Do you know the 'Natural history' of your problem?

In the preceding post, we provided an outline of five key features that can act as a reasonable proxy measure of the value of a clinical consultation. What follows below is a more in depth look at each of these features, including a practical guide for identifying their presence (or absence) so that you can increase your probability of finding a provider of high value care for your injury or pain problem. Let's start with the first of the five features- Your condition's Natural History. The value of a clinical consultation is influenced by the extent to which a practitioner educates you about the "Natural History" of your injury or condition.

Low Value Indicator: Practitioner fails to educate you about your condition’s “Natural History”

Many injuries and pain disorders are self-limiting problems that will mostly, if not entirely resolve in the absence of treatment. The period of time over which we expect symptoms to resolve is known as the "natural history" of a condition. It is easy for both provider and patient to assume that treatment provided within the time frame of a condition's natural history is responsible for any observed improvements in symptoms. Whilst we should be careful not to dismiss the notion that the recovery process is expedited by the provision of treatment during this window of time, we should also accept that the simple passage of time may be the key factor in one's recovery.

This should give you pause for thought. Thinking back on previous visits to a Physio, Massage Therapist, Naturopath etc, did your problem improve because of the treatment provided or would it have improved just as much over time, in the absence of treatment? Might you be crediting a treatment received for your recovery at the expense of your body’s own capacity to resolve symptoms? Has your healthcare provider attributed any portion of your improvements to the natural history of your condition? If not, why? What might this tell you about your practitioner's priorities with respect to educating you about your condition? What might motivate a provider, even if only unwittingly, to take credit for your body's natural recovery processes? Is there value in a treatment approach that stops short of educating you about your condition's natural history?

When a practitioner takes the time to explain to you the natural history of your condition three positive outcomes occur;

  • You are better able to participate in the process of deciding how much treatment is appropriate for your injury or pain problem. For example, if you knew that your sprained ankle was likely to fully recover on its own over 6-8 weeks, you might decide to scale back the number of treatment sessions to save yourself some expense, and perhaps to return for further treatment in the future if the ankle failed to fully recover as expected. On the other hand, you might have an important soccer match coming in only three weeks, which might change how you weigh the cost of getting a more treatment done, sooner.

  • You are left reassured about the overall trajectory of your recovery. The natural history leaves you with an understanding that your symptoms will (assuming a favourable natural history) have a finite end point. Having some clarity around the time frame for recovery is really valuable.

  • You can use the natural history of your condition as a benchmark for the impact of treatment. For example, if the natural history of your condition was 12 weeks, but you had still not recovered as expected by 16 weeks, despite receiving treatment, you have a more informed base upon which to inquire about your lack of progress.

The third point is of particular importance. It is easy for practitioner, even if only as an unwitting ego defense, to blame a patient for a lack of progress rather than face the possibility that the course of treatment has been inappropriate or ineffective. If you are better informed about your condition's natural history, you are better able to hold your practitioner to account and avoid the scenario in which practitioners blame an unfavourable outcome on either the patient's behaviour/effort or the severity of a patient's condition. Knowledge of your condition's natural history forms part of the basis from which you can assess the value of the treatment provided to you. If your provider has not explained to you how your condition will (or will not) improve in the absence of treatment, it is reasonable to conclude that you are receiving low value care and would be better served elsewhere.

In the next post in this series, we consider the next feature of a low value consultation; the failure to provide a patient with a timeline over which a proposed course of treatment will expedite recovery above and beyond the Natural History of an injury or condition.