Background: Idealism declines in medical students over the course of training, with some studies identifying the beginning of the decline in year 3 of US curricula. Purposes: This study tested the hypothesis that a decline in medical student idealism is detectable in the first two years of medical school. Methods: We sought to identify differences in survey responses between first-year (MS1) and second-year (MS2) medical students at the beginning (T1) and end (T2) of academic year 2010 on three proxies for idealism, including items asking about: (a) motivations for pursuing a medical career; (b) specialty choice; and (c) attitudes toward primary care. Principle component analysis was used to extract linear composite variables (LCVs) from responses to each group of questions; linear regression was then used to test the effect of on each LCV, controlling for race, ethnicity, rural or urban origins, gender, and marital status. Results: MS2s placed more emphasis on status/income concerns (β=0.153, p<0.001), and much less emphasis on idealism as a motivator (β=−0.081, p=0.054), in pursuing a medical career; more likely to consider lifestyle and family considerations (β=0.098, p=0.023), and less likely to consider idealistic motivations (β=−0.066, p=NS); and were more likely to endorse both negative/antagonistic (β=0.122, p=0.004) and negative/sympathetic (β=0.126, p=0.004) attitudes toward primary care. Conclusions: The results are suggestive that idealism decline begins earlier than noted in other studies, implying a need for curricular interventions in the first two years of medical school.