A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career

There is a lack of theory about what drives choice to be a generalist or specialist doctor, an important issue in many countries for increasing primary/preventative care. We did a realist evaluation to develop a theory to inform what works for whom, when and in what contexts, to yield doctors' choice to be a generalist or specialist. We interviewed 32 Australian doctors (graduates of a large university medical school) who had decided on a generalist (GP/public health) or specialist (all other specialties) career. They reflected on their personal responses to experiences at different times to stimulate their choice. Theory was refined and confirmed by testing it with 17 additional doctors of various specialties/career stages and by referring to wider literature. Our final theory showed the decision involved multi-level contextual factors intersecting with eight triggers to produce either a specialist or generalist choice. Both clinical and place-based exposures, as well as attributes, skills, norms and status of different fields affected choice. This occurred relative to the interests and expectations of different doctors, including their values for professional, socio-economic and lifestyle rewards, often intersecting with issues like gender and life stage. Applying this theory, it is possible to tailor selection and ongoing exposures to yield more generalists.