Primary Care Specialty Choice Research Articles

The Relationship Between Medical School Clerkships and Primary Care Specialty Choice: A Narrative Review

There is a persistent shortage of primary care physicians in the United States. Medical schools can help meet societal primary care health needs by graduating more students who select family medicine and other primary care careers. The objective of this narrative review was to evaluate the relationship between clerkships and primary care specialty choice. We conducted a systematic literature search and narrative review of research articles examining the association between clerkships and primary care specialty choice. We evaluated the quality of included articles using a validated scale, assessed for methodology and outcomes, and synthesized using a narrative approach. We identified 59 articles meeting our research criteria. A required primary care clerkship in the core clerkship year was associated with increased primary care specialty choice. This finding was strongest for family medicine clerkships and family medicine specialty choice. Clerkships that were longer, were of higher quality, exposed students to a wider scope of primary care practice, and occurred within an institutional climate supportive of primary care were also correlated with more students choosing a primary care specialty. While student self-reported interest in primary care often increased following a primary care clerkship, this interest was not always sustained or consistently associated with a primary care residency match or primary care career. Required family medicine and primary care clerkships were correlated with primary care specialty choice. More high-quality research is needed to better understand how to maximize the impact of clerkships on primary care specialty choice.

Impact of Curricula and Electives on Primary Care Specialty Choice: A Narrative Synthesis.

Educational components and electives that may influence medical student choice of primary care careers have been studied individually, but not reviewed or synthesized. Examining educational components and electives in a comprehensive manner may inform evidence-based approaches to raise the number of primary care physicians in the United States and help optimize use of finite resources. We sought to determine evidence-based educational components and electives associated with increased medical student choice of primary care careers. We searched PubMed, Scopus, and CINAHL for undergraduate medical education articles in English describing an educational component or elective and outcome relevant to primary care specialty choice. We assessed titles, then abstracts, and finally full texts for inclusion in a narrative synthesis. The searches returned 11,211 articles and we found 42 that met the inclusion criteria. The most described components were outpatient clinical rotations, preclinical courses, and preceptorships. The most common electives were international health, summer preceptorships, and rural medicine. While most articles described curricula that appeared to have a positive correlation with primary care specialty choice, six articles found limited benefit. In sum, results were mixed. The current literature is limited, and many contemporary electives have not been studied with respect to primary care choice. Increased attention and funding to studying the impact of electives and other educational components on primary care specialty choice is warranted.

Influences of Medical School Admissions Practices on Primary Care Career Choice.

Medical schools should understand how to matriculate students who are more likely to enter primary care specialties and put admissions processes into place that achieve this result. However, there are no existing reviews that have systematically evaluated medical school admission practices and primary care specialty choice. We conducted a narrative synthesis utilizing a systematic literature search to evaluate the effectiveness of medical school admission strategies designed to increase the percentage of graduates entering primary care specialties. We included 34 articles in the narrative review. Multiple prematriculation programs that appear to produce students with a high likelihood of entering primary care have been described in the literature. However, all of these studies are from single institutions, were observational, and limited by selection bias. Applicants who self-identify an interest in primary care, grew up with a rural background, and are older at matriculation are more likely to enter primary care, with stated interest in primary care being most predictive. Gender and race have been associated with primary care specialty choice in some studies, but not all. Insufficient literature on admissions policies and procedures exists to draw conclusions about best practices. Medical schools that want to increase the percentage of graduates entering primary care should consider developing a prematriculation program that attracts and prepares motivated and talented students with primary care interest. Admissions committees should understand which demographic criteria are associated with increased likelihood of entering primary care. The most important identifiable trait is an applicant's stated interest in primary care.

Medical School Characteristics, Policies, and Practices That Support Primary Care Specialty Choice: A Scoping Review of 5 Decades of Research.

