What influences career choices among graduates of a primary care training program?

To identify factors that influence primary care residents to become generalists or specialists.

Structured survey and interview.

A large university-based, internal medicine residency program in primary care.

Of 92 residency graduates who completed training between 1979 and 1993, 88 (96%) participated.

Although 82% of the participating graduates reported themselves very committed to primary care at the beginning of residency, only 68% pursued generalist careers. Factors influencing career choice that were more important to generalists than specialists included breadth of knowledge used in primary care practice (p = .04), breadth of clinical problems in practice (p = .001), and opportunity for continuity of care (p = .01). Although salary was rated "not important," 50% of generalists and specialists advocated increased salaries for generalists as a way to increase interest in primary care. Other promoting factors included mentors, increased prestige for generalists, community-based training, lifestyle changes, and decreased paperwork. Seventy-three percent of participants felt it was easier to be a specialist than a generalist.

A substantial minority of primary care residents pursue specialty careers. To produce more generalists, graduates recommend addressing income inequities, providing generalist role models, increasing community-based teaching, and increasing prestige for generalists.