by John Weeks
The concept of a “therapeutic order” is the background which defines my understanding of the optimal integrative medicine/integrated healthcare process.
It locked into my thinking with a big “well, duh!” 20 years ago as I listened to naturopathic physicians, like Pamela Snider, ND, Bruce Milliman, ND and Jim Sensenig, ND. The lesson was simple, intuitive. Use the least invasive things first. Self-care is at one end of the spectrum, “ectomies” at the other.
The logic is self-serving for natural healthcare practitioners. Natural therapies and natural agents with fewer adverse effects trump pharmaceuticals and procedures that are more dangerous. The charge to “do no harm” (or as little as possible) is inlaid in there.
Milt Hammerly, MD, who directs integrative medicine for the 19 state Catholic Health Initiatives hospital system, played a role as a group of us codified this thinking in 2001 as part of the Design Principles for Healthcare Renewal. Principle #3 of 10, which Hammerly helped shape, was:
Prioritize care in accordance with a hierarchy of treatment. Care, and the leveraging of resources to affect care, is prioritized along diagnostic and therapeutic hierarchies which begin with education and empowerment in healthy choices, then move to the least invasive approaches and escalate, as necessary, to approaches linked to increased likelihood of adverse effects or higher costs. The starting point for intervention is established through clarifying, with the individual receiving care, the risks associated with foregoing, and with undertaking, more invasive approaches. Chronology and cause are fundamental aspects of this healing order.1
I reflected on this immediately on encountering a notice of a new low back pain guideline published in October 2007 by the American College of Physicians and the American Pain Society. The series of 7 bullets in the simplified version of guideline began with diagnosis (#1-#4) then focused on self-care (#5), followed by the use of pharmaceuticals (#6) and concluded with “non-pharmacologic therapeutics” (#7). The later read:
"When self-care options do not result in improvement, clinicians should consider adding non-pharmacologic modalities shown to be of benefit. For acute low back pain, the only modality in this category is spinal manipulation. For chronic or subacute low back pain, modalities shown to be of benefit are intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation."2
I called Roger Chou, MD, the lead guideline author and asked him about this apparent therapeutic order.3 He stated that, despite the sequencing, “we did set up the guideline so that medicine didn't have to be the first choice.” He assured me that the team examined adverse effects and ran a “cost-benefit analysis”of each modality or agent considered. He concluded: “The evidence was not there to warrant a recommendation of non-pharmacological approaches as first-line therapy.” He explained: “A person might want to take a pill instead of traipsing over to the chiropractor.”
All in all, the guideline marks a significant recognition of natural approaches, historically speaking.Yet were this guideline a proper therapeutic order, #7 and #6 would have been reversed. There is good reason for this reversal. To maximize the value of self-care, one is best to follow self-care with care from those practitioners who are trained and disposed to take the time to educate them for additional self-care. One is more likely to find this among those complementary and alternative healthcare practitioners who use “non-pharmacological” approaches.
More importantly, the two categories should have been renamed. The new #6 would read “natural therapeutical” rather than “non-pharmacological” approaches. #7 would then read “non-natural therapeutics.” Such a language change would give the consumer and practitioner quite a different message.
Chou and his associates would argue that the evidence is stronger for the “non-natural therapies” than for chiropractic, yoga, acupuncture, massage and the other natural approaches. Some debate this assessment. Yet this of course begs a deeper evidentiary question:
If we have good evidence for the suppression of a symptom or disease and only moderate evidence supporting an approach which creates health, which of the two comes first in the therapeutic order?
Links:
1. http://theintegratorblog.com/site/index.php?option=com_content&task=view&id=29&Itemid=44
2. http://www.annals.org/cgi/content/full/147/7/478
3. http://theintegratorblog.com/site/index.php?option=com_content&task=view&id=382&Itemid=189