Taylor Walker is wiping down tables after the lunch rush at the Bunkhouse Bar and Grill in remote Arthur, Nebraska, a tiny dot of a town ringed by cattle ranches.
The 25-year-old has her young son in tow, and she is expecting another baby in August.
"I was just having some terrible pain with this pregnancy and I couldn't get in with my doctor," she says.
Visiting her obstetrician in North Platte is a four-hour, round-trip endeavor that usually means missing a day of work. She arrived to a recent visit only to learn that another doctor was on call and hers wasn't available.
"So then we had to make three trips down there just to get into my regular doctor," Walker says.
This inconvenience is part of life in Arthur County, a 700-square-mile slice of western Nebraska prairie that's home to only 465 people. According to census figures, it's the fifth least-populated county in the nation.
It's always been a chore to get to a doctor out here, and the situation is getting worse by some measures — here, and in many rural places. A new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that one out of every four people living in rural areas said they couldn't get the health care they needed recently. And about a quarter of those said the reason was that their health care location was too far or difficult to get to.
Rural hospitals are in decline. Over 100 have closed since 2010 and hundreds more are vulnerable. As of December 2018, there were more than 7,000 areas in the U.S. with health professional shortages, nearly 60 percent of which were in rural areas.
In Arthur County, it's a common refrain to hear residents talk about riding out illnesses or going without care unless the situation is dire or life-threatening. Folks will also give you an earful about what happens when they do visit a clinic or hospital. Because of high turnover, doctors don't know them or their family histories and every visit is like starting all over again, they say.
"It'd be nice to have some doctors stay and get to know their patients," says Theresa Bowlin, the lone staffer working at the Arthur County courthouse.
Arthur's population has been in a slow decline for decades. No one knows for sure, but it's likely the town hasn't had a full time doctor since the 1930s, though there was a mobile health clinic that used to park on the highway once a week up until the 1990s. But it got too expensive.
Bowlin says it's a perennial challenge to find a doctor who knows the community and understands the cowboy mentality about health care common here.
"The younger doctors coming in, they really don't know how a cowboy can go that long with pain and not come to the doctor until he absolutely has to," she says.
A generational shift
There's a changing of the guard going on in the health care industry, and its effects may be most apparent in rural America. As baby boomer doctors retire, independent family practices are closing, especially in small towns. Only 1% of doctors in their final year of medical school say they want to live in communities under 10,000; only 2% were wanted to live in towns of 25,000 or fewer.
Taking over a small-town practice is too expensive, or in some cases, too time-consuming for younger, millennial physicians. And a lot of the newly minted doctors out of medical training are opting to work at hospitals, rather than opening their own practices.
The nearest hospital to Arthur is 40 miles south in the town of Ogallala. Christopher Wong, 36, is one of just two family practice obstetricians at Ogallala Community Hospital, which serves a vast area of some 15,000 people spread across several counties.
Wong grew up in suburban Denver, about a three-hour drive away, but world's apart from western Nebraska
"Most of the people I take care of out here are ranchers and farmers," Wong says.
Wong first got interested in rural health care during med school, doing volunteer work in rural Louisiana after Hurricane Katrina. Still, working full time in a small town in rural Nebraska has been an adjustment.
One day, he did rounds at the hospital, saw dozens of patients at the clinic and signed a birth certificate for a baby he'd just delivered. He and the mother had to get a little creative, Wong recalled. She had a history of going into labor fast, but lives more than an hour's drive from the hospital. Plus it's calving season on her ranch. And she wasn't sure her husband would be nearby — or available — to drive her to the hospital.
"So we brought her into the hospital when she was 39 weeks so we could induce her," Wong says.
Being a doctor in a small town, you're always on, even when you're not. It's not like you can just clock out and leave work. Wong will bump into a patient at the grocery store who politely asks about this ailment or that problem. Everyone knows him and there's no anonymity. He's also on call every other weekend.
"It's very hard to get away," Wong says. "It's hard to separate it all."
He has a girlfriend in Denver and tries to get down there when he can. But it's a tough sell to convince a partner to move to rural Nebraska where there are few other young professionals or opportunities.
"I think that's why it's also hard to get physicians into rural practice because it's hard to maintain a personal life."
Burnout is high. Wong is approaching three years on the job in Ogallala and has no plans to leave. But it's a constant worry for hospital administrators.
"Work-life balance is a big piece, they want to go home at some time," says Drew Dostal, CEO of Ogallala Community.
Doctors like Wong, who do both family practice and obstetrics are already in high demand. Dostal even offers $100,000 signing bonuses to help ease their debt burden. It may get them out here for a few years, he says, but they're usually lured away by other offers and rarely become fully part of the community.
"Physicians who have to move on to help get their debt paid off ...[that] challenges patients as well," Dostal says. "They want to know [their doctor], they want them to stay forever, but it just isn't a reality in today's health care."
Dostal is currently looking for a third family practice doctor and could probably hire a fourth. Retaining doctors is key to keeping critical access hospitals like this one open. In the NPR poll, close to one out of every ten respondents said their small town hospital had recently closed.
Recruiting and retaining doctors is so pressing that hospital officials even try to become social matchmakers. If a doctor likes sports, for example, administrators may suggest they volunteer as team physician at the high school; or if they are an arts lover, they could volunteer on the planning committee for the local arts festival.
"If we don't do a better job of doing that, there is a risk for rural places to lose their hospital, or lose their providers that are in that hospital," says Dr. Jeffrey Bacon, the chief medical officer for three Banner Health hospitals in northeast Colorado and western Nebraska, including in Ogallala.
