Lessons in quality from the successful recognition and management of schwannomma in a tribal adolescent in rural Rajasthan, India: The pivotal role of plural, porous, and learning primary care teams

Abstract

Rural primary health care (PHC) teams often encounter complex cases where outcomes are impacted by limited access to diagnostics and delayed referrals. Achieving positive health outcomes in such contexts depends on a dynamic interplay of biopsychosocio-ecological factors influencing individuals, organizations, and society. These factors contribute to delays in seeking, reaching, and receiving care. Moreover, a mismatch often exists between problem-solving, learning needs, culture of primary care teams, and the frameworks used by educators and policymakers in health system design. In this context, an interprofessional group of primary care and health system practitioners, educators, and researchers presents an illustrative case of a tribal adolescent girl in rural Rajasthan, India. Her diagnosis, referral, and recovery were successfully managed by a rural primary care team comprising a physician, physiotherapist, community nurse, counselor, and outreach workers. Using the “Three Delays Framework”, we analyzed the team’s functioning that enabled early recognition and effective management of a complex condition. We identified cultural and structural elements that fostered quality in learning and problem-solving—specifically, interprofessional collaboration, plurality, “porous” and flattened team hierarchies, and reflexive, adaptive learning. This paper is aimed at primary care practitioners, educators, health systems designers, and policy makers whose thinking and decisions shape comprehensive PHC. We particularly highlight the need to consciously foster a culture of learning and problem-solving in primary care teams.

Introduction

Primary health care (PHC) teams in rural and resource-limited settings often manage complex cases where delayed diagnosis and treatment can worsen outcomes.[1] These delays stem not only from the unavailability of diagnostics or referral services but also from broader biopsychosocial and ecological factors that influence when and how people seek, reach, and receive care.[2,3] The “three delays” framework[4,5]—originally developed for maternal health—provides a useful lens to understand such barriers across the continuum of care.

Health outcomes in such contexts depend on the dynamic interaction of individual, organizational, and societal factors rather than solely on the structural “building blocks” of health systems.[6] Traditional health system design often underestimates the complexity of care coordination and the adaptive problem-solving required within PHC teams. This leads to a mismatch between how primary care teams learn and operate in real life and how educators or policymakers envision them.[7]

This paper presents a case of a tribal adolescent diagnosed and successfully managed for a rare spinal schwannoma in rural Rajasthan, India. Using the three delays framework, we illustrate how plural, porous, and learning PHC teams[4] navigate diagnostic uncertainty,[8] coordinate care, and sustain rehabilitation in resource-limited settings.

Methods

Practice context

The study took place in southern Rajasthan, where health priorities include malnutrition, anemia, tuberculosis, silicosis, chronic obstructive pulmonary disease, and musculoskeletal conditions. Communities face poor access to secondary care, limited transportation, and low health literacy.

Data extraction and analysis

Information for this report was retrospectively drawn from clinical records and team discussions at the AMRIT Clinic, run by Basic Healthcare Services.[9] Case reconstruction involved dialogue between the primary care physician, physiotherapist, and clinic team to map the clinical course and decision points.[10] Two experienced clinicians and researchers (CA and VS) analyzed the narrative through biopsychosocial and ecological lenses and reflected on enablers of quality and learning within the team. Insights were synthesized with reference to existing frameworks—principles of family medicine and primary care,[11] learning health systems, building blocks of health systems,[12] hardware and software of systems, and the learning mode misfits model.[13] Team reflections and literature on “Quality” as a lived, reflexive process[14] further informed the analysis.

Case summary

Diagnosis and management of schwannoma in a tribal adolescent from the perspective of the three delays framework has been outlined in Table 1 below and Figure 1 details the specific incidents from initial presentation to recovery that either contributed to delays or positive outcomes.

Table 1.

Diagnosis and management of schwannoma in a tribal adolescent from the perspective of the 3 delays framework

Relevant segments of the clinical case		Delay
Ms. D.A., a 15-year-old girl from a tribal village, presented with 8 months of progressive lower limb weakness, leaving her bedridden. Her family, living 7 km from the clinic and dependent on seasonal farm work, delayed seeking medical help due to limited awareness and access		Seeking care
Primary care (at clinic): At AMRIT Clinic, examination revealed upper motor neuron signs and a positive Babinski’s reflex, raising suspicion of a spinal lesion. Basic investigations were normal, but further imaging was needed[15] The family hesitated to follow through with the referral because of financial constraints, seasonal priorities, and cultural apprehensions. Tertiary Care (referred/coordinated by primary care): After persistent counseling and support from a community health worker, they reached a tertiary hospital a month later. (MRI) Magnetic Resonance Imaging revealed an extramedullary C6–T1 schwannoma		Reaching care
Surgery was recommended but delayed due to hospital strikes and prohibitive costs. Clinic staff and volunteers maintained contact, providing emotional and logistical support until surgery could be arranged. Following a successful laminectomy[16] and excision, she returned home with lower limb weakness but preserved bowel and bladder function Community Based Primary Care (Clinic and Home): Rehabilitation and recovery after the operation was implemented by the primary care team, comprising a physician, physiotherapist, and community health worker. A structured17-week home-based physiotherapy program[10] focusing on passive and active exercises, balance, mobility, and (ADL) Activities of Daily living independence was put in place. Using the Katz Index, (MMT) Manual Muscle Testing, and Community Balance and Mobility Scale, progress was monitored regularly. Family participation and (CHW) Community Health Worker visits reinforced motivation and adherence. By the end of the program, she regained near-normal mobility, resumed daily activities, and reintegrated into community life.		Receiving care

Figure 1.

