Exploring the Clash: Traditional Philosophy vs. Dispositional Approaches in Understanding Pain and Human Complexity

Hey everyone, welcome back for another episode of the Modern Pain Podcast. This week we're talking with Roger Kerry. I've had the privilege of knowing Roger for a while now and am always impressed by the depth of his thinking. He has an ability to challenge traditional philosophies of science that inform how we've thought and operated in research and clinical settings. In this episode we talk about what got Roger interested in philosophy of science and philosophy in general. We unpack the tension between traditional philosophy of science and dispositional approaches that make space for unique people and causation that can exist beyond strict empirical interpretations. We go a bit further into dispositionalism and how it may help a clinician in practice and how do we help students and clinicians who are dealing with the tension between looking at pain conditions through a linear find it and fix it approach and the complexity of humans and pain, which we know is anything but linear. We'll speak to this a bit in the episode and more to hopefully help you better understand why traditional philosophy that informs traditional evidence-based practice can sometimes fall short. Enjoy the episode.

This is the Modern Pain Podcast with Mark Kargela.

Welcome to the podcast, Roger. Hey, Mark, thanks, oh yeah, big thanks. Thanks for having me asking me along again and it's great to be doing some stuff with you again. Yeah, A while ago.

Yeah, it's been a bit. You came on and did it when we had our gosh. It was a masterclass on unpacking complexity of evidence when we had you come in and talk Before I talk. Similar topics today probably maybe go a little bit in a few different directions because there's been some different. I think you've published a few things and there's definitely been some other discussions online that we'll chat about. When it comes to causation and when it comes to how do you resolve the challenges of working with unique people and then trying to fit it into an evidence-based practice framework where we're looking at group level statistics and means and different philosophies of science that may not perfectly encapsulate unique people. We'll get into that discussion for sure today. I'd love if you could. A lot of folks I know listening on the podcast probably know of you, but if you don't mind introducing yourself for the folks that may not have come across your work.

So my name's Roger Kerry, as we said, I'm from the UK, a place called Nottingham, right in the middle of England Robin Hood, nottingham Forest, all that stuff. I'm a charter physiotherapist. I started life as a physiotherapist, just a job in a clinician, ended up doing whatever they call it now I don't know, there's all different names Extended scope practice, first contact practitioner in orthopedics and vascular clinics, and then moved into education, primarily still do some clinical consultation and rehab work and research. Now I'm a professor of physiotherapy education running a new physiotherapy program at the University of Nottingham.

Yeah, and I know you're busy with a lot of different things and we had chatted. We're going to see if we can get Roger to get his podcast back in there because I enjoy hearing Roger's perspective on things, but we'll save that discussion for maybe later. I'm wondering, Roger, I'd love to hear your journey to where you got into this. I know a lot of this predicated on your PhD work and getting into your dissertation phases and things talking about causation and things. But I'm curious just where that interest in that philosophy aspect of things I know. Personally myself, early in my career I didn't even consider philosophy of science and these different topics that really are such implicit informers of how we think and the actions we take in the clinic and what we consider knowledge in a encounter. I'm just curious where that maybe came from for you. Is that something that started early, even in high school days, or is that something that just developed as you got into your more professional career?

