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