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Fewer medical students are pursuing residency training in primary care disciplines. This report describes the career plans of residents enrolled in internal medicine training programs and their reasons for pursuing either generalist or subspecialist career paths.From 1998 to 2003, questionnaires were administered to residents participating in the Internal Medicine In-Training Examination. Each year, the survey included questions on career choices. In 2002, residents completed a more detailed survey about the specific reasons for their career choices. The authors report their responses.There has been a steady decline in the percentage of internal medicine residents planning to pursue generalist careers. In 1998, 54% of PGY3s planned to practice general internal medicine compared with 27% in 2003. Strikingly, in 2003, only 19% of PGY1s planned to pursue careers in general medicine.Residents choosing careers as generalists were influenced by opportunities for long-term relationships with patients, a broad content area of practice, caring for ambulatory patients, and time with family. The specific reasons for choosing one subspecialty over another varied greatly among the subspecialty disciplines. Women residents preferred disciplines that allowed more time for family. Both genders were attracted to a particular subspecialty for similar reasons.There has been a dramatic decrease in the number of internal medicine residents planning to pursue careers in general medicine. This trend will likely continue for the next few years, at least, and may have an impact on the manner in which the health needs of patients are met in the future.