That's a great question. It's going to stretch my mind back a bit, but I think it was an early start. I mean I just did regular sort of school and didn't do anything special in terms of philosophy or anything. I went down the sort of sciences route. But I think, to answer your question, it goes something like this I was doing a biology A level at some local college and I wasn't that committed or bothered or interested. But we had this teacher and I think he was like a standing teacher, a guy Mr Taylor his name was and he was from, he was African guy who came over and he randomly saw me in the street one day outside the college and he didn't know me. I don't think he knew me. I sort of knew him as this teacher. He just sort of writes stuff on the chalkboard and we always copy, and it just came over and he said, oh, you like these two books. And he gave me two books for free. He said these are two books of mine. I want you to have them. One was on cell biology and one was a really old, old editor of a one of Karl Popper's first books, who was a philosopher of science. I had never heard of him. I thought why on earth did he give me those? And I thought I'd better read them. I read Popper for a bit and I thought, oh my God, this is so fundamental to everything. I just started thinking about philosophy of science and how science works, how we know things, you know the nature of what we know, but also more importantly, I guess, for our discussion, is how the relationship between science and the real, the real world which is, which is, which is really really interesting, and I, I guess then, when I was whatever, 1920, it was a sort of it might be a phase, you know, I'm interested in this and then it all goes. But that wasn't the case. I just carried on being curious about stuff and then then trained to do physiotherapy and things like that, with this constant sort of nagging of hold on a minute. Well, how do you know that? What? How can you say that? What does that mean? Blah, blah, blah, blah, all that curiosity, stuff, and and then that that, just that just developed. And I think we work in a really, really interesting sort of patradish, really physical therapy, physiotherapy, because it's it's ripe for for this sort of thinking and pondering on on on life, because it's suitably sciencey. So it's sciencey in terms of their elements, of what we do that the sciences can relate to, and it's also suitably complex and nuanced and gray, and I think there's some bits of what we do that the sciences can't quite reach and therefore, what, what? What do we do if we're supposed to be practicing in a science based, evidence based sort of manner? So so all those things, and then, and then I ended up doing my PhD in a department of philosophy and University of Nottingham. My supervisors were a guy called Steve and Mumford, who was a philosopher of science and somebody you know quite well, mark Ronnie. Well, ronnie engine was my sort of informal supervisor. She sort of guided me the whole way through and she's Norwegian philosopher of science and I just I just sort of enjoyed their experience so much. It just gave me a real privileged opportunity to really sort of immerse myself in that, in that stuff, and I you know that was all framed in evidence based medicine. So I use the evidence based medicine framework as a sort of test bed for all these sorts and it was just just really interesting.

I'd love if we can unpack a little bit. I know these are deep discussions and obviously there will always continue to be questions and ponderings that go on. But there's tension between, like, evidence based healthcare and maybe traditional philosophy of science approaches. I know you've talked about that whole humane view of regularity and things that exist that kind of informs the traditional philosophy of science when we're trying to determine what's like the knowledge of the encounter that we can really make judgments, the empiricism, positivist type approach with things that also then, like you mentioned, science has tough time reaching some of the complexities of the human pain experience. You know there's more than just some of these objectified, empirical, measured ways of looking at people. I'm wondering if you can talk about your experience with how you've looked at that tension that exists between those two and obviously maybe we can maybe talk a little bit about traditional views of philosophy and then we can maybe get into the dispositionalist way that you know Ronnie has been a big, huge influence, been very grateful to get to know Ronnie and have learned a ton from her, hoping to get her on the podcast, but she's very busy, of course. But yeah, I as love, I know that's a massive question, but I'm wondering if you can unpack that a little bit.

