Beyond Overmedicalization: Rethinking Pain and Treatment in Modern Healthcare

Simon Kelly:
0:00

These kind of mill clinics you're seeing three people an hour you're just I would argue that you're actually de skilling in that kind of environment you're just applying something to someone there's no sort of critical thinking you don't even have time to critically think so you really need to look at that like the clinic set up, are they truly there for your benefit?

Mark Kargela:
0:18

Welcome back to another episode of the modern pain podcast this week we had one of our modern pain pro community members Simon Kelly on simon has been leading a lot of great discussions around the challenges we face in pain This naturally led us to discussing how the biomedical model of medicine has limitations and may not always provide the best solutions for patients. Due to overmedicalization and over-treatment.

Simon Kelly:
0:38

I think like most people that get into medicine or any sort of healthcare setting, like, yeah we want to help people and I just the more I sort of saw what was going on around me and the over medicalization and the over pathologization of things it just, it didn't sit well with me

Mark Kargela:
0:53

I talk with clinicians regularly who are struggling in high volume and revenue driven practices. Finding rewarding work in healthcare requires setting boundaries, seeking mentorship, and being skeptical of prevailing beliefs and practices.

Simon Kelly:
1:05

that's the advice I'd give to people, like if you're in that kind of mill setting you I believe you will burn out sooner or later and you gotta start setting boundaries for your own health earlier rather than later

Mark Kargela:
1:16

We discussed how the healthcare industry is influenced by capitalism, which in certain environments can lead to a focus on profit rather than the wellbeing of patients and clinicians.

Simon Kelly:
1:24

It was filling my pockets and it was filling my bank account but it wasn't filling my my moral compass was all over the place to be honest

Mark Kargela:
1:31

if you've had struggles with burning out or feeling like you aren't making the difference you want to make in patients' lives, then this episode is for you. Don't forget to check out modern pain care.com forward slash community. To join people like Simon and go deep with discussions and trainings. To help you crush, burnout and regain passion in your work. Onto the episode.

Announcer:
1:48

This is the Modern Pain Podcast with Mark Kargela.

Mark Kargela:
1:53

Simon, welcome to the podcast.

Simon Kelly:
1:55

Mark, how's it going? Thanks very much for having me.

Mark Kargela:
1:57

Good to have you. We've had some good discussions. Just a little bit of background is for those of you who are listening. Uh, I've gotten to know Simon Gausch over the last two to three months, uh, a lot more deeply from one. He was a listener and we, I think we had some emails back and forth at that time and then joined our community, our modern pain pro community where we've had him and we've had Bronnie Thompson and Mike, uh, Mike Stewart doing some great stuff and, and myself trying to, trying to all figure out some best practices around persistent pain. And how do we kind of incorporate a lot of this. stuff as far as what we know about modern pain science, psychologically informed care, all the things that we say, yeah, we need to do it. We need to do this better yet. Nobody's really given us the how to. So that pro that community has been all about that. You've struck me, Simon, as we've gotten to talk together of somebody Who's going through and really deeply thinking about that existential crisis of where we fit as healthcare professionals with the journey around pain and some of the, you know, even bigger topics and just health in general. But before we get into those topics and maybe you can kind of talk about your journey, you've had an interesting trip, um, as a healthcare professional started and maybe a little different arena and it moved your way into the physio realm. Um, and it's caused you some challenges, but I'd love if you could kind of unpack a little bit about your journey.

Simon Kelly:
3:07

Yeah, absolutely, Mark. Um, yeah, I'm an Irish guy. I'm working out of Canada. And, uh, yeah, I would have started my physio journey about 11 years ago, really. And I didn't have a kind of a moment of why I wanted to do physio. Part of it was like I just didn't want to sit in front of a computer ironically. I know we can't get away from them but, and I wanted to help people. I think that's why most people get into this healthcare system. But I never had a, I broke my leg and I broke my arm and I had lots of strains and aches growing up. I went to the physio for the breaks of the leg and arm but after that I didn't really go to the physio for any of my other injuries. So it was a really kind of a Suck it up and get on with it approach. I don't know if that's an Irish thing or my father and the way he kind of brought me up with towards pain. And I think there is benefits to that as well, actually, but we could maybe talk about later, but, and then I kind of got into this world where I felt like we were, I was very much cautious with pain. And I think, uh, you know, when do you push into it? When do you not? And, um, I kind of felt like I was Molly coddling people a lot more than I would have myself personally. And it was just a lot of friction and a lot of cognitive dissonance with that whole. Scenario and just like what is helping people like what what is all these interventions doing for us? You know, yes, it's reducing pain and I suppose I just got sucked into yeah I'm just helping someone their pain was reduced and I saw that happening and that's the observation I saw and I just kind of done that for many many years until I realized it. I just asked those hard questions like Why did this person get better and why did this person not? Why did I get better when I didn't get treatment for my groin or my ankle sprains? And, I'm not saying I'm great, I'm not gonna sit here and say I have a high pain threshold, like a lot of our patients do, but it's, it's more just, yeah, does everyone even need physio? Like what? How much support do they need? How much challenge do they need? And, and yeah, it's been a tough journey in that regard. I would have started out in sports and orthopedics, and then I eventually left that world. And currently I'm working, um, as an on site physio in factory settings. So I just manage all the claims. We call them WorkSafeBC claims here in Canada and obviously non occupational injuries. And then I set up my virtual clinic about two years ago, which was not a brainchild of COVID. It was really, I feel like that's the way the profession is kind of. Moving forward, um, and it's not just, uh, the P. S. BPS, I know the B part still has a, the biomedical part has a, has a role, but I think that's been on a pedestal for, for many, many years, but I'm just being careful not to swing too far towards the PS. side of things.