The United States, like many other nations, faces a chronic shortage of primary care physicians. The purpose of this scoping review was to synthesize literature describing evidence-based institutional practices and interventions that support medical students' choices of primary care specialties, published in the United States, Canada, Australia, and New Zealand. We surveyed peer-reviewed, published research. An experienced medical librarian conducted searches of multiple databases. Articles were selected for inclusion based on explicit criteria. We charted articles by topic, methodology, year of publication, journal, country of origin, and presence or absence of funding. We then scored included articles for quality. Finally, we defined and described six common stages of development of institutional interventions. We reviewed 8,083 articles and identified 199 articles meeting inclusion criteria and 41 related articles. As a group, studies were of low quality, but improved over time. Most were quantitative studies conducted in the United States. Many studies utilized one of four common methodologic approaches: retrospective surveys, studies of programs or curricula, large-scale multi-institution comparisons, and single-institution exemplars. Most studies developed groundwork or examined effectiveness or impact, with few studies of planning or piloting. Few studies examined state or regional workforce outcomes. Research examining medical school interventions and institutional practices to support primary care specialty choice would benefit from stronger theoretical grounding, greater investment in planning and piloting, consistent use of language, more qualitative methods, and innovative approaches. Robust funding mechanisms are needed to advance these goals.

How Medical Education Pathways Influence Primary Care Specialty Choice.

Primary care is associated with improved patient health and reductions in health disparities. Consequently, the demand for primary care physicians is increasing. To meet this demand, medical schools have employed strategies to graduate students interested in primary care careers, including medical education pathways-structured, longitudinal experiences that are explicitly separate from the main curricular scope of the undergraduate medical education experience. Our goal was to explore and identify common characteristics of medical education pathways that influence primary care specialty choice. Using research articles identified through a scoping review, we performed a qualitative content analysis of studies that evaluated the impact of medical education pathways on medical students' choices of primary care careers. Sixty-three papers described 43 medical education pathways; most studies used quantitative methods to describe outcomes. Program characteristics mapped onto five levels of an emerging socioecological model: state or national, community, institutional, relational, and individual. Successful medical education pathway programs complement a medical school curriculum that supports a common goal, and demonstrate multiple levels of structural and institutional factors that develop community connectedness, relatedness, and longitudinal community engagement in students. Further work is needed to better understand how each of these levels influence career choice and to reassess how to measure and report medical education outcomes that will more accurately predict the student choice of primary care careers.

Medical student residency preferences and motivational factors: a longitudinal, single-institution perspective

BackgroundA high proportion of medical school graduates pursue specialties different from those declared at matriculation. While these choices influence the career paths, satisfaction, and potential regret students will experience, they also impact the supply and demand ratio of the shorthanded physician workforce across many specialties. In this study, we investigate how the choice of medical specialty and the factors motivating those choices change between the beginning and end of medical school training.MethodsA questionnaire was administered annually from 2017 to 2020 to a cohort of medical students at the University of Connecticut to determine longitudinal preferences regarding residency choice, motivational factors influencing residency choice, future career path, and demographic information.ResultsThe questionnaire respondent totals were as follows: n = 76 (Year 1), n = 54 (Year 2), n = 31 (Year 3), and n = 65 (Year 4). Amongst newly matriculated students, 25.0% were interested in primary care, which increased ~ 1.4-fold to 35.4% in the final year of medical school. In contrast, 38.2% of matriculated students expressed interest in surgical specialties, which decreased ~ 2.5-fold to 15.4% in the final year. Specialty choices in the final year that exhibited the largest absolute change from matriculation were orthopedic surgery (− 9.9%), family medicine (+ 8.1%), radiology (+ 7.9%), general surgery (− 7.2%), and anesthesiology (+ 6.2%). Newly matriculated students interested in primary care demonstrated no differences in their ranking of motivational factors compared to students interested in surgery, but many of these factors significantly deviated between the two career paths in the final year. Specifically, students interested in surgical specialties were more motivated by the rewards of salary and prestige compared to primary care students, who more highly ranked match confidence and family/location factors.ConclusionsWe identified how residency choices change from the beginning to the end of medical school, how certain motivational factors change with time, how these results diverge between primary care and surgery specialty choice, and propose a new theory based on risk-reward balance regarding residency choice. Our study promotes awareness of student preferences and may help guide school curricula in developing more student-tailored training approaches. This could foster positive long-term changes regarding career satisfaction and the physician workforce.