Yeah, but it is the question, isn't it? It is that thing about the relationship between this thing called science and this thing we call life, you know, I guess. I guess some people would say and those people being scientists, hardcore scientists or, in our game, perhaps trialists or something like that, you know, they wouldn't have too much concern about this stuff because they have a view of life where life sciences, life, life is science and the job of science is just to expose the world, the bits of the world we don't yet know about, and confirm some other bits. So that's that positive view where we assume this is, this is sort of objective thing in life and all we have to do is try is try and find it, and science is the method of finding that. And that's very appealing to be, to be like that, and it would save a lot of lot of stress and hassle and time pondering on things. And I do admire people who whose jobs and life so are based on those assumptions and that was a bit of a cheeky word to throw in at the end there because they are assumptions. You know, there's no law, there's no universal law that says that, that that is how life is, that's a. That's a human concept. You know the positivist ideal and the sign the scientific ideal is is humans made that up. You know it didn't just come out of the big bang and they said this is how you do an experiment. You know this. This, this is all the human concept. So we make choices and that is a choice to view the view the world like that, which is great, because we do need that stuff and hopefully the point we'll get on to is all of this stuff is really useful, it's just how we package it together and do it. But there's this. The whole thing is full of paradoxes. You know the other end of the spectrum which you don't really want to spend too much talking about, because I don't. If we just assume we're talking in the in the sort of parameters of science, philosophy of sciences, about science, and there's other stuff outside that pseudo scientific stuff, made up stuff, unicorns, that sort of thing, crystal therapy that's part of a world that we have to acknowledge. But we don't need to bring that stuff into our world of health care and if we do, it does have to go under evaluation and, you know, investigation to see if it stands up to some of these tenants of science or or research, but that field of sciences is is full of paradoxes as well. You know the idea of science and being really pedantic here, but if we're going to have a talk about this sort of stuff, we've really got to be accurate about what we're talking about. So, you know, think about people like Richard Feynman and these pop populist advocates of science, who are phenomenally intelligent and amazing, and look at the, you know, look at the definitions of science. The true sciences is something experimental, where the the only way to access that truth is to set up conditions that are so tightly controlled that you know you can't account for the outcome by anything other than the variable that you're interested in. So so science is all about stripping away or the variables and complexity, and, of course, the paradox there is. The more you do that, the further you move away from the real world, which is, which is complex, and again, not using the word complex just as a casual thing, you know that there's a technical definition for complexity and that's what the world is. So you know I'm not making this stuff up, this is stuff that's written about in science and philosophy of science and everything. There's that paradox as the is the is, the better we get at science, the further away from from the real world we get. So what, what? What the scientists would say is probably something like that. That's not quite true or accurate. And you can still piece that bit of information back into that complex world and you start to build up this picture and you start to break down that complexity by plugging those things back in. But again the paradox is there that if you found something in an experiment that's an outcome of a very controlled situation and you plug that back into complexity, then there is no way, there's no, there's no logical explanation for how that can survive in complexity, because suddenly you've got all the other variables again, so so that that sort of breaks down. So so then again you could look at health care, medicine and physiotherapy and such like and think, well, how is there a compromise? We could reach there with this sort of quality of science we do and the real world. And you know, things like pragmatic, randomized, controlled trials are a good example where you try and build some real worldness and complexity into the experiment. But then the problem is that there's no longer an experiment in sort of scientific terms, but you're still finding something out. Now I I'm of this sort of opinion that there's a difference between science and research. You could have scientific research, you could have non scientific research, but research still discovers something. It's it's it's what we call as truth and what we call as sort of causal links or whatever. So we could do research which is something like a pragmatic randomized control trial and find stuff out. But again, I still think there's a limit in that, in, in, in the inferences you can make from that. And this is going back to Hugh Popper and the problem of induction and the problem of inferring stuff even from the from the hardest sort of science. You know, pearson, carl Pearson, wasn't it the statistician when, you know, when the idea of a t test was was sort of developed turn of the century in the journal biometric, the first paper that was, that presented the idea of having two sort of populations represented by bell curves and you can statistically see if there was a difference. Not in that very first paper he clearly stated that this was an excellent way of finding out if there was a an effect between two variables. And he said but the one thing you should never do as a scientist or a statistician is infer anything from that experimental population, even though we talk about a population being a sample from a wider population or something you know. Back then he said you should never. That is not the job of science or statistics. The job of science and statistics is to look at that experiment and find something that inferring from that is a completely different cattle of fish. And you've got, there is no, there's no method of inferring, there's no logic of inference. But what evidence makes healthcare is is that we do stuff, research. Some of it may be good in science, and then we say, there you go. So let's make some guidelines now and let's do a systematic view of these pieces of information, and so that's what works for low back pain, and that's that's where the challenge is. You know we've got that information, but what does it? What does it really mean?

Yeah, yeah, I know we had Chad Cook on and we had kind of he had spoke to some of the challenges with systematic reviews and all the different things when we're having data of trials that aren't really all that well designed to translate to the real world. And you nicely kind of pointed out the challenges of taking very controlled settings where we're trying to minimize variables and complexity. Yet that goes completely opposite of what we see in the clinic with real humans and in real world context, with real environments, real social pressures, real financial pressures, all the things that that come into that. Maybe we can chat a little bit about how that framework that you nicely discussed there, and maybe Dispositionalism and how maybe you came across that I know obviously part of that in your PhD trainings and your dealings with Steven Mumford and Ronnie and you on that but how that might help us Consider more than just that empirical you know Very measured, objectified way of looking at the world to try to make sense and or make whatever, that world view of truth that you know, that the empiricism, the positivist way of looking at. I'm wondering where you feel like that alternative way, and I don't want to see an alternative, but maybe a different? What philosophy of looking at how we can gain some knowledge, especially for clinicians who are Seeing these good guidelines that you speak of in these systematic reviews just not fitting unique people in front of them? I'm wondering how you feel the you know that this, this positionalism, approach and thought process may, may help a clinician out.

