Editor's note: This is one of several stories about what is called a rural Minnesota health care crisis.

Primary-care doctors, long the cornerstone of rural America's medical community, are becoming increasingly hard to lure.

Interviews with health care leaders across Minnesota showed a combination of factors adding up to a medical doctor shortage. The shortage of primary-care physicians is everywhere, but more acute in rural areas. A lack of specialists is especially felt outside the Twin Cities.

"Everybody is looking" for doctors, said Dr. Raymond Christensen, associate director of the rural physician program at the University of Minnesota Medical School, Duluth campus.

CEO Chuck Hofius of Perham Memorial Hospital, a community-owned facility, said that while advanced providers such as nurse practitioners and physician assistants sometimes can be tough to find, "the doctors are the ones that are particularly hard."

For one thing, rural Minnesota communities often find it tough to compete with bigger cities' amenities that range from museums and professional sports to high-class restaurants and jobs for spouses.

"We have all the amenities that you may want ... " Hofius said of the Perham area. "There still are not enough providers that want to work in a rural area."

The Perham clinic operated by Sanford Health has 11 doctors, and a dozen nurse practitioners and physician assistants, Hofius said. About half of the doctors likely will retire in the next few years, he added.

Hofius, who helps Sanford recruit doctors, said three more doctors are needed now and others are needed to replace the ones preparing to retire.

Competing against bigger cities is a given.

"You are on call here more than you are in an urban area," Hofius said.

Many doctors also want to specialize, he said, which often is not possible in rural areas that need more general practitioners.

In Grand Rapids, CEO MIke Youso of Grand Itasca Clinic and Hospital said he has been lucky in recruiting doctors, but it is becoming harder "because there are less and less of them. You have more people retiring." Northern Minnesota communities with forests and lakes surrounding them often have easier times recruiting than those to the south, where farms dominate.

"If we are competing for folks ... it is easy to sell Grand Rapids as a place to live," Youso said. "There are a lot of amenities in this town for a northern Minnesota rural community."

Being a larger rural hospital, along with those in cities such as Fergus Falls and Alexandria, also helps, Youso said. "It is easier to recruit doctors where you have a medical staff of 50-plus. ... We are small, but we are not tiny." Many doctor recruiters have changed tactics.

Kris Olson of Duluth-based Essentia Health-with hospitals and clinics across Wisconsin, Minnesota, North Dakota and Idaho-said Essentia no longer casts a wide net for doctors. Instead, the health care firm just recruits people likely to want to live in the Midwest. "We can't tell you it isn't going to snow," Olson said, acknowledging one of the drawbacks to recruiting from other parts of the country. Olson, who works in Fargo, and other recruiters said they are focusing more on their own employees, either as potential doctors or to bring names of friends and family thinking about being a rural doctor.

She added that she is looking ahead. In late August, she signed a doctor who will not go to work for Essentia until 2020.

Hofius said his Perham facility is doing much the same, even talking to potential doctors before they reach medical school.

In parts of greater Minnesota, the demand for doctors is growing rapidly.

Sanford Medical Center in Bemidji, for instance, plans to add 50 to 60 more health care providers-doctors, physician assistants, advanced practice providers and so on-over the next few years. "You're seeing Bemidji and the greater Bemidji region become more of a destination center," said Bryan Nermoe, executive vice president for Sanford Health of Northern Minnesota.

Carolyn Olson of rural Marshall knows about the doctor shortage all too well. Her husband, Jonathan, is a multiple sclerosis patient who regularly needs to see a neurologist.

While praising the ACMC Health system the family uses, the shortage of neurologists means it takes six months to get an appointment, Olson said. In rural areas overall, she added, "it is more difficult to get timely appointments."

"Health care has given us a lot of gray hair," she said.

Moving to rural

State and federal officials have established several programs to encourage doctors and other medical professionals to set up practice in rural communities.

"That often is the first thing out of their mouths," Chief Medical Officer Ken Flowe of Willmar's Rice Memorial Hospital said about doctor recruits.

The programs forgive student loans to professionals who locate in rural areas for several years. The state program, expanded two years ago, could help 300 with student loans.

The University of Minnesota Medical School, Duluth campus focuses on turning out rural doctors and many doctors in small Minnesota communities come from the school, Christensen said.

UMD medical students are required to be in touch with existing rural medical professionals so they can learn what it is like. Each summer, about 60 medical students from the university's Duluth and Twin Cities campuses spend time in rural areas.

Pharmacy, nursing, therapy and other medical students also are exposed to rural work.

One hindrance to doctors working in rural Minnesota, Christensen said, is that there are few rural residency positions. A residency is near the end of a doctor's training, and if they are located in urban areas-or even in other states-there is a strong chance they will stay there.

"Our docs get scattered," Christensen said.

The 'trailing spouse' issue

It is not just doctors and other health care professionals who hesitate to move to rural areas.

Recruiters frequently talk about the "trailing spouse" problem: A significant other may either want more amenities or finds it impossible to land a professional job in a small town. Kris Olson of Essentia Health said she works to connect the significant other with places he or she could work. "We totally understand." Most doctor recruiters interviewed for this story agreed that they try to help the "trailing spouse" find a job. In some cases, the spouse can telecommute from home, and just occasionally show up at the office in a city miles away. Sometimes the medical community can help locate a local job, but there are times when it is impossible for a significant other to find employment in his or her career field. Chief Medical Officer Ken Flowe of Rice Memorial Hospital said that for doctors a place like Willmar does not seem small because they are involved in the relatively large medical community. For a significant other, however, the 20,000 population city can feel small