In the late 1950s and 1960s, further subspecialization of internal medicine changed some areas from predominantly "thinking" to "doing" fields. The gastroenterologist learned to pass scopes through the mouth and the rectum, and the pulmonologist started to use the bronchoscope. The cardiologist began implanting cardiac pacemakers and passing catheters. The increased compensation for these procedures helped to lure young physicians into the subspecialties, and the general internist became an endangered species.

Fortunately, the Department of Family and Preventive Medicine at the University of Utah, formed in 1970 by Dr. C. Hilmon Castle, created a three-year residency in Family Practice leading to medical board certification. This program stresses the areas of medicine and pediatrics but also provides some training in obstetrics, surgery, and psychiatry, tailored to some degree to the location of the intended practice. From 1970 to 1992, 262 family practice physicians were graduated, of whom half chose to practice in smaller communities and rural areas to replace the vanishing general practitioner.

Since the 1970s and 1980s, preventive medicine has suffered from the lack of primary-care physicians. Patients without a family doctor and those who have no insurance and can't afford preventive medical care have been flocking to hospital emergency rooms, having neglected early warning signs. There, with no previous acquaintance with the physician and no medical "history," they receive the most expensive and most impersonal form of medical care.

While "hanging out a shingle" was the expected step following medical training in the past, fewer and fewer young physicians now go into solo practice or join another physician. The cost of setting up an office after having incurred considerable debt going to school, as well as the prospect of having to be at the beck and call of patients at all hours and on weekends, directs many young M.D.s to seek employment by hospital emergency rooms, existing clinics, or health maintenance organizations (HMOs).