Bacon and other hospital officials say a more effective solution than social matchmaking or signing bonuses might be if medical schools did more active recruiting in small towns.
In January, Ogallala Community was thrilled to hire Jessica Leibhart to join Wong as a second family practice OB-GYN. Leibhart, 36, grew up in Imperial, Neb., about fifty miles south of Ogallala.
"I was looking to get back to my roots," Leibhart says. "This was really close and looked like the right fit for us."
Leibhart relocated from the Omaha area and her family already had contacts in Ogallala, so the transition has been smooth. She knows that in a small town it's virtually impossible to escape your job.
"If we're at Walmart or my husband and I will be out for dinner and then pretty soon someone stops by, but that's part of it," Leibhart says. "And that truly is becoming part of the community and part of the family that the small town is."
Finding doctors who want to be part of the small town family, may be one solution to addressing the worsening doctor shortage in rural America, and the growing urban-rural divide.
AUDIE CORNISH, HOST:
There aren't enough doctors. That's true across the country but especially in rural areas. A quarter of people living in rural America say they recently couldn't get the health care they needed. That stat comes from a new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. NPR's Kirk Siegler has more.
KIRK SIEGLER, BYLINE: Taylor Walker is wrapping up the lunch shift at the Bunkhouse Bar and Grill in Arthur, Neb. It's a tiny dot of a town ringed by cattle ranches.
(SOUNDBITE OF DISHES RATTLING)
SIEGLER: She's 25, pregnant, due in August. It's four hours round-trip to see her obstetrician in North Platte.
TAYLOR WALKER: I was just, like, having some terrible pain with this pregnancy. And I couldn't get in with my doctor.
SIEGLER: You miss a day of work and get all the way down there only to find out that your doctor isn't the one who's on call.
WALKER: So then we had to make three trips down there just to get in to my regular doctor.
SIEGLER: This inconvenience is part of life in Arthur County - a 700-square-mile slice of Nebraska prairie that's home to only 465 people. It's always been a chore to get to a doctor out here, but things are getting worse.
WALKER: We rarely ever go to the doctor, unless if we have to, just because everything is so far away and expensive. So...
SIEGLER: Another complaint you hear is that doctors don't stay in rural America anymore. At the old courthouse, Theresa Bowlin says it used to be you'd have one family doctor who knew your family history - delivered all your kids. Today, she says, the new doctors don't know us.
THERESA BOWLIN: For us here, if they understand our lifestyle better - younger doctors coming in, they really don't understand how a cowboy can go that long with pain and not come to the doctor till he absolutely has to.
SIEGLER: Small-town family practices are closing, and the new generation of doctors tends to arrive from cities and work out of hospitals. The closest hospital to Arthur is 40 miles south. Dr. Christopher Wong is one of just two family practice docs at the 18-bed Ogallala Community Hospital.
CHRISTOPHER WONG: Yeah, so right now, we're walking through our clinic here. And...
SIEGLER: Wong is from suburban Denver - three hours away but worlds apart from western Nebraska.
WONG: I mean, I grew up in city life. I mean, most of the people I take care out here are ranchers and farmers.
SIEGLER: It's been an adjustment. Today Dr. Wong is signing a birth certificate after a recent delivery. He and the mom got creative. She tends to go into labor fast, he says. But she lives more than an hour from the hospital, and this is calving season on her ranch.
WONG: There's complications with making sure her husband's there and present, to having someone to bring her to the hospital. So we brought her into the hospital when she was 39 weeks so we could induce her.
SIEGLER: Just another day - and a doctor in a small town is always on even when he's not. Wong runs into a patient at the store who will ask him about this ailment or that. He also takes call every other weekend. He's got a girlfriend in Denver and tries to get down there when he can.
WONG: It's very hard to get away. It's very hard to separate it all. And I think that's why it's also hard to get physicians into rural practice because it's hard to maintain a personal life.
SIEGLER: Burnout is high. The hospital's CEO Drew Dostal understands why.
DREW DOSTAL: Work-life balance is a big piece. They want to go home at some time.
SIEGLER: Each year, American medical schools churn out far fewer doctors like Wong who do family practice and OB than there are open positions. Dostal even offers $100,000 signing bonuses - says it may get them out here for a few years. But they don't tend to become part of the community, and they're usually lured away.
DOSTAL: And I think the challenge of that - physicians who have to move on to help get their debt paid off challenges the patients as well. They want to know them. They want them to stay forever. But it just isn't a reality in today's health care.
SIEGLER: This hospital serves a huge area of about 15,000 people from Ogallala to tiny Arthur. And they need at least one more family practice doc.
(SOUNDBITE OF PHONE RINGING)
SIEGLER: Retaining doctors is inextricably linked to critical-access hospitals like this staying open. In our poll, nearly one of every 10 respondents said their small-town hospital had recently closed. Hospital officials told me a more effective solution than signing bonuses might be if medical schools did more to go out and recruit potential students from rural towns, like Dr. Jessica Leibhart.
JESSICA LEIBHART: I was looking to get back to my roots. And being from Imperial, Neb., about 50 miles away, this was really close and looked like the right fit for us.
SIEGLER: In January, the hospital was thrilled to hire Leibhart, a second family practice OB to join Dr. Wong.
LEIBHART: You know, my husband and I'll be out for dinner. And then pretty soon, someone stops by. But that's part of it. And that truly is becoming part of the community and part of the family that this small town is.
SIEGLER: Doctors who want to be part of the small-town family may be one solution to addressing the worsening doctor shortage in rural America.
Kirk Siegler, NPR News, Ogallala, Neb. Transcript provided by NPR, Copyright NPR.