For years, Ed Garner has been the only practicing physician for 11,000 square miles of Van Horn, Texas, where he sees patients day and night at the only hospital in more than 100 miles in either direction, Eli Saslow reports for the Washington Post. 

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A 'medical desert'

Between hospital closings and a lack of medical professionals, 80% of rural America is "medically underserved," according to the federal government. About 20% of the U.S. population lives in rural America, but it is home to fewer than 10% of doctors in the United States, and the proportions are only getting worse, according to Saslow.

On top of that, the rural physician workforce is older than their urban counter parts. Half of rural physicians are over 50 and more than a quarter are over 60, Saslow reports. And over the next decade, the number of rural doctors is projected to fall by 23%.

'Out here, it's just me'

In Texas, the rural areas are particularly underserved, Saslow reports. Of the state's 254 counties, more than half have no general surgeons, 121 counties have no medical specialists, and 35 have no doctors at all. It's not uncommon for counties to have just one doctor, Saslow reports.  

Garner, age 68, is the only working physician for three rural counties in El Paso, Texas, spanning 11,000 square miles.

Garner, who has practiced rural family medicine for over 40 years, took the job as the only doctor in Van Horn about eight years ago for a few reasons, including "better pay, an adventure at the end of his career, and work that felt more essential," Saslow writes.

As the only doctor for thousands of miles, Garner fills a host of roles, including medical director of Culberson County, head physician for an immigration detention center, director of a rural health clinic, chief of staff for Culberson Hospital, and medical director for the hospital's ED. 

At the hospital, his shifts are usually 24 hours long, Saslow writes.

During the day, Garner treats common conditions as a family medicine doctor, Saslow reports.

But at night, Garner's job becomes "unpredictable and ominous," with Garner remaining as most of the staff leaves for the night.

One night, Garner treated a truck driver who collapsed with numbness in his back and legs after arriving in Van Dorn.

"Here I am in the middle of nowhere, and I can't even move," the patient said.

Garner told the patient he would need to see a neurosurgeon or an orthopedic surgeon for next steps.

"All right. Let's do it," the patient said, expecting to see the next doctor.

"I'm sorry, but the best we can do is transport you to El Paso," Garner explained. "You need a specialist, and out here, it's just me."

The second doctor in Van Horn

During the eight years Garner has spent as Van Horn's only doctor, administrators at Culberson Hospital did whatever they could to accommodate him. They increased Garner's pay, hired traveling physicians to take shifts in the ED, hired a team of nurses and physician assistants, and even lobbied the state to loosen restrictions on telemedicine so out-of-state doctors could lend a hand.

But for five of those years, Culberson focused most of its efforts on finding another doctor, Saslow reports. They ultimately found David Cummings, a recent medical school graduate who'd  completed a rural family medicine residency in Nevada.

Cummings was one of fewer than 2% of medical school students that wanted to practice in towns with fewer than 25,000 people. As a result, he was "the focus of a nonstop medical bidding war," between rural counties, Saslow writes.

Van Horn offered Cummings a three-year contract that guaranteed $300,000 for the first year, 50% more than what Cummings would've earned in a larger city. The federal government also will forgive most of Cummings debt for working in a rural, medically underserved area.

But beyond the financial incentives, another reason Cummings signed on with Van Dorn instead of another rural community is that he knew there would be another doctor, Garner, down the hall. He didn't want to begin his career as a county's only doctor—even though Cummings knew that, eventually, he'd be the only doctor in Van Horn.

Before Cummings had the licensing he needed to work on his own, he shadowed Garner during a few overnight shifts. During one round, Cummings asked Garner, "How do you deal with being on your own?"

Garner replied, "Reps, experience. I'm not sure I've gotten totally comfortable with it yet." He added, adding, "[I] mostly try not to think about it. You operate in denial. You treat one patient and move on to the next" (Saslow, Washington Post, 9/28).