Medical School Outcomes, Primary Care Specialty Choice, and Practice in Medically Underserved Areas by Physician Alumni of MEDPREP, a Postbaccalaureate Premedical Program for Underrepresented and Disadvantaged Students

ABSTRACTProblem: Minorities continue to be underrepresented as physicians in medicine, and the United States currently has a number of medically underserved communities. MEDPREP, a postbaccalaureate medical school preparatory program for socioeconomically disadvantaged or underrepresented in medicine students, has a stated mission to increase the numbers of physicians from minority or disadvantaged backgrounds and physicians working with underserved populations. This study aims to determine how MEDPREP enhances U.S. physician diversity and practice within underserved communities. Intervention: MEDPREP recruits disadvantaged and underrepresented in medicine students to complete a 2-year academic enhancement program that includes science coursework, standardized test preparation, study/time management training, and emphasis on professional development. Five hundred twenty-five disadvantaged or underrepresented students over 15 years completed MEDPREP and were tracked through entry into medical practice. Context: MEDPREP accepts up to 36 students per year, with two thirds coming from the Midwest region and another 20% from nearby states in the South. Students complete science, test preparation, academic enhancement, and professionalism coursework taught predominantly by MEDPREP faculty on the Southern Illinois University Carbondale campus. Students apply broadly to medical schools in the region and nation but are also offered direct entry into our School of Medicine upon meeting articulation program requirements. Outcome: Seventy-nine percent of students completing MEDPREP became practicing physicians. Fifty-eight percent attended public medical schools, and 62% attended medical schools in the Midwest. Fifty-three percent of program alumni chose primary care specialties compared to 34% of U.S. physicians, and MEDPREP alumni were 2.7 times more likely to work in medically underserved areas than physicians nationally. Lessons Learned: MEDPREP increases the number of disadvantaged and underrepresented students entering and graduating from medical school, choosing primary care specialties, and working in medically underserved areas. MEDPREP may therefore serve as a model for increasing physician diversity and addressing the needs of medically underserved communities.

Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career: A Systematic Review.

Increasing the attractiveness of primary care careers is a key step in addressing the growing shortage of primary care physicians. The purpose of this review was to (1) identify interventions aimed at increasing the proportion of undergraduate medical students choosing a primary care specialty, (2) describe the characteristics of these interventions, (3) assess the quality of the studies, and (4) compare the findings to those of a previous literature review within a global context. We searched MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, The Cochrane Library, and Dissertations & Theses A&I for articles published between 1993 and February 20, 2015. We included quantitative and qualitative studies reporting on primary care specialty choice outcomes of interventions in the undergraduate medical curriculum, without geographic restrictions. Data extracted included study characteristics, intervention details, and relevant outcomes. Studies were assessed for quality and strength of findings using a five-point scale. The review included 72 articles reporting on 66 different interventions. Longitudinal programs were the only intervention consistently associated with an increased proportion of students choosing primary care. Successful interventions were characterized by diverse teaching formats, student selection, and good-quality teaching. Study quality had not improved since recommendations were published in 1995. Many studies used cross-sectional designs and non-validated surveys, did not include control groups, and were not based on a theory or conceptual framework. Our review supports the value of longitudinal, multifaceted, primary care programs to increase the proportion of students choosing primary care specialties. Isolated modules or clerkships did not appear to be effective. Our results are in line with the conclusions from previous reviews and add an international perspective, but the evidence is limited by the overall low methodological quality of the included studies. Future research should use more rigorous evaluation methods and include long-term outcomes.

Promoting Sustainable Community Service in the 4th Year of Medical School: A Longitudinal Service-Learning Elective

Background: To address the country's most pressing healthcare needs, medical students must choose careers in primary care and commit to working with underserved populations. Involvement in student service organizations has been shown to strengthen leadership, empathy, and commitment to underserved health and may lead students to pursue careers in primary care. Description: In 2010, the University of Chicago Pritzker School of Medicine developed a novel 1-year longitudinal service-learning elective called SERVE (Service, Education, Reflection, Volunteerism Elective). Students earned elective credit for completing three course requirements: 10 service sessions, monthly reflections, and a service-learning project. Evaluation: One third of the class enrolled in the course (33/99), 25 students completed the course, and 20 completed the final evaluation. Both quantitative and qualitative analyses of the final evaluations demonstrated high satisfaction with the course, and appreciation of the opportunity to volunteer, teach, and develop service projects. SERVE students reported a strong commitment to continuing community service after graduation, with 100% planning to continue volunteering and 70% strongly agreeing with the statement that they would practice in an underserved community in the future. This commitment was higher than that expressed by the graduating class of 2012 (34%) and higher compared to a national average (30.9%). Conclusions: SERVE is a unique 1-year course that reengages 4th-year medical students in service to their communities in a structured educational environment. SERVE students report that the course has increased their involvement in the community, supported their growth into a teaching role, and enhanced continuity within student-run free clinics. Future directions include assessing the impact of SERVE students on the experience of preclinical medical students in student-run free clinics; community response to SERVE projects; and the impact of SERVE on volunteerism, primary care specialty choice, and future practice in underserved communities for class participants during their medical careers.