Yes, yeah, thanks Mark for giving me that opportunity, and I'm In this very familiar position again of desperately thinking. I'll come make this as sort of simple and engaging as possible and, and again, just to you know, safety net this and provide my caveats, even though we might talk. So you've mentioned this word, dispositionalism, and this is a theory of causation, but it's again it's. It still fits within the field of science. So we're talking that within science. What are the different ways of thinking about causation? Again, it's not some mystical, weird stuff that gives the green light for anybody to go ahead and do whatever they want and all that Sort of stuff. This is still process here. They still method here. This, there's still strong logical arguments that we need to test everything with. And so, with all that in mind, if it starts to sound a bit weird, just keep thinking no, it's still in these parameters. And again, the other thing to say is there's a difference between being we all know this is different between being critical of something. So we would you have in this critical discussion here about Experiments, trials, whatever, but not dismissing them. We just, we just got to work out what role they're playing in in life. You know, not for a minute and I, or Ronnie or Stephen or whatever else, is saying, oh, don't, don't do research anymore, don't do science anymore. That's all I was saying. This is all good stuff, but what does it mean? So the, so the link to this thing called Dispositionalism is basically the way, evident, the way healthcare works, the way if you, if you take a framework like evidence-based medicine but and by that I mean in this sort of modern version of that you know the post 92 guy at sack it's a Idea of medicine should work, and then we all jumped onto it and now we call that evidence-based healthcare. But the principles are still the same. There's a shift from Personal, biased observations of what's going on in the clinic to something more systematic and which eventually we package up as trials and whatever. And If you want to sort of understand that from a philosophical point of view, it's quite easy, because you can use those methods that are prioritized in evidence-based healthcare and they give you a clue to to to what science in that, in that sense, considers, as is the idea of causation. So the reason we we're happy to make causal associations from a randomized controlled trial, for example, and not say from An observation, a longitudinal Observation or study, something is, is the idea of Control groups and randomization and things like this. Again, it's that idea if we can control things enough, we can start to infer causation. Now, that's that's. That's got a very particular sort of method to it and the best way to describe that is that it's a humane idea of causation, which is the Scottish philosopher David Hume set out the idea of causation that it should be something that you see regularly. It occurs regularly. The events, the cause and the effect, occur very close together, which makes sense. You know, if I do what, if I've got some keys here and a badge, and if I bash that with that and that moves this cause, I attribute causation to that. The keys made the badge move because they occurred very close in time and space together. And if I do that enough, if I do that regularly, I can start to think, yeah, yeah, of course the bloody keys are a cause of the badge moving. And so there's these little two or three principles there about this regularity theory, this Humean theory of causation, and then to sort of the belt and braces. Part of that is then to observe that a thousand times, but then observe the badge without the keys and see what happens. So we've got this counterfactual group, which is the control group or the placebo group or whatever. And now I'm looking at that badge and it's not moving and I'm going well, it ain't moving there, but it was moving then. So the cause of the movements was that condition, the keys. So you couldn't. So that's a regularity theory, a Humean theory of causation, which is sound and of course, to humans, to us humans, that makes absolute sense. You know, it would be odd to think that the keys weren't the cause of the badge moving in that situation. But then we put the badge in another world where I'm just grabbing anything I've got. There's nothing prepared here, mark, I haven't prepared as I've got props, I've just got my badge.

This is an amazing improv performance. I'm very impressed at the moment, so keep going.

