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Despite decades of research, interventions to increase the rate of medical students choosing primary care specialties have not been widely successful.A systematic literature review incorporating a secondary data analysis. A model was developed by applying decision-making theories to the pertinent literature and incorporating systematic feedback from colleagues and experts.The model illustrates multiple pathways to specialty choice. Students can be characterized as those who maintain a commitment to primary care throughout medical school, those who are never interested in primary care, and those who change preferences. Multiple categories of factors affect these students differently, including demographics, the medical school experience, student interests, perceived specialty characteristics, lifestyle and financial considerations, the health care environment, identity development, and the choice process.This theoretical model is a guide to targeting interventions toward cultivation of more primary care physicians and clarifies areas needing further research.