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.