Using the three-delay framework to delineate facilitators and barriers to a positive health outcome

Discussion

This case highlights the diagnostic acuity and coordinated care required in rural primary care, where clinicians must maintain a high index of suspicion for uncommon conditions such as schwannomas—rare, slow-growing nerve sheath tumors, especially in children.[15,16,17,18] Primary care relies on keen observation, clinical skills, and interprofessional collaboration to navigate undifferentiated presentations. Using the three-delay model, the case illustrates how individual fears, system gaps, and facility-level challenges interact to shape outcomes. Facilitators—including timely counseling, reassurance, referrals, and home-based follow-up—proved crucial. Importantly, barriers are non-linear and recurrent; overcoming one does not ensure smooth progression through the care pathway.[18,19,20]

Elements of team culture that enable quality

Several interrelated cultural elements of the primary care team contributed to the positive outcome: (a) Plurality: Inclusion of diverse professional roles—physicians, nurses, physiotherapists, and CHWs—enabled holistic problem-solving; Porosity: The team welcomed multiple perspectives and integrated inputs from the community and tertiary specialists; Flatness: Decision-making was shared rather than hierarchical, allowing faster response and coordination; Reflexive and adaptive learning: The team reflected on the internal discussion, sharing of perspectives and experiences, and possible ways to navigate complexity that resulted in adjusted strategies and learning in real time, which facilitated care delivery; Interprofessional collaboration: Open communication and mutual respect across professions enhanced coordination and patient trust. Regular team discussions, feedback loops, and reflective practice sessions promoted rapid adaptation to new challenges, allowing effective care even in the absence of advanced resources, as illustrated in Table 2.

Table 2.

Definitions of terms used to describe elements of culture that enable quality in primary care

“Flat” health systems—Systems that are not typically hierarchical (with stakeholders other than physicians or administrators being key drivers and decision-makers)

Plurality—Containing members of different professional backgrounds (e.g. physicians, nurses, physiotherapists, counselors, community health workers etc.) in a healthcare team

Porosity—Ability of a system to accept and integrate people and viewpoints arising from different professional backgrounds and different types of knowledge, skills, and insights/inputs to work towards a common goal

Interprofessional collaboration—Collaborative work between members of different professional backgrounds towards a common goal

Reflexive learning—This type of learning is a way of being in the world that involves turning back to look at oneself, to notice patterns in one’s experience, about factors that influence one’s way of thinking and feeling, observing how one’s thinking changes, adapts, and grows one’s actions in the present. Conversely, Reflective learning tells you what you learnt from the past to modify in the future

Adaptive and agile learning—Learning systems that allow for reflexive thinking and adapting problem-solving strategies to the present context

Often local practices engage in several types of customized, nimble innovations that contribute to high-quality health services without either describing or recording them as such. By examining a health system’s structure (team composition and hierarchy) and functions (interactions with patient/patient’s family, between team members, and with the larger health ecosystem; clinical decisions and inter-clinical supportive services) in the context of a single clinical case, our analysis helps facilities map systemic actions/innovations to improve individual patient outcomes. Application of the three delays framework enables practitioners and policy makers to gain insights into patients’ challenges and priorities from the latter’s perspective. Such insights will enable health facility managers to test the resilience of their system even in the case of complex patient journeys, such as the one outlined here.

Conclusion

This case demonstrates that primary care teams are central to navigating diagnostic uncertainty and coordinating complex care in rural, resource-limited contexts. The successful recognition and management of a rare schwannoma in a tribal adolescent was not merely a result of clinical skill or technology but of trust, collaboration, and sustained engagement between the care team and the family.

Three key lessons emerge. First, primary care must retain a high index of suspicion for rare and complex presentations, even amidst common conditions. Second, a mismatch persists between the dynamic, adaptive learning required in primary care and the rigid structures that often shape health systems—highlighting the need for greater alignment. Third, quality in primary care is fundamentally cultural, emerging from teams that are plural, porous, reflexive, adaptive, and less hierarchical.

Ultimately, health outcomes are shaped by motivated teams capable of dynamic problem-solving. Strengthening such cultures within PHC systems can enhance diagnostic acumen, referral coordination, and rehabilitation outcomes—even in resource-constrained settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.