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The Principle of Using the Least Invasive First: Strategic Lever for Transforming Medicine? PDF Print E-mail
Written by John Weeks   

The Principle of Using the Least Invasive First: Strategic Lever for Transforming Medicine?

The medical principle to "above all, do no harm" seems a no-brainer. It's been there since Hippocrates. What could be a more obvious guide for all participants in the provision of health care?

Hippocrates: the long echo of primem non nocere
Yet we live in a world in which virtually every pharmaceutical drug arrives attached to small print of multiple potential adverse effects.  We know since the publication of To Err is Human that over 100,000 people a year are killed from the regular practice of medicine. Natural approaches are not without adverse effects. Herbs or vitamins may interact harmfully with each other or with pharmaceuticals. A dose of prescribed yoga or other exercise may lead to injury.

The Hippocratic charge co-habits a relativistic drawer with "evidence-base medicine." Each is an ideal. That a practitioner of any sort will do harm, from time to time, is guaranteed.

I was reminded of these balancing acts while reading the "core principles of integrative medicine" propounded by the new American Board of Integrative Medicine (ABOIM). This board is creating a specialty that will define integrative practice by MDs and DOs. One of five bulleted principles defining practice is care in which "appropriate consideration (is) given to use of less-invasive and less-harmful interventions, when possible, while addressing the whole person in addition to the disease."

Could this principle be a strategic lever for transformation?

The absolute in the Hippocratic principle is here made relative, and actionable. What if all practitioners had the knowledge, skills and attitudes to appropriately engage the approaches and practices of the typically less-invasive integrative health therapies, health professionals and disciplines?

Above all, do no harm
Consider a regular medical doctor treating pain. The doctor is accustomed to triaging between watchful waiting, a spectrum of over-the-counter and prescription medications, and referral for imaging or surgery. A conventional doctor who additionally respects the potential in behavioral health or physical therapy interventions will also use these options to stem the medical cascade.
Hippocrates would be expected to smile more broadly with each expansion of less-invasive options. The prescriber has more choices about what is least likely to produce harm.

Those ensconced in integrative health and medicine will know that such conventional practitioners have a huge blind spot obscuring their application of the Hippocratic precept.

The ABOIM principles for integrative medicine suggest what is missing. An MD/DO who is board certified in integrative medicine must be "able to use conventional and alternative methods to facilitate the body's innate healing response." He or she must also be "open to critical consideration of new paradigms."

Notably, the pain guidelines of the Joint Commission (2000) and the American Board of Internal Medicine (2007) list some at least of these therapies.  A 2013 consumer publication from the Journal of the American Medical Association on low back pain states that chiropractic and acupuncture may be useful.

Suddenly the spectrum from which one calibrates harm, the data-set that maps the clinician's decision tree, is inflated into a hologram of options. New diagnostic approaches may reveal toxicities, hormonal imbalances, stress and other lifestyle factors that in turn prompt less invasive approaches. If one further highlights the principal of inter-professionalism and team care, choices with lower danger expand. Might one or more lifestyle changes he useful? Herbs, vitamins and minerals? Counseling? Acupuncture? Mindfulness practices? Massage? Relaxation? Yoga?

A Biblical phrase captures the radicalism of this proposition: the first (say, an orthopedist) may become last, and the last (say, a chiropractor) become first.

This Hippocratic lever for transformative change in the care people receive demands two inter-related campaigns. One is a massive education of conventional practitioners to open their blind spots to other less invasive choices. 

The naturopathic therapeutic order
Success will rest in the second campaign.  Typically, when so-called "CAM" is mentioned in conventional guidelines, it is merely as a last resort. These choices are recommended not as conscious selections of less-invasive options. The integrative health and medicine community must create guides and foster research to clarify the use of these modalities, health professionals and disciplines as less invasive, less harmful paths.

We have some starts.  A concept articulated by the naturopathic doctors is useful. They offer a "therapeutic order" as a roadmap. Other disciplines have similar concepts. Now the idea of such an order would seem to have a new set of adherents in the new MDs/DOs who will be board certified in integrative medicine.

Such campaigns are antidotes to the present plague of conventional physician errors via their ignorance of options. These integrative modalities and practitioners are bridges across the chasm separating conventional from optimal care in this era in which unnecessary harm from the regular practice of medicine abounds.

Hippocrates, on seeing such campaigns, would likely raise a toast.


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