Academic Achievement and Primary Care Specialty Selection of Volunteers at a Student-Run Free Clinic

Background: Previous studies have reached conflicting conclusions about the associations between service and academic achievement and service and primary care specialty choice. Purposes: This study examines the associations between service at a student-run clinic and academic achievement and primary care specialty choice. Methods: Retrospective review of medical student service and statistical analysis of grade point average (GPA), Step 1 and Step 2 Clinical Knowledge (CK) scores, and specialty choice were conducted, as approved by our Institutional Review Board. Results: Volunteers, compared to nonvolunteers, had higher GPA (3.59 ± 0.33 vs. 3.40 ± 0.39, p < .001), Step 1 (229 ± 19 vs. 220 ± 21, p < .001), and Step 2 CK (240 ± 18 vs. 230 ± 21, p < .001) scores, but did not pursue primary care specialties at a significantly higher percentage (52% vs. 51%, χ2 = .051, p = .82). Conclusions: Further exploration of the associations between service and academic achievement and primary care specialty choice is warranted.

Videotaped Patient Stories: Impact on Medical Students' Attitudes Regarding Healthcare for the Uninsured and Underinsured

The attitudes of medical students toward the current United States healthcare system are not well described in the literature. A graded survey was developed to assess awareness and motivation toward the care of the uninsured and underinsured as well as the impact of a video intervention on these attitudes. The survey, which showed good internal consistency (Cronbach’s alpha = 0.85), was administered before and after viewing a collection of videotaped patient stories. Although a spectrum of beliefs emerged from the analysis of survey responses, some common attitudes were identified. Eighty-five percent of respondents either agreed or strongly agreed that medical care should be provided to everyone, regardless of their ability to pay. In addition, 66% indicated they would be willing to forgo a portion of their income to provide care to those who do not have access to healthcare services. These values were strongly correlated with increasing respondent age and primary care specialty choice (p<0.01). The video intervention did not heavily influence student responses, perhaps due to a ceiling effect created by the large number of students who were already sympathetic toward the underserved. Overall, this data reflects that United States medical students recognize a need to provide care to the underserved and are willing to make personal sacrifices to meet that need.

Policy implications of a financial incentive programme to retain a physician workforce in underserved Japanese rural areas

Existing evidence supports the effectiveness of a financial incentive policy for medical students and early-career physicians in return for obligatory rural service. But whether the experience of contractual rural service affects the physician's choice of practice location after the service is completed remains unknown. This study analysed the practice location of Jichi Medical University (JMU) graduates. JMU is a Japanese medical education programme with a contract system under which all graduates have an obligation to serve in underserved areas for about six years in exchange for a 6-year undergraduate tuition waiver. 484 JMU graduates who were under rural service in 2000 and had completed the service by 2006 were included in the study. The rurality of the communities was determined by population density quintiles. The proportion of those practicing in the communities with the highest rurality quintile in 2000 (30.8%) decreased dramatically (8.7%) in 2006, but the geographic distribution of the participants after contract was still biased toward rural areas compared with the distribution pattern of all Japanese physicians. The flow of participants from rural to urban communities was largely unidirectional. In 2006, 452 (93.4%) practiced in places with the same or lower rurality than in 2000, while only 32 (6.6%) practiced in places with higher rurality as compared to the placements of 2000. Multivariate analysis showed that service experience in the communities of the first and second highest quintiles of rurality was associated with choosing such places after contract, independent of known predictors of rural practice, such as having a rural background and primary care specialty choice. Although the effect of contractual rural service substantially decreased after finishing the service, the experience of rural service early in the physician's career had a positive impact on the later choice of a rural practice. The results from this study support the use of a policy that attracts early-career physicians to practice in rural areas.