Mark Kargela:
5:30

That's that's always the challenge. You know, you hear the discussions about the pendulum swinging and everybody getting too far to the psychosocial. We just had Derek Griffin on and We had talked like, you know, for all this discussion of the pendulum swinging way to the psychosocial. When we have patients enter our clinics, I don't see evidence of it from, from what they're telling me, how much imaging they're having, how many procedures they're having, how many traditional ways of getting after pain. I can get the concerns because I don't think we can just simply throw away that there are times where red flags need to be screened, where true ACL ruptures happen and people might need some guidance and things. I do think it's fascinating your thoughts on, and, and worth discussing this, does everybody need physio? So. A couple things I would say is there probably are people that, like yourself, have injuries and have zero pursuit of anything. They just get on with it. They have, and we could probably talk about what's in their world, in their context, that just supports them to just continue on. And then the folks we see probably, I guess, in physio are folks that, For whatever reason, based on their injury. And it could be a myriad of things that are in their context, in their world, in their thought processes, beliefs, whatever, that just makes them feel like they need to seek help to overcome this thing. So, but there's so much we could talk about as far as over medicalizing that too, instead of like straddling, like, Hey, you need to sign up for this 20 visit package for 3, 500. So I can like really, really capitalize on your natural history here. I'm curious what you, where you kind of think, uh, that, that. Like, does everybody need physio? Like, how does that fit and how does that challenge you as somebody who's trying to like launch a virtual practice and, and like your own business? I know, obviously in your industrial setting, it's not as we've talked about that, it's not as quite as pressure of like generating clients, you obviously have a factory there and workers that are going to need help, but how do you resolve that challenge between yeah, does not everybody need physio, but Hey, I'm trying to figure out a way to make a sustainable business on the virtual front.

Simon Kelly:
7:27

My upbringing was very much like don't fear pain, go through pain, all the rest of it. And yes, there's definitely times where, you know, you want to pull back like you like whatever stress fractures and things like that. And, you know, I didn't always get it right. And I think it was a lot of my experience growing up. Maybe it was my family. My family, like, we play an Irish sport in Ireland, it's called hurling for any of the Irish listeners. It's basically a medieval sport where we run around with no padding and a stick. It's pretty, uh, medieval, uh, ancestral kind of sport, and I was kind of surrounded with that kind of attitude, I suppose. Yeah, just get on with it, get through it, and yeah, it could have repercussions or you could injure your ankle sprain if you're playing a game and you just damaged your ankle, and I kind of got that side of it, but I would argue that it was very beneficial for me maybe later in life, um, that I didn't. I, I, nothing is linear in this world, but that's definitely one impact that I'm grateful I kind of upbringing, but later in life then, I think the demographic of people that do come to us are, they're not me, I need to realize that, they're obviously concerned, and I think one of the other points is, especially if it's somebody's first injury, or if they've had a terrible experience the first time around, Yeah, that's definitely going to impact how they view this new and current injury, because most people tend to think it's going to follow, follow the same pattern as before, or maybe they've just no reference points. Like, I got injured many, many times because I played so many sports, so I had a lot, and in my experience, it got better. Now I know it's not, this is all anecdotal evidence and we'll talk about this later in the podcast, but that's kind of, I just saw a lot of people like, and we've all experienced this, it's just, what are we doing like in, in, in the clinic? Are we just like modifying pain symptoms? Is it actually improving structure? Do they need to get stronger? Um, are we kind of a shoulder to cry on? Or these kind of things, and it kind of, These things are important, don't get me wrong. These are just, these are like the intangible things that I, I would argue that, Uh, interaction is much better than intervention. Which kind of led me into this, um, virtual physio world and I think we are partly to blame to blame for that problem like we've kind of set this expectation I think as physios and who knows where that was born out of was it because in order to retain clients we we just felt the need at this sort of commission bias to be like we've got to do something when somebody comes in the door and I would argue that it was I could have even stemmed out of clinics just competing, like, look, and if we give pain relieving modalities, you know, you're going to release pain. And then, like you said earlier, we're all jumping and piggybacking on the whole natural history kind of side of things. I just couldn't get over that, personally. I couldn't, I can't jump on that bandwagon once I realized that maybe some of these passive interventions weren't needed. And it's not just passive interventions. I tend to swing a bit too heavily that side of the pendulum at times, like not everyone needs. They're a quad to get stronger, to get out of pain. We kind of know that now. I know Jared and Paul was talking about that and Greg Lemon and these guys, you know, like, when do we need strength? Like, when do you need to be specific? And you sort of mentioned it with ACL. Yeah, of course you're going to need to be more specific with ACLs and reconstruction and stuff. But again, I personally didn't rehab a lot of ACL clients. So my view is basically like, wow, I'm really just coming off the back of natural history. And I think there is a, there's a place in the world for virtual physio. Which kind of led me into chronic pain and being a little bit more like, Whoa, I can't practice in just treating symptoms and just pain, relieving sort of things. I need to. To venture into like the deeper concepts of why people are sort of getting better and and it's been a journey I would say it was a love hate relationship. Definitely a hate hate relationship from times and But I'm starting to get a little bit more enjoyment out of it as well But it's taken a lot out of out of me as a person and I think a lot of maybe hopefully the listeners can relate To that that we don't have all the answers. I mean science doesn't have all the answers. Nobody knows really what Why someone is in pain and I think it's very important for people to know you really need to get comfortable with that question and that's that's the excess existential crisis that I think one and every other physio I talked to has either gone through or is currently still going through and I think it definitely feels like swimming upstream.

