Respecting the Therapeutic Order
The first week of school was a whirlwind. I am loving cardiology. It feels like I'm skydiving--terrifyingly fun! Every week in the cardiology tutorial we have a case that illustrates a different aspect of cardiovascular disease. For this first week, we had a patient wanting to identify and address her cardiovascular disease risk factors. Our homework was to write a script in lay-friendly language explaining her risk factors, how those factors contributed to her chances of having a cardiovascular event, like a heart attack or stroke, and what her natural and conventional options were for addressing all of the above.
We were given free rein to create a treatment plan! Do you know how EXCITING that is for a medical student? I love getting a taste of what I get to do in the future. It didn't take too long after I dove into the homework for me to start researching herbs, supplements, and pharmaceuticals. But then it hit me. I was creating this super long script...and forgetting the foundations of naturopathic philosophy along the way.
Naturopathy ascribes to a specific therapeutic order that codified by Dr. Jared Zeff back in the 1990s. While these are therapies that NDs have used since the advent of what we recognize as naturopathic medicine, it was not presented as it is now until the 90s. (The American Association of Naturopathic Medical Colleges (AANMC) provides a nice visual.) It's a pyramid. The base of the pyramid are the least invasive therapies and at the top of the pyramid are the most invasive therapies.
1. Establish the Foundations for Health
I think everyone has a sense that certain lifestyle choices lead to good or poor health outcomes. For instance, cigarette smoking is the most preventable cause of mortality in the US (1). Smoking is not a good foundation for health. Naturopathic doctors are skilled at identifying AND addressing these areas, or determinants of health, in a patient's life that can result in disease later on such as: genetics, maternal exposures, environmental exposures, psychological factors, poor nutrition, socio-economic factors, and physical or emotional factors. This is done through a detailed history intake. There's a reason why a first visit with an ND usually takes anywhere from a half hour to two hours!
2. Stimulate Self Healing Mechanisms/the Vis Medicatrix Naturae
This sounds a little weird, but I promise it's not (or at least it doesn't have to be). The Vis is what is often referred to at the "vital force" in older medical texts. A hundred or more years ago, doctors thought that there was life force that drove good health. While people can certainly still believe that, I take the Vis to mean that the human body was intended or designed to function a certain way, so we should respect our biology and remove barriers that would otherwise impede our bodies to function as nature intended. Pretty simple, but in practice it can mean lifestyle modification, better nutrition, utilizing herbs or homeopathy. A lot of philosophy could be read into the Vis, but that's a discussion for another time.
3. Support and/or Nourish Weakened Systems
Does a patient have cardiovascular disease? Does a patient have gastrointestinal disease? Which organ system of the body is in trouble? What can be done to help this organ system? Therapies at this level of the order can be generalized or specific, and probably depends on the doc. I think therapeutic diets are a great example of therapies that occur at this level of the order. Some botanical medicines often fall into this category too.
4. Correct Structural Integrity
The placing of physical medicine in the therapeutic order has always intrigued me. I wouldn't prescribe an adjustment, manipulation, or physical therapy for every malady, but this level of therapies could include acupuncture, massage or prescription exercise. Physical medicine is, well, more physical, and could be considered more invasive because of its nature; therefore, it's kind of in the middle of the therapeutic order.
5. Nutriceuticals or "Natural Symptom Control"
Nutraceuticals are what ND's are well known for: supplements and botanicals! Some supplements are pretty innocuous, like taking a multivitamin, fish oil, or magnesium. Those supplements more often fall under supporting a weakened organ system. Some others should be only be taken as recommended by a doctor, like St. John's Wort, 5-HTP, N-Acetyl Cysteine, etc. I think most of what you would see walking through the supplement section of Natural Grocers could be gathered under this level of the therapeutic order.
It's not good to start here without first making sure you're not missing anything that falls under categories 1-4. Supplements are cost prohibitive for many people, and why on earth would it be a good idea to give a patient just one more little pill to worry about? Maybe some people really do benefit from a regimen that includes a half dozen or more nutraceuticals (I was one of those people), but I would hope that only happens in concert with addressing health determinants.
This is where my mind went when I started thinking about my case patient. I had to make myself draw out the therapeutic order and make 100% certain I was addressing her levels of stress, sedentary living, poor diet and smoking habit first!
Yes, they do fall into the naturopathic therapeutic order. I don't like pharmaceuticals because they're another form of dependency and they often come with serious side effects. From personal experience, it's really no fun to be dependent on taking something everyday and risking side effects if you miss a dose. I would rather eliminate the need for the prescription (see therapies 1-5!). But some people really need their prescriptions, and that's just how it is. And we're thankful they exist.
Cutting someone open is pretty invasive, but I won't deny that surgery can be necessary for better patient outcomes.
It was good for me to take a step back and remembering to focus on health determinants and other lifestyle factors. I don't want to jump the gun and go straight to nutriceuticals or pharmaceuticals and miss opportunities for patients to really change their lives. Realistically, the therapeutic order encompasses ALL of medicine. However, barring emergent circumstances, I know I prefer to see if a patient's condition can be changed or cured through low force, minimally invasive therapies before writing scripts or referring for procedures.
Summarizing the naturopathic therapeutic order barely scraps the surface all that it has to offer. I recommend reading the article listed in the references below titled "A Hierarchy of Healing: The Therapeutic Order." Perhaps in the future I can elucidate each category a little more. If you have questions or would like to share your thoughts, comment below or send me an email.
1. CDC. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/index.htm. Accessed January 14, 2018.
2. Zeff J, Snider P, and Myers S . A hierarchy of healing: The therapeutic order. From ResearchGate. https://www.researchgate.net/publication/43328689_A_Hierarchy_of_Healing_The_Therapeutic_Order. Accessed January 14, 2018.