CONTEXT: The delineation between selection of surgery and non-surgery residency programmes could provide a pragmatic view of the influences on medical graduates' careers. This would also help coordinators and educators of residency programmes in surgery to further understand the dynamics of specialty selection. AIMS: To identify the different factors that influence the graduates to select surgical specialties in Pakistan. SETTINGS AND DESIGNS: A cross-sectional survey was conducted in 4 teaching hospitals of Karachi between July 1999 and January 2001. SUBJECTS AND METHODS: A total of 455 residents in 1-5 years of residency programmes were contacted. Three hundred and forty-one residents consented to the interview. Residents who were registered both with the College of Physicians and Surgeons of Pakistan (CPSP) and the Post Graduate Medical Education (PGME) office of the selected hospitals were included in this study. STATISTICAL METHOD USED: Logistic regression analysis. RESULTS: Final multivariate analysis identified 4 factors that remained significantly associated with the selection of surgical specialty: deriving gratification from direct patient care (adjusted odds ratio [aOR] = 5.79; 95% confidence interval [CI]: 1.24, 26.99), procedure-based medical practice (aOR = 2.85; 95% CI: 1.23, 6.61), nature of clinical problems (aOR = 3.39; 95% CI: 1.47, 7.84), and lack of consideration of stress during professional work (aOR = 2.27, 95%CI: 1.25, 4.13). CONCLUSIONS: Direct patient care is perceived to be an integral part of surgery residency and immediate patient outcome is a positive influence in selecting surgical specialty. The inclination towards surgery appeared to be determined by the type of procedures and technical skills involved in its practice. The nature of clinical problems is an important determinant of the choice of specialty. Stress was not perceived to be an important influencing factor for those who decided to select surgical specialties.