Mark Kargela:
11:32

There's plenty of folks looking to intervene with natural history. And I think you definitely physio, we have our own, uh, glass house to live in before we start chucking rocks at others. Um, on the, on the natural history front, I sometimes wonder how much is just culturally driven into like, it's just the way our cultures evolved to where, especially Western medicine has just been this, like, you need this like sage Jedi. Healer. Um, obviously it's evolved over time. You can look at it. If you read some of, uh, Oh, Ben and daddy's work around the patient and the doctor relationship and all these things and the evolutionary push to, for people to seek healers in different cultures and things like that. And, and even if it may not be something, and I sometimes wonder too, yet like natural history. definitely can help for some people, but some of this belief that somebody needs some support to get there, be it, you know, obviously I think we over technicalize it. Maybe it is just that, that confidence building, that, that, that caring, that, that listening ear and that validating voice that gets somebody like, okay, I can move forward now. Now, obviously we have patients that don't move forward and there's more to it and there's more in their context that does that. But as, as you've kind of thought about. Our natural history, how, how far did it get you to the point? Did you ever get any points where you're like, I just need to like physio is not for me. I know I've shared my, my struggles with like, man, this just isn't happening. I don't, I, I was, there was a point I was studying JavaScript and within the last few years, I was like, I'm just going to go into web design and do some, some coding. And just like, cause I just, I couldn't resolve some of the challenges. I mean, I'm wondering where you're at with, with some of those challenges

Simon Kelly:
13:09

In the earlier years, I think a lot of us just, well, I certainly was in denial, I think, for a long time. I was like, look, like you said, I think we're working in silos, you know, we're in echo chambers, everyone around you is doing this kind of approach, you know, appeal to authority bias, you know, I'm new and naive, you just come up with Oodles and oodles of explanations for why you don't feel good deep down inside. Just, I'd describe it like a beating drum, really. It was just quietly going off in the background, and it just got louder and louder and louder, to the point where I was like, yeah. I, I would have questioned, it's, it's ironic. The first five years of my career, I actually felt great, because I didn't ask these questions. I was just sort of, I would say I was burying my head in the sand, and I was like, look, 80 percent of people are getting better here. You know, off what I'm doing, but was it off I'm doing? I didn't come to those questions till later on in life. And I think that's, yeah, I question it every day. Like I still question it, Mark, if I'm honest. I'm like, this is, this is hard work, you know? And social media has all these like quick fixes. You know, this, this one exercise will fix your back or this one magic trick will do this and it can get exhausting. So I'd be lying if I said I wasn't thinking about it. Frequently enough, uh, because it's hard. It's hard dealing with, uh, complex human beings. And, and that's why I think the pushback is, is nice to see. But I also see some good people, good people like yourself. And I didn't have that community, let's say two or three years ago, which is why I like being here, talking to you here today. It's kind of like, wow, there's everyone kind of went through this kind of thing. And I, I, it's a tip of the hat for you and me, even to still be sitting here. Cause I know a lot of people that just said, right, this is, I'm out of here. This is, this is tough. So it's, it's, And it's funny, like, you know, because I would say it kind of, my empathy kind of reduced. I suppose you could call it a burnout, really. You just, I just didn't have the capacity to, to take on people's, um, pain experiences at a certain time in my life. And that, it was at that time that I really felt backed into a corner. You have all these other things about leaving your clinic and leaving the clientele that you've built up. financial strains that everyone goes through, but yeah, I just had to get out and it was the best decision I ever made actually. Leaving sports and orthopedic work kind of behind or that kind of private practice was exactly. The thing that I needed to do to get my head right. And I would argue, a lot of people like me and you, like, if you have a salary based job, it takes a lot, a lot of pressure off to like, client retention, KPIs, and it allows you to research. I would argue a lot of young people don't have time to scratch their head, they're just, it's just that sea of uncertainty as we speak about it. Just trying to normalize that kind of uncertainty.

Mark Kargela:
15:39

It becomes challenging to find like rewarding work when you're in some of those kind of high volume, high productivity settings, where again, you kind of, if you're really thinking about, you know, your place in this and like, am I helping? I mean, sometimes I remember having been in some settings where I didn't last too long because of that, a very model. I've like just feeling like I'm just a cog in a wheel and I'm not really making any difference. I'm, I'm wondering where you feel the pursuit for rewarding work lies for people. Cause I'm sure there are people listening to this podcast. Like, man, I feel that I feel this, this struggle. I feel the struggle. I'm in it right now. I have, you know, 40 patients I'm seeing a day and barely can get time to have a, like a human conversation with any of them to really level and show that I'm a You know, a caring human being and this, this pain science stuff where we're supposed to be really getting into somebody's context and understanding it. I don't have any time for that. I mean, where do you feel like it sounds like you found some rewarding work. I mean, what were you recommend folks who are struggling with that existential challenge of where they fit and where they want to go?