Well, I'll grab whatever I've got. I've got my keys again and this is the real world now and they're bashing this but also I've got this pen here as well, this Mont Blanc pen by the way, that's quite a nice pen and that's at play in the world as well. And then I've got these other keys here and that's at play in the world. Now I'm not sure what's the cause of the badge moving, because I've reintroduced what we found in the experiment into a world where there's mess. So in some ways we're back to square one and we think well, what we'll do then is design another experiment, and this time we'll have an experimental group with these two things in and a control group with the three things, and then we put it back and the same things happen. So next one we do okay, let's have all these three things in, and then one more thing as well, the phone in there as well, that can bash, and the same things happens. But it goes back into the real world and the idea of complexity is, you know, one of the ideas is that there's an unknown number of variables and it's also unknown at how those variables affect each other as well. So then I set up an experiment where I look at the association between these two causes and then their combined effect on that, for example. So I can keep doing the science, I can keep doing the response to the real world and back again, but it never solves the problem. That's just an ad infinitum thing. And that just goes on and on and it still doesn't solve the problem of how you can use what we found in the science in the real world. It just creates further questions, which again is great. You know, the creation of further questions that allows us to explore more and more and more, but it is an infinite thing. We will never get to an answer doing that, but we need answers because there's a guy with neck pain and headache out there who's been struggling for three months and he really wants some help. So I want to know what to do. So how do we do that? So one thing is to accept the limits of what we just said and say that's how the world is, but it's our best shot. Well, so we've got to go on. That's the best way of knowing at least something. It's better than just randomly flicking a coin and saying this will probably be the cause of it. So if we now think about the causes as the treatment and the effect as the health response, at least if there were some trials that showed that, say, exercise plus manual therapy was better than soft tissue massage or something like that, I've got at least a starting point. There is some value in that finding, but it still doesn't mean that manual therapy and exercise is going to be better than soft tissue stuff For this guy. I still don't know that because of complexity and all those things you said, mark. The situation of that person who's done exercise, has had manual therapy before, is stressed at work, blah, blah, blah. All those variables suddenly come in. So there's this utilitarian view that can be presented which says so what? You know, it's cannon fodder. If he doesn't respond to the intervention, there are no responders, and that's life and that's it. But if we keep doing this enough, hopefully, on average 51% of the population will be responders to health interventions and 49% won't. We still won because it's been slightly better than that. So there is that view, that the utilitarian view, that we should accept something from science, apply it and don't worry about the people it doesn't work for, and largely that's what health systems are based on. If health costs are at the forefront of the conversation as well, but at least there's. You know, you're not forever trying numerous interventions on the off chance they might work or something. We've got something to go off. So there's that view. However, what you know, when I was looking at this and I was doing my PhD and everything and having these discussions and thinking, is that the answer? Then Does the world just say, yeah, that's fine, it's better than not doing that, so let's do it. Or you say there must be something better. You know, 49% of the population is still a lot of people who aren't responded to health interventions, and the one way out of that is to reconceptualize what we think of causation. So, instead of thinking of causation as just something that falls out of a controlled setup, causation is something more than that and some something more fundamental. And it doesn't have to be something that relies on those human principles of regularity spatial, temporal, spatial, you know, approximation and all that stuff and it doesn't have to be something that relies on a control group, the observation of a control group where the effect doesn't happen. Again, that's a very human concept. You know, we've just been told that if it doesn't happen, then it does happen there, then that's the cause. So there's this idea of, as Mark's just mentioned, dispositionism, which basically says the stuff that I'm trying to get my words right here so not to confuse things even further. We so, for example, prop time again this is a cup and it's made of a certain stuff. What's what's what? A cup's made of Ceramics yeah, that's the word I was after and this cup has a disposition of fragility, and so what that means is, if I drop it from the table onto a hard floor, it will, it will break, and what. So what dispositionist would say the reason for that? The causal explanation for that was because it was disposed to break, because fragility was one of the properties of that ceramic. What the human would say was the cause of the breakage was the falling from from the table. And we can prove that because you can set up an experiment where we have 20 cups on 20 tables at the same height and we push each one off and they will break. So the cause was the pushing and the falling of the thing, where the dispositionist would say the causal explanation was more about the properties of the thing and it just so happened that it fell off, and that was an example of manifesting its properties. And we could have manifested those properties in different ways. I could have got a hammer and smashed it and it would have still broken. So the outcome is still the same it's broken. But it was anchored on the fact that the object was predisposed to break because it had this, this, this property of fragility. But the humane would say we don't know, the hammer's broken, what we need to do is set up an experiment to get 20 other cups and 20 hammers and smash each one. Then we'll know. Then we'll say the hammer caused the breakage. Dispositioning says no, it's the same thing that caused the breakage. It was its disposition to fragility. So we've got two different ideas of what the cause of an effect was. The humane would say it's these discrete interventions, the push-in, the bash-in. The dispositionist would say the cause is its disposition to break in certain contexts. And hopefully it's quite easy to see how that maps onto healthcare. If somebody is a responder or not to treatment, it's not because of the intervention, it's because of their dispositions, which we talk about all the time, and we talked about already the biopsychosocial model. All those biological, psychological, sociological parts of that people's life are creating a very unique individual with all those. Imagine each variable in each of those three things and imagine their interactions. Imagine the infinite combinations of complexity within that just one person and we're then trying to say, oh well, a sort of quick C3, 4, should cure you, or something like that. We speak of interventions, but really we should be speaking about the nature of the human in front of us and then trying to map the things we can do onto that. If this is making sense Now, you'll see that a randomized controlled trial can still have an important role in that, because we still need some order of things and some sort of starting points again. But rather than prioritizing randomized controlled trials as being the systematic views of randomized controlled trials, as being holding some superior grasp of causation, what we really want is a number of methods lab studies, case studies, personal observations, longitudinal studies, controlled studies, and if they're all saying the same thing, that's when we can start to believe there's some sort of truth somewhere. But that's expensive and that would take a long time if we want to understand everything. But we shouldn't give up on that. But in the meantime we can access what is going to help somebody by understanding that person better rather than understanding the intervention better, and I guess that's a sort of little long summary in answer to your question about Sophie Ramblidon.

