PURPOSE: To describe the decision-making processes reported by graduating medical students in choosing primary care (PC) or non-primary-care (NPC) specialties. METHOD: Members of the University of Washington School of Medicine's graduating class of 1995 were invited to participate in focus groups. Six specialty-choice pathways were defined based on a previously administered survey of recalled preferences at matriculation and stated choice at the time of the National Resident Matching Program. Students were assigned to focus groups based on specialty-choice pathway. Transcribed discussions and summaries were thematically coded and analyzed using grounded theory and quantitative comparisons. RESULTS: Of 157 students, 140 (89%) completed the initial survey, and 133 (85%) provided enough information to be classified by pathway. In all, 47 students participated in the focus group discussions. The PC students cited PC orientation, diversity of patients and activities, role models and mentors, interaction with patients, and overall medical school culture as having influenced their choice. The NPC students cited lifestyle, controllable hours, opportunities to do procedures, therapeutic urgency and effect, active tempo, exciting settings, and intellectual challenge. Role models influenced PC career choice much more than NPC career choice, and often served to refute negative stereotypes. The sense of personal fit between themselves and specialties was important to the students in all groups, but differed in emphasis according to career-choice pathways. Those whose preferences did not change experienced a confirmation of pre-existing beliefs, while those who switched specialty areas developed a sense of fit through the inclusion or elimination of different practice aspects. Those who switched specialty areas reported more negative influences and misunderstanding of their initially preferred specialties. CONCLUSION: The process of specialty choice can be described usefully as a socially constructed process of "trying on possible selves" (i.e., projecting oneself into hypothetical career and personal roles). This may explain role models' exceptional influence in disproving negative stereotypes. Medical students' choices can best be facilitated by recognizing their needs to gain knowledge not only about specialty content, but also about practitioners' lives and the students' own present and possible selves.
(C) 1997 Association of American Medical Colleges