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In the central Idaho community of Arco, where Lost Rivers Medical Center is located, the elk and bear outnumber the human population of a thousand. The view from the hospital is flat grassland surrounded by mountain ranges that make for formidable driving in wintertime.
"We're actually considered a frontier area, which I didn't even know was a census designation until I moved there," says Brad Huerta, CEO of the hospital. "I didn't think there's anything more rural than rural."
There are no stoplights in the area. Nor is there a Costco, a Starbucks or — more critically — a surgeon. With 63 full-time employees, the hospital is the county's largest employer, serving an area larger than Rhode Island.
Six years ago, the hospital declared bankruptcy and was on the cusp of closing. Like many other rural hospitals, it was beset by challenges, including chronic difficulties recruiting medical staff willing to live and work in remote, sparsely populated communities. A hot job market made that even harder.
But against the odds, Huerta has turned Lost Rivers around. He trimmed budgets, but also invested in new technologies and services. And he focused on recruitment.
He targeted older physicians — semiretired empty nesters willing to work part time. He also lured recruits using the area's best asset: the great outdoors.
"You like mountain climbing, we're gonna go mountain climbing," says Huerta, who also uses his local connections to take recruits and their families on ATV tours or flights on small planes, if they're interested. "The big joke in health care is you don't recruit the person you recruit their spouse."
Huerta's approach has paid off; Lost Rivers is now fully staffed.
Recruitment is a life or death issue, not just for patients in those areas, but for the hospitals themselves, says Alan Morgan, CEO of the National Rural Health Association. Over the last decade, more than 100 rural hospitals have closed, he says, and over the next decade, another 700 more are at risk.
"Keeping access to health care in rural America is simply a challenge no matter how you look at it, but this shortage of rural health care professionals just is an unfortunate driving issue towards more closures," Morgan says.
And that's affecting the health of rural communities. "Most certainly the workforce shortages in rural America are contributing towards the decreased life expectancy that we're seeing in rural America," he says.
For some rural hospitals, that dire need is the basis of their recruiting pitch: Come here. Make a difference.
That is the crux of Benjamin Anderson's approach at Kearny County Hospital in the southwestern Kansas town of Lakin.
With a population of about 2,000, last year The Washington Post ranked Lakin one of the country's most "middle of nowhere" places.
Anderson says he's found success targeting people motivated by mission over money: "A person that is driven toward the relief of human suffering and the pursuit of justice and equity."
It's not that the hospital ignores practical concerns. Hospital staff often house-hunt for recruits, or manage home renovations for incoming workers. Anderson, who isn't a doctor, also personally babysits the children of his staff, because Lakin lacks nanny services.
"I mean as a CEO I do a lot of different things, but that's among the most important, because it communicates we love you," Anderson says. "We're gonna live in a remote area but we're gonna live here and support each other."
But the cornerstone of the hospital's recruitment pitch is 10 weeks of paid sabbatical a year, which allows time for doctors to serve on medical missions overseas.
Anderson says he came to appreciate the draw of that after a mentor told him, "Go with them and see what motivates them; see why they would want to go there." Anderson did. It not only changed his life, he says, "I realized that in rural Kansas we have more in common with rural Zimbabwe than we do with Boston, Mass."
It's a compelling enough draw that every couple of weeks, Anderson gets a call from physicians saying they want to work in Lakin, despite its remoteness.
One of those callers was Dr. Daniel Linville. He'd read about Kearny County Hospital and its sabbaticals in a magazine article during medical school. Last fall, Linville joined the hospital, having done mission work since childhood in Ecuador, Kenya and Belize.
He says he and his physician wife were also drawn to the surprisingly diverse population Kearny County Hospital serves, including immigrants from Somalia, Vietnam, Laos and Guatemala. In that sense, says Linville, every day feels like an international medical mission, requiring everything from delivering babies to treating dementia.
But life in Lakin also been an adjustment.
"Now that we've been out here practicing for a little bit, we realize exactly how rural we are," Linville says. It's not just that same-day shipping takes four days; transferring a patient to the next biggest hospital in Wichita means the ambulance and staff are gone for an 8-hour round-trip ride.
And, in an incredibly tight-knit community where he is a newcomer, he's often reminded that patients see him as another doctor just passing through.
"We're seen a little bit as outsiders," Linville says. "We get asked frequently: 'How long are you here for?'"
"I don't know," he tells them; "But for now, I'm happy."
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