Brazilian medical students’ attitudes towards patient-centered care

Background: The doctor-patient relationship is essencial to medical care (Engel 1980; Balint 1984), however, medical schools focus mainly on biomedical subjects and don’t give the necessary attention to communication skills, humanistic attitudes, and professional values (Haidet et al. 2001, 2002).Methods: Attitudes of medical students towards the doctor-patient relationship have been examined and the Patient-Practitioner Orientation Scale (PPOS) has been used to measure students’ and practitioners’ patient-centered beliefs, first in USA (Haidet et al. 2002), and then in several other countries (Choi & Moon 2005; Tsimtsiou et al. 2005; Shankar et al. 2006).This study aimed to examine the attitudes of Brazilian medical students towards the doctor-patient relationship by using the PPOS.The scale was translated into Portuguese and was administered to approximately 800 students in their first, fifth, seventh, ninth, tenth and twelfth semesters of medical school along with a socio-demographic questionnaire.Results: A total of 738 students (>90%) completed data collection. For the entire cohort, female gender (p < 0.000), later semester in medical school (p < 0.000), primary-care specialty choice (p < 0.02) and lower familial income (p < 0.03) were significantly associated with more patient-centered attitudes. Sharing sub-scores, measuring beliefs about power and information between physician and patient, were significantly more patient-centered for twelfth semester male students than for first semester males (p < 0.000), but not for female students. Caring sub-scores, which measure beliefs about attending to patient's emotions and lifestyle, did not change with the years of school. In general, Caring scores were considerably higher than Sharing scores. Total PPOS scores in Brazil are comparable to those found among medical students in the United States, however they are considerably higher than PPOS total scores in Nepal, Greece, and Korea.Conclusions: Communication skills and patient care needs to be critically examined by Brazilian teachers and students aiming to change attitudes toward the doctor-patient relationship to be more patient-centered attitudes.

Doctor-patient interaction in Finnish primary health care as perceived by first year medical students

BackgroundIn Finland, public health care is the responsibility of primary health care centres, which render a wide range of community level preventive, curative and rehabilitative medical care. Since 1990's, medical studies have involved early familiarization of medical students with general practice from the beginning of the studies, as this pre-clinical familiarisation helps medical students understand patients as human beings, recognise the importance of the doctor-patient relationship and identify practicing general practitioners (GPs) as role models for their professional development. Focused on doctor-patient relationship, we analysed the reports of 2002 first year medical students in the University of Kuopio. The students observed GPs' work during their 2-day visit to primary health care centres.MethodsWe analysed systematically the texts of 127 written reports of 2002, which represents 95.5% of the 133 first year pre-clinical medical students reports. The reports of 2003 (N = 118) and 2004 (N = 130) were used as reference material.ResultsMajority of the students reported GPs as positive role models. Some students reported GPs' poor attitudes, which they, however, regarded as a learning opportunity. Students generally observed a great variety of responsibilities in general practice, and expressed admiration for the skills and abilities required. They appreciated the GPs' interest in patients concerns. GPs' communication styles were found to vary considerably. Students reported some factors disturbing the consultation session, such as the GP staring at the computer screen and other team members entering the room. Working with marginalized groups, the chronically and terminally ill, and dying patients was seen as an area for development in the busy Finnish primary health care centres.ConclusionDuring the analysis, we discovered that medical students' perceptions in this study are in line with the previous findings about the importance of role model (good or bad) in making good doctors. Therefore, medical students' pre-clinical primary health care centre visits may influence their attitudes towards primary health care work and the doctor-patient relationship. We welcome more European studies on the role of early pre-clinical general practice exposure on medical students' primary care specialty choice.

MEDICAL STUDENTS' SPECIALTY CHOICE AND THE NEED FOR PRIMARY CARE: Our Future

Recent changes in the health care environment have directed increasing attention to the recognized oversupply of specialists and relative lack of primary care physicians. Despite this imbalance and the need for more primary care physicians, US medical schools are not producing them in adequate numbers. To effect change in the production of primary care physicians, a comprehensive approach that addresses key factors in medical student specialty choice is needed. This article discusses such factors and how they affect medical students during the course of their training. Issues concerning primary care specialty choice and the physician work force are important to the development of the future US health care system.

The state of the literature on primary care specialty choice

A large body of research on medical students' choice of primary care specialties has been published. However, the literature is difficult to interpret because of multiple biases, design weaknesses, small numbers of subjects, inconsistencies in both dependent and independent variables, and conflicting results. These weaknesses have been noted by authors who have reviewed the work in this area, but the authors have given little direction for ways to improve and build upon the current state of the literature. This paper provides a quantitative description of the content of the specialty choice literature. As part of a larger project that included an exhaustive literature analysis, all research on primary care specialty choice published between 1987 and 1993 was collected and summarized according to study questions, designs, data sources, samples, theory, and outcome variables. Portions of this information were used to rate the quality of each study, yielding a score from zero to 100 that indicated the trustworthiness of the study's conclusions. Overall, the studies examined were found to use predominantly cross-sectional designs and to lack theoretical basis. Special curricular tracks, student personality, and self-reported influences were the most frequently studied determinants of primary care specialty choices. The results confirm previous qualitative descriptions of the state of the literature on specialty choice, and lead to recommendations for approaches to improve the quality of further work in this area. The research agenda that emerged from the larger project is also presented.