Simon Kelly:
16:37

It's not an easy thing to do, like, but you really need to, like, as you, we mentioned before, these kind of mill clinics, you know, you're seeing three people an hour, you're just, I would argue that you're actually de skilling in that kind of environment. You're just applying something to someone. There's no sort of critical thinking. You don't even have time to critically, critically think. So you really need to look at that, like, the clinic set up, are they truly there for your benefit? Are you able to practice your morals, your values, your belief in that kind of environment? And to be honest. You know, I went straight into private practice directly out of physio school, so there was, I didn't go to the hospital at all, so there's definitely pros to having, I would argue, any person even that is spreading good information on social media, most people I believe anyway, have a salary based job, and they're kind of doing this on the side because you need that security, financially, everybody does, I mean that's just something, so if you're in a kind of a You know, you're being paid by the client kind of set up. I think it's very, very hard and you will eventually probably burn out and get slowly resentful like I, like I did. Um, I was just too afraid to make the change. I think like for many reasons, I suppose some of it was accepting that maybe I'm not as needed. Maybe we don't always have to do, like, throw the kitchen sink at people and all the treatments I was doing back then, like ultrasound and massage and, and that's exhausting. I think those, especially like hands on treatment is quite exhausting physically, not to mention the mental load of people sort of offloading on you their pain experiences. And if you don't find a way to sort of. Be safe financially. I don't think there's too many other routes where you're going to get to where you can actually research, critically think, find communities like we are here and, and That's the one thing I will say though, there is people out there. I was very anti social media just because that's me as a person, not because of I just think sometimes I'd, I'd waste a lot of time on it. So I didn't go on it for many, many years and it turns out that was the very place that I actually found. People like yourself, but there's lots of people which maybe I won't mention online that you can go the other way too, so you need to, I think lack of mentorship, lack of good mentorship is one of the prime problems. I think I would have elevated people who own the clinic I was in. Their age of the, the clinician that was running the clinic. And I think that's definitely a false way to look at it. Don't just elevate someone because you think of their experience.'cause they're older than you'cause you own a clinic that they know more than you. I would argue some of the new grads are actually coming out with better information than some people with what we would deem high experience. So I suppose I was falling foul of, you know, um. Authority bias, somebody just ahead of me, like, and then that's the, that's the advice I'd give to people, like, if you're in that kind of mill setting, you, I believe you will burn out sooner or later, and you gotta start setting boundaries for your own health earlier rather than later.

Mark Kargela:
19:21

I've had, Many conversations with clinicians struggling in that environment. I think there is rewarding work to be had. I've had Craig Liebenson discuss on his pod, on the pod with, uh, where he's basically just helping physios, chiros, and other healthcare professionals. Like, you just got to get out. Like, it's just, that's not a place for you to succeed. I'm not saying that's for everybody. Some people might enjoy, The high volume settings and things behind it. It's it wasn't for me. And it's I think it's very tough to find a way to do good person centered pain care where people need a little bit more of a lot more of an individualized human touch to really understand their unique circumstances. There are people where natural history could, you know, Hang out with three other people and get a little bit of an entertainment session with some, some guidance here and there on some exercise and do fine. But I do think we, we miss the boat on that. We've spoke to a little bit about how kind of, and maybe this goes into biomedicine a bit in traditional medicine theory, like how it's kind of. Um, you know, definitely made some leaps and bounds and some amazing developments when we talk biomedical with some of the diseases that no longer, you know, rid us as humans, although some of them coming back, of course, for various reasons, but, um, uh, and some of the, you know, amazing breakthroughs we've had in it, but it seems like, and I, and I've agreed with you on this, as far as it seems like that model has kind of run its course a bit, or at least hit its, saturation point of how much it's going to move us forward in better producing health among human beings. I'm, I'm wondering if you can kind of unpack your thoughts a little bit about that as far as medicine and it's kind of where it's been and where it's kind of at and maybe where you think we need to go.

