It’s the High Lonesome for a Reason

The plain gives man new and novel sensations of elation, of vastness, of romance, of awe, and often nauseating loneliness. – Walter Prescott Webb, The Great Plains (1931)

By Leaflet – Own work, CC BY-SA 3.0, Source: Wikimedia Commons 

Yet, America remains attached to the idea of Yeoman farmer and the rural bucolic existence.  It lays deeply burrowed in our collective mythology.  Many people who live in small town America are very proud of this association. Indeed, I have been to some places that seem to live this ideal every day.  They are very rare.

rural america is no spring chicken

Firstly, Rural America is much older than America as a whole (interestingly, the places where this is not true are largely in areas where refugees and immigrants are moving in to work in industrial agriculture – but we won’t touch that lightning rod for now).  Some of this age difference is due to youth moving to cities and larger towns for jobs.

However, I also increasingly hear narratives about people on fixed incomes – the disabled, the elderly, the rare retired military, government, or railroad worker who actually receives a pension moving to the small towns because of affordability.

This is especially noticeable in places not too far from larger towns/cities on the borders of the High Plains.  So, young people are leaving and older people moving in – a demographic double whammy.

what kind of person retires to high plains?

It takes a special kind of soul to thrive on the High Plains.  You have to love the sky and the wind and the sun.  You also have to be pretty self-reliant.  Self-Reliance is the central tenet of High Plains life, help is usually not close and may be unreachable.

Unfortunately, no amount of grit or curmudgeonliness will keep you healthy and independent forever, though it does seem to help.  I have seen dozens of people who retired to a rural area and bought a small acreage in their fifties or early sixties when they were still quite healthy.

This seems to last a good 5-10 years.  Property is a lot of work.  Roads may be plowed by the county after a snowstorm, but your driveway won’t be. A half-mile snowed-in driveway is a glacier to a wheelchair.  Moreover, 48-72 hours may pass before the county gets the road clear.

chronically ill in the middle of nowhere

One of my first patients in my real practice was Kathleen (obviously not her real name), an older woman who was supposedly in for a diabetes check up and establish care.  We sat down to go over her A1C and her medications.  A quick chart review revealed that she was undergoing treatment for Stage III-IV ovarian cancer, at 79.

Ovarian cancer that is this far along is not a curable disease.  It is what the patient will die from (if the treatment doesn’t kill them first).  Kathleen had already gone through surgery, chemotherapy, and radiation.  She was struggling to keep her medicines straight.

Her oncologist had told her this cancer was incurable.  Despite this, she still suffered through treatments thinking that a cure was possible.  We had hours of conversation about goals of care, she still wanted treatment.  It took me a while to understand this, seeing how much she was suffering.

caring for the seriously ill requires community

She lived on 2 acres on a gravel road, miles out of town.  They could be snowed in for days at a time.  She was too weak to cook for herself, she was losing weight.  Then I met her husband, he had significant dementia.

SHE was the caregiver in the relationship.   She felt she couldn’t leave her husband and his dementia made it impossible to reason with him. Children were in other states and not helpful.  Elder protective services were involved – but to no avail.

She was in and out of the hospital and the ED.  When you have no one to give you a ride and you are not doing well, the only option is the ambulance.  An ambulance can only take you to ED.   Discussions about nursing homes, hospice, assisted living went nowhere for over a year.

In the end, she had a chronic pneumothorax with an indwelling chest tube with a valve. She was constantly in pain and short of breath.  Finally, one of my partners transferred her to a hospice house an hour away, almost against her will.  She was simply too weak to fight.

This is an extreme example, but it is easy to imagine a bunch of hardheaded, tough people who are now on oxygen due to smoking, or with arthritis and limited mobility, or early dementia as yet unnoticed (no one has visited grandma in 6 months).

My experience doctoring over the last 2 years around rural America has left me feeling that the social isolation of rural America is literally killing people.

social isolation is a growing epidemic

The New York Times has written 2 articles on it within the last 2 years.  Additionally, an increasing amount of psychological and health publications are delving into the risks of social isolation, and it is more acute in rural areas.  These risks even include increased mortality.  This risk can be up to a 50% increase.

As a traveling doctor, I often feel powerless in the face of these realities.  I see people in the ED who are just destined to float back and forth between the hospital, nursing home, home (see hardheadedness above) and back until death or a permanent stay in the nursing home.  And I often just feel myself helping keep the assembly-line moving, unable to help renew the sinewy bonds of community.

Loneliness, thy other name, thy one true synonym, is prairie. – William A. Quayle, The Prairie and the Sea (1905)

On quiet evenings, when I walk around the edges of the little High Plains hamlets where I work, I stare up at that fantastic sky and think about my own isolation.  Watching the windmills turning wind to electricity on the ridgetops, I find the space to feel my loneliness.

By USFWS Mountain- Uploaded by Magnus Manske, Public Domain,

The loneliest kind of loneliness is the that felt when surrounded by a sea of humanity.  The High Plains welcome those feelings of isolation.  The sky seems to open up and embrace the lonely. Some of my loneliness stems from the grief of losing my daughter, I know.  However, I also feel the professional isolation.

physicians are not immune

As I have said before, there are times where I am the only doctor in an area the size of Rhode Island.  I am almost never physically adjacent to others of my profession.

How does one stay connected to the community of healers without a home base? How do you discuss tough cases when you are the only one in the doctor’s lounge?

Increasingly, researchers are identifying feelings of isolation as playing a role in physician well-being and burnout.  I know that the isolation I felt in my acute grief and how my partners reacted was worse that than anything I feel now.  It is one thing to be lonely by physical distance, another when social and professional exclusion and competition isolate you.

I think that the rise of the physician blogging community is a reaction to these feelings of isolation that we have in our work space.  Physicians are supposed to be social people, to connect with people.  We need our community to thrive.

Self-reliance and rugged individualism appear to be contributing to significant suffering and premature death in rural America.  Am I too at risk?  I don’t know, but I am trying to do something about it, and hopefully it helps.


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