No, that was great. I appreciate the depth you went with it because that I think, was a great explanation of contrasting that human view of science and empiricist view versus what we consider in the dispositionalism look at things, how that focuses on uniqueness of the person and some of the dispositions that each unique human holds. I think Matt Lowe did a great case study that looked at that and we'll link it in the show notes. That looked at a vector model of how do we kind of see what things are existing, what are the dispositions in that patient? Maybe and again, you can maybe look at that through a biopsychosocial lens of all the factors. I mean, obviously we're never going to perfectly. There's probably factors we don't even understand exist in the human at the moment. But that gives us ideas of what things predispose, or our dispositions of people maybe, to a positive treatment effect or a negative treatment effect or maybe an experience of pain or away from an experience of pain, and we can start bringing those into clinical encounters All within, like you said, the guardrails of clinical guidelines and evidence-based practice. Those things in form maybe help us get to see what things in these controlled settings give us a disposition towards an effect that we carry moving forward. But yeah, no, it's interesting to see how these things all interplay. The question that comes up for me is you've obviously thought deeply in this and you've had the good fortune of being in some very high level thinkers to help push into this and you're probably our average clinician. That might be a struggle. I know it was for me as I was getting into reading some of I got into reading even David Hume's works and some things. It's heavy stuff and it's good things, but it definitely to me and use a good job like a set of bringing it down to more of a maybe layman's level as far as a beginning level philosopher's view of things. But I'm wondering where you think you know as clinicians and we see some of these things like narrative-based medicine from John Lorner and other things that are really showing the value of maybe getting to know that unique person in front of you. Yet we have academic teaching where it's, you know there's it's how do you rectify some of the challenges of and I know I always tell students like you're gonna get on Rotations and you're gonna see how these things that you learn in school that are looked at is very objective and black and white and how we have to resolve this to unique people and how does that fit? Like I know, you have this breadth of things you want to do with this low back pain patient and students want to run through like the whole PowerPoint checklist of things. Yet that may not fit with unique people. I'm just wondering how you feel in Education we can find a balance of that. So where we're starting to recognize the nuance of unique people, yet still teaching to the professional requirements we have to show that there's a physio who's got a knowledge base that's sufficient to be a safe practitioner To enter that very muddy, gray world of clinical practice where they're gonna face unique humans and people that are in that waiting room with neck pain and headache. That and that doesn't fit that clinical practice guideline. It sure doesn't fit the the PowerPoint description of what neck pain and headache look like. I'm wondering how you think that's a challenging question, I know, but I'm wondering what your thoughts are on how we can Prepare not even just students but clinicians who are struggling with that tension that exists.