Simon Kelly:
20:58

I think like most people that get into medicine or any sort of healthcare setting, like, yeah, we want to help people. And I just, the more I sort of saw what was going on around me. And the over medicalization and the over pathologization of things, it just, it didn't sit well with me. Yeah, it was filling my pockets and it was filling my bank account, but it wasn't filling my, my moral compass was all over the place, to be honest. And I think, like, medicine is good. Like, we had, we did, they had some golden years from the 1930s, roughly, to the 1980s, where we did discover, The double helix of DNA and you know, there was eradication of smallpox. We came up with MRI, CT scans, that, that's a story for another podcast, whether to how beneficial that is, but, um, and lots of, lots of other things like, um, and I think our, what's medicine is really, and this isn't to kind of put down medicine, but I believe like, you know, we improve sanitation or we improved. nutrition around that same time. And this is like, of course there's lots of variables. Nothing is linear, but you know, it's I think medicine took a lot of credit for that. And then everyone elevated medicine and and doctors and anyone sort of involved in healthcare to like. I would almost say godly like, um, status, and sort of, I'm not saying every doctor is godly like, or guru, like gurus, but that's kind of what I saw, and I was like, whoa, like, you know, you, you know, you notice these other things that get people better, like natural history, and contextual factors, and concomitant factors, and our own biases, and intervention might actually play a role, but how much of the percentage is it in, in those kind of things, and you know, You know, I read a book by, um, Seamus O'Malley, Can Medicine Be Cured, and you can kind of hear from that title. And, and, I used to feel bad. I used to think I was negative. Or I used to think I was too, uh, like, cynical was another word I would use. But I, I would actually argue, looking back, that I was just being sceptical. And I think we need to be sceptical, because the opposite of that is naivety, where you're just, you're spoon fed whatever the hell somebody tells you, and if you think that person is on a pedestal in the first place, like so much as society puts medicine and doctors, you're going to believe it. Which sometimes gets people better. And I call it a Asher's paradox is a paradox where you know the better if if if the health care professional or the doctor or practitioner Believes in the efficacy of an intervention well then The outcome of the patient is so much stronger and that kind of makes sense because you're going to prime it, you're going to frame it to the client because you yourself believe it or maybe you yourself got that treatment and I think, I think that's, and there's a French microbiologist called Rene Dubois kind of said, it's easy to think that you're empty in the sea with a pail of water when the tide is receding. And, and that's kind of where that kind of quote and the whole like, like, maybe we're taking way too much credit and we're inflating our own egos and sort of the profession to these godly like statuses, which I think is very, very dangerous, especially when you're dealing with human beings and maybe not in our case, life or death situations, but. Somebody does make those decisions and, and we need to realize that that is another human being that's making a decision. Based off, you'd be hoping the research, but again, research has its, has its flaws in many ways. Like it's even medications, you know, lots of people, lots of these medications are done on healthy individuals in the first place to, to trial them. But older populations are the ones with, with medications as long as your arm. And none of these trials were ever done in that kind of population in the first place because they're too fragile. Okay. So we don't really know, and usually it's at a population level. We don't even know at an individual level how one medication works, not to mind if an older person is on 20 medications. So I find that very, uh, kind of scary. Kind of scary how we're, you know, and I, I believe like polyprescribing is another kind of major problem, especially as we get into our older ages. So my skepticism comes from, from a bit of that, I suppose. And, and how much are we helping? And has, is medicine gone the other way? Where is the money coming to fund? These research papers, and we, and I don't want to hype on too much about big pharma, but you have to sort of question the efficacy and sort of, uh, for example, like they don't really want to develop antibiotics because they're short term, in my opinion, and short term, there's not a great ROI on short term medication. So they want to develop something that somebody has to take for 30 to 40 years. And then give it out to the masses. Like a diabetes medication, or a high pressure medication. Because, look at the money it generates for them, you know? And that book is eye opening, to be honest. Because it's really scary how the world turns. And I think I was just a bit naive when I was

Mark Kargela:
25:26

There's plenty to be concerned about. I think we've seen big pharma fund studies that have moved metrics around blood pressure and various other things that have all of a sudden made people much more, uh, in the metrics of where prescriptions should be given. So, I mean, there is challenges with the capitalistic system, right? I mean, there's going to be perverse incentives to create a need for health care because it, it, you know, Generates revenue. So I, I sometimes, and that becomes a major philosophical, uh, discussion around how do you balance it? Right. How do you balance the good of the people, um, and balance the need for, you know, these, these institutions and things to be able to, you know, run a, a, Profitable business that allows them to pay their employees. Well, they give their employees vacations and give them the benefits that we all want. Um, yet, I think we have rightful concerns over some of the ways that that health care has has taken some of the revenue based pursuits in in health care and maybe Move them to the detriment of maybe evidence based practice and especially person centered practice, I think over medicalizing so many things we do over medicalizing life in general of some of the things where, you know, my, my wife, she's going to love it that I've shared this, but, you know, she, she's had a lot of stress lately and, you know, having some GI challenges that, uh, but I, I'm, I think she goes to the doctor. She's gonna get IBS. She get a medication tomorrow for her IBS where, you know, Just going through a stressful period of life, you know, why, why do we need to medicate life? I mean, granted, there are times where we need help medically, especially mental health. I have no issues. I've had times where I've leaned on antidepressants and things like that when I've went through some rough stretches. But man, I just think there is, there is some challenges we have for, for sure. I'm wondering where, because I think there's a, there's a pressure for us as, as, as practitioners, right? We want to feel like we're worthy, we belong, and we're helping. So I think there's this wanting to ascribe the changes that we see in clinic to ourselves. Not, I guess you could say selfishly. I don't think purposely selfishly, but. to feel like all this work we've put in and we're, we're getting in these careers to, to help people and to navigate their pain. So we want to feel like we're making a difference yet how we're taught to make a difference with all these Jedi, you know, pokes into the tissues and all sorts of pontificating. I mean, you could look at Con Ed this weekend of all the things that we claim in the tissues that are causing pain, be it a trigger point, be it some, uh, mysterious fascial thing, a suture in the cranium that's off, uh, some cerebrospinal fluid that isn't flowing. I kid, but it's not a joke. I mean, it's, it's true. It's the reality of things yet. All those things have patients that rave and think it's better. I would argue it's because it's all a common thing where they're, they're all engaging with practitioners who are confident that are singing a narrative that that patient believes and moves forward, I guess, to circle back to this, this challenge of as clinicians. How do you think we find, do we have to like swallow our ego and be okay that we're more of a support system coach versus somebody who has to be this Superman Batman thing? I think, you know, I sit on that from our many discussion. I'm just curious where you where you fall on that kind of thought process. How do we find satisfaction in a job when it may not be this? I'm fixing you. I'm doing something that's correcting things. But some people find that very challenging. I know I did for a period of my life and I really find it much more fun now and satisfactory to come alongside somebody. I'm curious what your thoughts are.

