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The Lone Hospitalist in the Nuba Mountains of Sudan


 

The lives of academic hospitalists are fraught with pitfalls and perils that can lead the unsuspecting far afield of their original intentions. It was in the murky depths of such professional perplexity that I recently found myself, lying in bed and attempting repose in vain. Thoughts of living a life underpaid, underresourced, and overworked buzzed in my psyche. After some tossing and turning, I slipped out of bed and into my home office and began watching cooking videos, which tend to have a calming effect on me, on The New York Times website.

The title of the first video in the queue, however, caught my eye: “The Worst Atrocity You’ve Never Heard Of,” by Times columnist Nicholas Kristof. To be honest, I try to avoid reading about the multitude of human disasters in Africa—the sheer numbers, size, scope, and hopelessness of human suffering make reading about them an exercise in despair and futility. Yet I clicked the link and began to see and hear about the plight of the people living in the Nuba Mountains of Sudan.

The Nuba Mountains, in the southern region of Sudan, lie north of a new border recently established between Sudan and the new country of South Sudan, for whose independence the Sudan People’s Liberation Army rebels fought in a war that ended in 2005. The rebels, however, continue to fight the Sudanese government in the Nuba Mountain region, with the Sudanese Air Force escalating a bombing campaign against the rebels in 2011. Since 2012, 3,740 bombs have been dropped on civilian targets in the Nuba Mountain region, resulting in countless deaths, shrapnel injuries, and burns.

In the midst of this mayhem, few medical providers have stood their ground. On January 20, a fighter jet dropped a cluster of 13 bombs into a hospital operated by Médecins Sans Frontières (MSF) in the Nuba Mountains village of Frandala—the second time the hospital had been bombed. MSF suspended its operations in Sudan soon thereafter. That left exactly one hospital operating in an area of the Nuba Mountains the size of Switzerland, with a population of 750,000. And, since 2008, there has been only one physician, Tom Catena, MD, at Mother of Mercy Hospital.

From repairing orthopedic injuries, delivering babies, and treating horrific trauma and burns, to handling measles and malaria outbreaks, Dr. Catena ministers to the ill and dying without regard to religion or reimbursement.

Dr. Catena, who received his medical degree from Duke University after being an all-Ivy League nose guard and Rhodes Scholar candidate at Brown, came to Mother of Mercy Hospital after missionary medicine work elsewhere in Africa and Latin America. Since his arrival at the 435-bed hospital, he has been the only physician there other than the occasional visitor. He is on call 24-7 and leaves only rarely. The hospital runs off the electrical grid, has no running water, subsists on scarce medical supplies, and has nary an X-ray machine to aid in diagnosing more trauma in one year than an average ED physician would see in an entire career. Trained in family medicine, he performs more than 1,000 operations yearly on patients suffering from the most egregious trauma and burns imaginable, with only the most basic support staff.

“He is Jesus Christ,” asserted a local Muslim chief in The New York Times video, with any difference in religious background—Dr. Catena is a devout Catholic—fading into irrelevance in the face of such heroic care. From repairing orthopedic injuries, delivering babies, and treating horrific trauma and burns, to handling measles and malaria outbreaks, Dr. Catena ministers to the ill and dying without regard to religion or reimbursement.

And, yet, why? Why would Dr. Catena forgo a comfortable life anywhere in the United States, give up the possibility of practicing in any number of lucrative professional settings (based on the diverse skill set he displays in the video), to earn $350 monthly, with no retirement plan, no disability, and no health insurance? As I watched the video, any concern I had regarding my own future earnings and career evaporated, at least momentarily, in the glow of Dr. Catena’s selfless devotion to his patients. One could understand volunteering in this fashion for a month, maybe a year, but seven years? What could keep him going?

I later referred to an article written by Pat Cawley, MD, and others last year and published in the Journal of Hospital Medicine, outlining the characteristics of an effective hospital medicine group, because, in effect, Dr. Catena is a one-man HMG—a solo practice if you will. It is tempting to ascribe his ability to persevere and even thrive in the most inhospitable work environment possible to religious fervor alone. But although he is clearly a devout Catholic, his laconic, “aw shucks” manner suggests the demeanor of an old-time country doctor more than a zealot. As I reread Dr. Cawley’s article, I found that, not surprisingly, Dr. Catena’s “group” fails on many counts. A small sampling:

  • 1.2: The HMG has an active leadership development plan that is supported with appropriate budget, time, and other resources. Underresourced seems an understatement here.
  • 4.5: The HMG is supported by appropriate practice management information technology, clinical information technology, and data analytics. The last HMG on earth without an EMR?
  • 10.1: Hospitalist compensation is market competitive. And the market is…?

On other characteristics, however, Dr. Catena does surprisingly well:

  • 3.2: All HMG team members (including physicians, nurse practitioners, physician assistants, and ancillary staff) have clearly defined, meaningful roles. Dr. Catena spends extensive time training undereducated but well-meaning local volunteers in providing ancillary services.
  • 5.4: The HMG periodically solicits satisfaction feedback from key stakeholder groups, which is shared with all hospitalists and used to develop and implement improvement plans. The local population is so thankful for his care, they have tried to introduce him to local eligible women in the hope that he will marry and never leave.
  • 9.1: The HMG’s hospitalists provide care that respects and responds to patient and family preferences, needs, and values. Dr. Catena’s humility and respect for the Nubian people and culture is what keeps him at Mother of Mercy, despite 11 bombings, grueling work, and negligible pay.

But the one characteristic missing from Dr. Cawley’s list is likely what keeps Dr. Catena in the Nuba Mountains: He practices at the limit of his skill set on a daily basis and spends the majority of his time in doing what he loves most, patient care (when he is not in his self-dug bomb shelter hole), not being chained behind a computer.

It is the failure of Dr. Catena’s group on one of the last characteristics, however, that likely is its greatest:

  • 10.3: The HMG’s hospitalists are actively engaged in sourcing and recruiting new members. Somehow, I think finding someone to take Dr. Catena’s place will be difficult.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to wwch@ucsd.edu.

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