And well, and patients as well, you know, because there's an expectation from patients that there'll be a thing that will make them better and all the power is in the thing, you know, the, the drug or whatever. So if I did have the answer to that, that question mark would be be very happy, very happy. It's obviously difficult, you know it's. There isn't a clear answer. So so we we're just starting a new curriculum this September, three-year program, physiotherapy, and we tried as much as possible to do what you've just said and build a curriculum around that. And and that's not easy because, again, you know, there's all these tensions, like you. Like you say there's still got to be some guidance for students. You can't, you can't just say to students the world's complex, good luck. You know You've got to give them Something and some of that stuff still has got to be very procedural and you know, particularly with who are to patient safety there are, there are things we need to to ensure there's some certain packages of knowledge that go with that. But I think what we're trying to do and again, there's nothing new in what I'm going to say because you know, throughout history Things have been done differently and people have tried things. But if you know, essentially I think the point we're going to get to is is if we've got good clinical reasoning, we can. That'll help us a lot and we've always had that and you know. So, going back to Mark Jones's early statement, jones's early stuff on that, basically he was saying probably about the same what I'm going to say. I'll probably use some different words in it. But and but, the difference between the late 80s, early 90s and now is we have got this thing called evidence. But all that clinical reasoning module Idea would do says it will keep, keep the clinical reason, just just let the evidence fall into it somehow. That's a nice thought, but again it's that's easier said than done and it still doesn't solve things like the problem of induction, like how can you just say that we saw that, so it's going to work now, and then that that will inform my reasoning. So this, there is still those, those problems. But Again, from an education point of view, if we can educate, if we can turn the mindset around from here's a load of stuff, learn it and do it to here's a, here's a lot of mess, let's learn how to work stuff out, and Then you've, then you're a quick, quick for life. And again, that's not a get-out clause, it's not again, it's not that that just say, well, we're working town. It's giving some real, real, proper tools and ways to, to use science and use and this is the a bit of a crux of it as well the clinical reasoning process Probably maps closer to what people like Richard Feynman would say he is Signs than a randomized control trial, because what we do in good clinical practice is really think and listen to the patient and engage with them and you know, factoring things like the risk of sort of just throwing everything at them over the treatment or whatever. We try something and we and and we work with the patient to see their response for that and adjust it accordingly and Respond for that. So we're control, we're sort of controlling Things a lot more than could be controlled in a trial. But that control is now context-specific and Embracing of the complexity, because you're responding all the time to two different things. I I gave a Talk recently. I was over at the Canadian manual therapy group in Winnipeg and they were just amazing, but was talking about manual therapy and this sort of thing bit Not as deep, I don't think, but this sort of thing and I was talking about the way we teach and learn manual therapy here in Nottingham, which is a bit different to sort of a lot of places, and Somebody asked a question and they said and I was talking about this basically that I'm on your therapy, need It'd be so protocol driven or sort of system driven or whatever, and is, as long as you're safe and comfortable in what you're doing, is efficient, you can work with the patient to do that. Somebody said well, how do you know what you did last time, how are you going to notate that and how you're going to do exactly the same thing as you did last time? And to me that's missing the point. You're not going to do the exactly same thing as you last time because things have changed. The context, the world, that little world you're dealing with you and the patient in their world, has changed since last time. So you, therefore, you need to change and adapt. So we are. We are literally little walking scientific labs once we engage with the patient and we can do that. But it does rely on a sort of readjustment of an idea of causation, and which is what we, which is why we presented disposition as a more reasonable explanation for what you see in health care than than the traditional scientific ontology Of causation. But teaching all this stuff is not easy. We can't just go into a group of 18 year olds and say, right, let's talk about this position ontology today before we get going. So you know, you just have to do it in in very engaging and accessible ways, whilst not dismissing at all the value of what science has got to offer, which is some guidance and some Direction. But it's not the answer to everything that we see in health care.