Simon Kelly:
28:48

Look, I would have had the same, um, kind of journey or echo in the same things you just said there. It's, I suppose, I didn't think I was being a Jedi with my hands, but I certainly thought, yeah, it was necessary. And like I said earlier, it just totally clashed with my upbringing. I would never go anywhere for any of these passive modalities and I did have painful experiences. I mean, and it just, it just. It just, it didn't sit right for many, many years, and I, I get that some people need it, and I don't want to bash on passive, uh, treatments too much on this, because I know I have my own sort of resentment towards that side of it and how I was educated, so I, I get that it's useful for some people, but I would argue in a totally different way. I would also argue that it's not, I don't think physios are best placed in our system to deliver that. Treatment, I think, like RMTs and masseuses and like a nice room and, and, and scents and smells and getting there for an hour, like that's a great way to, to de stress. I mean, everyone loves a massage. I, I, I think anyway, most people I talk to love it, but. That question of is it needed or not, does it actually make you, does it make, uh, structure healthier? Is it necessary to recover? And I think for me, the answer was kind of no, like it's kind of like a nice to have, it's kind of like a pain medication. So I personally don't want to deliver an intervention that is physically exhausting for where I think other things can be just as useful. And I'm not going to hype on, like sometimes you don't even need pain science, sometimes you don't need. Specific exercise. Sometimes you don't need any exercise, like you said there. So sometimes you just need someone. Sometimes no intervention is an intervention. Sometimes the client is nervous, just one occasion. And you're just like, look. You do need to get to the bottom of it. How do you feel? And I think doctors have that kind of part of it fairly okay. I used to not like doctors because I'm like, Oh, they're just discharging them, you know. They could get re injured and all this kind of stuff. And, and, but I still, I still argue that maybe it's not happening as much anymore, but they still prescribe way too much. I just think we don't need to do, like, sometimes you don't need any exercises. You don't need any massage. You don't need any prescription drugs. You can mention to the client, These things are helpful for pain relief. It's a kind of a nice to have and I get it. Some things are time bound. Maybe you're getting married tomorrow and you want to walk down the aisle without a limp in your ankle and that's fine. But let, let the client decide and that's where the patient centered care comes in. Like, let them decide on these things. And I just think ice and heat and these kind of very inexpensive ways to modulate your pain are just as useful as sometimes manipulations, massage for an hour. And, and I know that doesn't sit well with a lot of people. It didn't sit well with me personally. I really didn't like swallowing that pill. I was after spending eight years kind of doing this thinking. You know, I got this person better and, and I think a lot of clients I was seeing, you know, if you put, if you break down the numbers, maybe 80 percent might've had a good natural history if they're young, fit and healthy and got the reassurance. And it's like you said, Mark, it's interaction more than intervention. And the crux of what we do is, should we be given an intervention? In what way do we, do we frame that intervention? I mean, we're all biased, don't get me wrong. I'm biased about paying education and exercise. But that also isn't a panacea either. So, really, the question is, what is the intervention? How can we move forward? And I think that's, that's where we're at. Like, some people don't mind giving out these pain modulating, some people might look at it and say, everything works. Uh, but I really, that doesn't sit well with me at all. I don't like that everything works approach. It's kind of like throw the kitchen sink at it. And I think it really has like cultural and societal, um, repercussions. Like you said, someone comes in like Batman, then the natural history of sciatica, let's say, is 12 months and somebody gets it. Somebody rubs cabbage on their back for four days in a row and they're like There's the cabbage in the back. And then they start spreading like, to all their friends, Listen, get the cabbage on your back, man. That's what, that's what worked. And, and, it's frustrating, cause, cause that person's belief is so strong, that that was the only thing that got them better. And yeah, I just, I can't deal, I can't, I can't work in that thing when I know that it's, It's not just the cabbage, um, but then I don't know, I don't, the answer is I don't know to your question. I don't know and I don't think anybody knows. I think, I think I can only practice by being biased and everyone's a bit biased. I can practice by, I like exercise because it has secondary benefits. You know, we all know those benefits. I think it gets, excuse me, it gets people moving, but I have to be very careful in how I present it as well. Like if I'm saying, oh, you need to get stronger in your shoulder, you know, that might be incorrect. You might not need to get stronger in your shoulder, and that's, that was hard for me to swallow even a few weeks ago when some of the guys were talking about it. I was like, oh, now I have to kind of readjust how I, I think it does lots of other things, you know, you have cognitive behavioral therapies, you know, you're, you're confronting fears, and that's the only way I personally can sort of practice at the moment. I sort of have a bit of resentment definitely towards. The hands on treatments, the modalities, the IMSs, um, am I saying they don't work for everybody? Of course not. I don't think anyone could say that. But how much of the intervention, like I said, is it, is it just the clinic? Is it just where, the context of where it was delivered? Is it because your mother told you to go to that person because it really helped her? I would argue that's taken like 90, 90 to 95 percent. I would argue there's only 5, 10 percent of the intervention and then the question is should we be doing the intervention at all?

