSIS OF THE LITERATURE

This paper analyzes and synthesizes the literature on primary care spe cialty choice from 1987 through 1993. To improve the validity and usef ulness of the conclusions drawn from the literature, the authors devel oped a model of medical student specialty choice to guide the synthesi s, and used only high quality research (a final total of 73 articles). They found that students; predominantly enter medical school with a p reference for primary care careers, but that this preference diminishe s over time (particularly over the clinical clerkship years). Student characteristics associated with primary care career choice are: being female, older, and married; having a broad undergraduate background; h aving non-physician parents; having relatively low income expectations ; being interested in diverse patients and health problems; and having less interest in prestige, high technology, and surgery. Other traits , such as value orientation, personality, or life situation, yet to be reliably measured, may actually be responsible for some of these asso ciations. Two curricular experiences are associated with increases in the numbers of students choosing primary care: required family practic e clerkships and longitudinal primary care experiences. Overall, the n umber of required weeks in family practice shows the strongest associa tion. Students are influenced by the cultures of the institutions in w hich they train, and an important factor in this influence is the rela tive representation of academically credible, full-time primary care f aculty within each institution's governance and everyday operation. In turn, the institutional culture and faculty composition are largely d etermined by each school's mission and funding sources-explaining, per haps, the strong and consistent association frequently found between p ublic schools and a greater output of primary care physicians. Factors that do not influence primary care specialty choice include early exp osure to family practice faculty or to family practitioners in their o wn clinics, having a high family medicine faculty-to-student ratio, an d student debt level, unless exceptionally high. Also, students view a lack of understanding of the specialties as a major impediment to the ir career decisions, and it appears they acquire I distorted images of the primary care specialties as they learn within major academic sett ings. Strikingly few schools produce a majority of primary care gradua tes who enter family practice, general internal medicine, or general p ractice residencies or who actually practice as generalists. Even spec ially designed tracks seldom produce more than 60% primary care gradua tes. Twelve recommendations for strategies to increase the proportion of primary care physicians are provided.