Determinants of primary care specialty choice: a non-statistical meta-analysis of the literature.

This paper analyzes and synthesizes the literature on primary care specialty choice from 1987 through 1993. To improve the validity and usefulness of the conclusions drawn from the literature, the authors developed a model of medical student specialty choice to guide the synthesis, and used only high-quality research (a final total of 73 articles). They found that students predominantly enter medical school with a preference for primary care careers, but that this preference diminishes 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; having 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 associations. Two curricular experiences are associated with increases in the numbers of students choosing primary care: required family practice clerkships and longitudinal primary care experiences. Overall, the number of required weeks in family practice shows the strongest association. Students are influenced by the cultures of the institutions in which they train, and an important factor in this influence is the relative representation of academically credible, full-time primary care faculty within each institution's governance and everyday operation. In turn, the institutional culture and faculty composition are largely determined by each school's mission and funding sources--explaining, perhaps, the strong and consistent association frequently found between public schools and a greater output of primary care physicians. Factors that do not influence primary care specialty choice include early exposure to family practice faculty or to family practitioners in their own clinics, having a high family medicine faculty-to-student ratio, and student debt level, unless exceptionally high. Also, students view a lack of understanding of the specialties as a major impediment to their career decisions, and it appears they acquire distorted images of the primary care specialties as they learn within major academic settings. Strikingly few schools produce a majority of primary care graduates who enter family practice, general internal medicine, or general practice residencies or who actually practice as generalists. Even specially designed tracks seldom produce more than 60% primary care graduates. Twelve recommendations for strategies to increase the proportion of primary care physicians are provided.

A systematic approach to conducting a non-statistical meta-analysis of research literature

Literature analyses and syntheses are becoming increasingly important as a means of periodically bringing coherence to a research area, contributing new knowledge revealed by integrating single studies, and quickly informing scientists of the state of the field. As a result, there is a need for approaches that can provide replicable, reliable, and trustworthy results. Over the last decade many researchers have begun using the statistical meta-analysis approach to integrate studies. However, the single studies conducted in many areas are not of the type amenable to statistical meta-analysis but are more appropriate for non-statistical analysis and synthesis. The present paper describes (1) a rigorous approach to conducting a non-statistical meta-analysis of research literature and (2) an example of how this approach was applied to the literature of determinants of primary care specialty choice published between 1987 and 1993. This approach includes model development, literature retrieval, literature coding, rating references for quality, annotating high-quality references, and synthesizing only the subset of the literature found of sufficient quality to be considered. Also, the basic results of each included study are reported in the synthesis so that readers have before them all the "data points" used in the synthesis. Thus, readers can draw their own interpretations without having to re-collect the data, just as they would be able to do in any single study that presents original data as well as conclusions and discussion.

Influence of medical school curriculum on primary care specialty choice

There is a growing consensus that the proportion of primary care physicians in the United States is inadequate to meet health care needs. Many graduating medical students continue to choose to subspecialize. The literature on curriculum and specialty choice is fraught with confounders and a lack of randomized trials, and recommendations for strategies to increase the production of generalists have not been based on clear evidence that the interventions will be effective, thus making it difficult for medical schools to react responsibly to these recommendations. To assist educators and policymakers in their efforts to produce more generalists, the author critically reviewed the literature on curriculum and primary care specialty choice from 1982 through April 1993. A literature search was conducted using the MEDLINE, Educational Resources Information Center, and PsychInfo databases. Of more than 150 studies found in the search, 31 were determined to be relevant and to meet inclusion criteria. The results confirm that the determinants of specialty choice are multifactorial and that there are many weaknesses in the published literature, making interpretation difficult. Important trends did emerge, however, providing direction for intervention and recommendations for further investigation. The evidence suggests that three types of curricular experiences may increase interest in primary care: third-year required family medicine clerkships (especially those that are six, rather than four, weeks long), continuity experiences in primary care settings, and, most promising of all, primary care tracks.