Mark Kargela:
34:01

it gets into this whole cultural meaning that it's subscribed to these interventions. And we can probably go around the world. You, you mentioned the, the, the cabbage on the back. There are some strange interventions. I remember Adrian Lowe put, putting a video up. I think it was an African culture where this, it was proposed that this gentleman was kneeling in front of another gentleman who was either a shaman, a shaman, a healer, or something like that, and had headaches. And the shamanic healers chanting and then wailing this guy in the head and just chanting and wailing this guy in the head. And this guy was willingly seeking out the treatment because it was in that culture that signaled healing. So I think we have to recognize in our culture, it, the needle may signal healing, the, the, you know, the manipulation, the massage, whatever it is for that person. Now, obviously we have to recognize when people seek those interventions and healing doesn't occur in that, what are the, putting the brakes on natural history and recovery? I'd argue it's probably, it has little to do with some biomechanics and kinesiology. There's probably some context in their world that is not allowing them to kind of. That's negatively impacted them again. It could be genetics and all sorts of, you know, pro inflammatory immune dysfunctions, things like that, too. So I'm not saying there couldn't be some medical components of it, but we see so much around. psychosocial factors and things that become much more predictive of somebody's long term trajectory than any finding on an MRI or x ray. I'm not saying they, those can't have at times some, some benefit because we've seen studies where degrees of numbers of degenerative changes can have some predictability. So again, I don't want to get too, too anti medical, but I guess the question I have is we almost become countercultural, right? We, we become a physiotherapist or a chiropractor. I've worked with some great chiropractors who are really having this challenge too, because current culture is just apply the shiny tool, man, just, and, and make the outcome and make it happen yet. We know there's so much more to it than that, than that our intervention that's really driving things. I would agree. I think there's not a ton in a lot of circumstances that needs to be super specific around the intervention. The intervention is probably not the technique, technical components of itself aren't really dictating the outcome. It's probably more the ritual and all of these things. But how do you Cause this becomes like, okay, our culture is what drives our bottom line as a business, right? If you have a bunch of people who want the cabbage yet, I always joke with students who are struggling in some of these milk clinics. I'm like, recognize, I agree with the challenges you're having morally and ethically, yet you're trying to sell salads and McDonald's like you got to realize the context you're in. So I'm just. I'm just wondering, uh, with us kind of taking, I guess, a counter pop, counter popular culture approach with pain care because current popular culture is like slap the most shiny, lasery, needly, fancy, you know, intervention to, to make a change yet we're trying to do something different. I mean, I have thoughts on. We need to get content out there on YouTube and other places where people can have an ulterior culture to develop. So instead, cause it ain't going to happen through a research study. People don't read it and it ain't going to, research doesn't impact culture. YouTube impacts culture a lot, a hell of a lot more than, than research does. And even though I struggle with social media, like yourself, I Again, my question would be, well, how do you think, as somebody who's, you know, struggling with the culture, rightfully so, of, of pain care, how do you find a way to deal with it, and then make yourself a, And maybe we don't have the answers to this. I don't know, but how do we then, you know, generate a practice that's one rewarding to ourselves and a feasible financial practice. I'm curious where your thoughts are

