Sunday, August 21, 2016

Collaborative Care - Are the Challenges the Same Everywhere?

by Lhuri Dwianti Rahmartani and Paul Uhlig

Today’s Tidbit is from a young physician leader from Indonesia.

Lhuri Dwianti Rahmartani and two of her sisters, who are also physicians, attended All Together Better Health VII in Pittsburgh two years ago. At that time, Lhuri was President of IYHPS, Indonesia’s Young Health Professionals’ Society.

Lhuri wrote recently with some questions about collaborative care. She has given permission for me to respond to her questions as a Tidbit:

Dear Paul,

How are you doing? I hope everything is going well for you. I've been a silent reader of the weekly tidbits. Although I sometimes missed an e-mail or two and didn't contribute much to the discussion, it's always a pleasure for me to read it. So thanks a lot for adding me to the list! :) …

I would like to ask a few questions. I am looking for your perspective and suggestion about the role of facilities and culture in establishing collaborative care.

Firstly, I think providing collaborative care would be a lot easier when all the facilities meet the standard. In my opinion, it may be harder for people in poor facilities with limited resources and overload patients to create such ideal social field model. Healthcare providers may have to deal with stress factors that come from overcrowded wards, substandard equipment, low incentives, etc. They might even skip meals and have no time to take care of themselves. In this case, finding a moment to sit together, relax, and discuss about GLITCHs might not be as easy as described. Do you have a recommendation or suggestion for this situation?

Next, considering culture, I think it is important to talk about health literacy. Ideally, patients and families are part of the team. However I find involving patients and families in the care can be difficult when they are not very health-literate. Please correct me if I'm wrong. I guess in the US and other developed countries, cooperating with patients are made more possible since they mostly know what's going on with their body. In developing countries like mine, often you'll meet patients and families who are very clueless about their condition and would solely rely on the doctors' order.

I personally want my patients to understand why and how they are being treated. But explaining the rationale behind treatments may take up more time and sometimes are not very useful. If you ever encounter this kind of situation, I'd be happy to hear your strategies :)

There are several more notes that I'd like to share but I guess that's it for the moment. Please accept my apologies for taking ages to write. I've been meaning to do so but I've been busy focusing myself being a clumsy new mother in the past 9 months. Now it's midnight and my son is asleep so I finally get the chance to write this e-mail.

Thank you again for staying in touch.

With best wishes,


Dear Lhuri,

 How exciting about your new son! Thanks for allowing me to share your message as a Tidbit.  Your questions are very interesting and important.
Your first question is familiar. To paraphrase, you ask: “How, in the impossibly busy life that healthcare requires, can people ever find time to sit together, relax, and discuss their work?”
I haven’t been to Indonesia to experience the challenges you describe firsthand. However, I know that here in the US, most people experience a similar sense of not having even a minute for themselves. And, during frequent conversations with a care team from the UK, those practitioners also describe similar overstressed conditions. I wonder if feelings of stressful overwork are part of health care everywhere right now. I will answer based on what I know in the US and from conversations with my friends in the UK, with the possibility that there may be similarities for you as well.

What I have experienced is that, at first, most people can’t imagine they could possibly find regular times to talk together about how care could become even better. Then, when somehow they do make time, these moments become among the most valued and protected times of their week. As people do find ways to connect and reflect, their time together becomes a treasured place of healing and solace and hope in their busy world. Their work starts having new meaning. So my advice is, just try it and see what happens! I think you will be surprised.
Your second question asks: Is collaborative care easier in places where people are more health-literate?
Interestingly – and perhaps surprisingly – I have come to believe that the most important part of health care isn’t the how or why of particular treatments. Instead, I increasingly believe that what matters most in health care is establishing human connections. After connections have been created among people, remarkable things become possible that were simply not possible before. The new things can be health literacy, and anything else you hope to accomplish. This insight, which was very surprising at first, is that what really matters for care – the thing that is truly foundational – is connections. Collaborative care has taught me that health and healing begin with this.
From this perspective, it is not a great worry if health literacy is missing or not at first. As connections are established, learning and literacy have a safe new home. And from that, all sorts of things become possible. I’m not sure whether people know more about their health in the US than in Indonesia, but I do know that, even in the US, most patients and families are overwhelmed as they struggle to understand and respond to a major illness. As connections are progressively established, everything becomes better – including learning and health literacy.

And, I should emphasize that learning and literacy in collaborative care are multidirectional. Rather than health professionals teaching patients in a one-way flow, everyone learns and teaches together in collaborative care, about all sorts of things. This shift – from one-way teaching to multidirectional learning and teaching – is very noticeable. It is central to the richness of collaborative care.

So my response is: I’m not sure if health literacy matters as much as it might seem at first. Rather, the foundation of care seems to be connections. Start there, and you can go anywhere.
I look forward to many more conversations as you carry this work forward.

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