Simon Kelly:
37:28

It's super hard, Mark. And there's no, there's no one answer. Like part of the reason I got into the salary based job, as I said, was just to kind of take that pressure, that financial load off and it'll, it opens so many doors like, and I think the problem here is observation is not better than experimentation. Like when somebody observes something happening to just, it's so hard to break that belief that that was the thing that did it. Or that was the thing that's got me better and, and, and they will spread that. I think we have to accept that there is going to be always a certain amount of that, um, in the world. And I, I don't know if you know, um, Ian Harris and, and, um, James Randi, he's, James Randi is like a Canadian magician. And I think there's a bit of a magician in us all, like, we don't want to admit that, but I certainly wanted it a bit more black or white when I first came into this world. But James Randi would sort of, And I'll tell a small story, like, how I keep saying about all this kind of stuff. It's, he was like a myth buster, where people would, I don't know if you've ever heard of water diviners. They're like people who go around with sticks and find where water are, where water is in the ground, sorry. And he, this James Randi guy went to Australia, and he lined out ten pipes in the ground, and he was like, he found some of these water diviners, and you kind of know where this story is going. He basically set up an experiment, and was like, Look. Can you check, I put water in pipe 3. So he actually told him where he put the water. Can you go over and see, is your stick working? Are you happy with the, with the environment and the climate and all that stuff? And the water divider was like, oh yeah, this is, yeah. And the stick starts going down or it shakes or something. It gives him a sign anyway. And he's like, yeah, there's water in pipe 3. So then obviously he mixed up where the water was. And he was like, okay. Can you tell me where the water is? And he did it numerous times and the water diviner got it right. I think it was 11 and a half percent or 12%, which is slightly more than chance alone. So, but then the water diviner would be like, yeah, but I, I, I found water. This is the observation, but every time I do it, I find water. So, Ian Harris was the one giving the lecture on this and he showed a map of Australia which is fairly mapped out now because people have been looking for water for donkeys of years. And it turns out that Australia is, is almost 60 to 70 percent covered in water in the bigger cities, which means anyone can dig and find water, you, me. And like, when you sort of hear stories like that, or another thing he asked them to do is, okay, and now I'm going to tell you to not find water. He asked the Water Diviner to not find water, not in the pipe scenario, but in general, and he couldn't not find water. Ha ha ha. So I kind of find those things very, very intriguing about I get it, and this doesn't just apply to Water Diviners. I have nothing against Water Diviners. It applies to me and you. Sometimes we get it wrong. We're just so fallible as human beings. Like, if you, if we see it, just like magicians, we believe it. But that is not The true picture, and I think, uh, I describe it like Paleo's Cave, like, you know, I think a lot of the time we're like those little men in the cave, and we're just looking at the shadows making noises, and we just, a lot of people just stay in that cave, and I feel like I just want to go back and pull people out of the cave, and yes, it's going to burn your eyes, and yes, you haven't Being in sunlight in 10 years prior, but at the other end of that, your universe just expands and we're, we're a long way off, I think. But we are making inroads, maybe. And those, when you see hard evidence like that, I don't like to shove pain science down people's throats. I just, I just tell them a story like I told you. I'm like, look. What do you make of that story? You know, why do you think your pain is episodic? Or, like, if it was true osteoarthritis, well then you'd have pain 24 7 and you just, you have to poke holes in people's narrative and not just go for the old like, yeah, that's the tightest traps I've ever seen you know, they're the worst knots I've ever seen and just whack in a needle like, you can, sorry, you can I can't I just don't think there's much skill to that. I think, I think that's just, you're just treating symptoms like we just said. And sometimes there's iatrogenic effects and cultural knock on effects and social effects of, oh yeah, of course Western Medicine wants us to believe that that's what everybody needs because it does drive that capitalistic model, but it's not getting the patient better. And sometimes we can actually have worse effects and that's, that's what a lot of people don't know. A lot of people's answer to this is. We do all these knee operations and they work. So let's say you have a graph and if you just do natural history, there's a blue line and natural history is a red line. Some of the surgeons would be like, well it works, so why does it matter? And I'm like, it doesn't matter because like, taxpayers are paying for an intervention that might not even be needed. And also maybe people, there is adverse effects if the client is older and they bleed out on the table or they get pneumonia in the hospital after being cut open and they die and all these other things. And this sounds negative. I'm not being negative. I know me and HIPAA operations are pretty successful, but I would argue, why are they successful? And I think that one of the main things, and I'm sorry I'll let you talk in a minute, is a lot of patients see us at our very worst. Which means they're up here on the graph. So no matter what you do. And this doesn't go for everyone, of course there's caveats. If you do no treatment, they'll probably get better. If you do some treatment, they'll probably get better. And like, you've probably heard of bloodletting back in the day where basically they thought they could rid people of diseases by just draining their blood out of the body. And it was just a given. It was just like, this works. The question now is how much blood do we have to let? How frequent? How often? Blah, blah, blah, blah, blah. And they realized when they'd done that, the less bloodletting you did, the better the person recovered. In other words, don't do that, don't bloodlet at all. And there's the same with people that had heart attacks. We used to tell them to lie in bed for a whole week, don't move for a week, and they got better. And people are like, oh, it must have been the bed rest. And one day someone came along and said, uh, actually, why don't you just walk one day after this and just see what happens. And it turns out that they actually got better, even quicker. So I think, I don't know, that's a few examples for the listeners and yourself to sort of just think about. Like, let's be honest, like, when, when surgeries were once performed with no, like nobody washing their hands and stuff, we didn't, we didn't know that one time. And that's fair enough. I have to accept that we have to make mistakes. We have to go through this process. To get to the next process, put it. It's just comical to think we never washed our hands before and cutting someone off. That seems like common knowledge now. And I think that's, we need to have these discussions. Like, why is that person getting better? What are, what are the commonalities between these people? And sometimes, as I said, science doesn't have all the answers either. So I'm not going to hype on sciences. I'm not jumping on a pedestal. I just think it's much better than anecdotal observational evidence.

Mark Kargela:
43:42

It's always, you know, fascinating to kind of think about what things we're doing right now, as we speak that we're going to look back on in. 10, 20 years of like, God, we used to not even wash our hands when we did surgery. I mean, obviously that's not us, but, uh, and it's hard for people because I can't remember who did the quote, but you know, it's like in medical school, 50%, what we're teaching you is going to be, you know, within 10 or so years is going to be proven to be incorrect. The problem is we don't know what 50 percent it is. Um, and that's just the uncertainty you have to live in in the world because the world is not black and white, you know, and it's I think we want it to be because it's what gives us stability. What's lowers our anxiety. You know, it's it's just a lot of times we can't cope with that uncertainty. We need certainty. To not have, you know, the high blood pressure and the tension and the anxiety that sometimes the world and I think there's some people that navigate it very well. And it's, I think you've, you've brought out. I love the allegory in the cave, you know, Plato's, uh, you know, parable there around some of how our reality can be skewed based on our context. And I think that's when I'm actually about to incorporate that into a conference presentation. I'm gonna do here in a bit, but, um, it's just. Yeah. Helping clinicians see, and it's just, it's tough because there's so much cultural pressure to not see it, to just, to just continue with the status quo and to, to not rock the boat and different things. Simon really appreciate I always appreciate somebody thinking deeply and really challenging some of the some of the going status quo thoughts out there So thank you for what you're doing and thank you for your time

Simon Kelly:
45:11

Thank you so much, Mark. I really appreciate it.

Mark Kargela:
45:13

All right, for all of you who's listening, don't hesitate to subscribe on wherever you're listening to this podcast. If you're watching on YouTube, we'd love if you could subscribe there, maybe even give it a like so we can spread more of this information to other physios that might be having this existential crisis that Simon and I spoke to today. We'll leave it there this week. We'll talk to y'all next week.

Announcer:
45:31

This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.