Yeah, yeah, it's always interesting and I know I have this kind of tussle myself just internally, like you know. You almost want to just more the ship to the dock and not take it out on the sea because it's much more comfortable to more yourself to Very black and white, objective ways of looking at the world, of there's a or B choice and that's about as complex as it gets. Yet when we get out in the clinical world, man, and there's just so much complexity and and and I agree I think, good clinical, sound, clinical reasoning skills, it almost becomes you have to get comfortable and discomfort and uncertainty and complexity that exists, that you can't avoid. You can try to and pretend it doesn't exist but but dang it, there's not going to be. Nobody's going to bet 1000% or 100% with patients on you know this intervention work and even within the same patient one one day this treatment works well. Like you said that that unique N equals one research study changes the next time they come in the door. There can be different, there's different factors that play there in a different point in time in their journey. So yeah, it's, it's. It's fascinating stuff to me. It's what makes clinic fun. Again, as far as like Embracing that challenge and embracing an uncertainty and trying to find and it kind of gives you some creativity in the clinic to where you can kind of see what today. You know, maybe I do have some information from what responded in the past and maybe I'll try that. But if it doesn't work, well, man, how do I Get into that with that person and see if I can move them again in a positive direction? So what I also will do in the show notes is link our unpacking of the complexity of evidence of whole master class. We had David Nicles, we had Roger, we had mcthacker, we had Matt low, we had Ronnie. You will talk about this position is I mean you can watch that we had A few on a Moffat who did an amazing job with her, her talk. We had two patients. We had Tina price and Jillette Belton who would kind of share their perspective as a patient. I think it's probably one of the more. I mean obviously I'm biased in this thought process but I think it was Underappreciated piece of work from just a lot of brilliant people. I was just fortunate enough to hang out and listen and learn from a lot of the folks on this. But I will link that in the show notes we have a whole free YouTube playlist of that you guys can all guys and girls can all listen to and watch to kind of see how this stuff if you want to go a little bit deeper into it because I greatly appreciate Roger and Ronnie and Matt low and David Nichols is going to come on David's going to challenge my thinking, as he always does, but it's it's just fun having these discussions and I think there's just a lot of hope to that. There's ways we can move forward and deal with this complexity. It's not like, oh my gosh, it's complex and it's just this evidence based health care thing isn't going to work. I think Roger's done a great job of showing how those are still important things we're doing in evidence based health care randomized controlled trials but it doesn't always account for the complexity we see it. But it can be part of the information we gather To engage with that complexity and hopefully move people forward in a positive light under our care. So, roger, I want to respect your time. I really appreciate it and I've greatly one of the better improv performances I've ever seen on the podcast I should have prepared. Honestly, I was very impressed. Like man, he's just doing this off the cuff. You should. You should be doing improv for For a living, but no, it was great. I really appreciate your time, I really appreciate the work you're doing. How can folks get you know, follow you up? Maybe there's some social media places. I know I've nudged you well, you're nudging yourself to to get the podcast back, but maybe you can talk about that. You have some episodes recorded that I know folks could get some value from, but maybe you could share Kind of where you're at and where people can kind of view some of your work.

Yeah, well, I did Twitter at Roger Kerry one. The podcast is mainly about higher education, not specifically about physiotherapy or health care. We bring everybody in. That's called anarchy in the age and it's had a little bit of a holiday, but we're hoping to get so well, we are planning to get some really good guests back on that again to talk about those challenges of how you teach this stuff, or you are, more important, to have people learn about this stuff. So, yeah, look out for that in the coming weeks or months and if you're ever over in Nottingham in the UK, just come by and have a beer and a chat.

That's an open invite to everybody.

There we go. Go have a beer with.

Roger Kerry, I know I would definitely do that and I'm hoping to one day get over to the UK so I can share a beer with you, sir. But again thank you for your time and those of you who are in education space definitely should be looking at the podcast. You can obviously see the tensions and we see it. I'm not as much in the academic, I'm in the clinical faculty and our university where one of the most important things is more mentoring clinic. But it's interesting just to see real time that tussle that students come in with of a very empiricist way of looking at the world and then facing patients where it's and trying to help them navigate that uncertainty. And folks like Roger and the others we spoke about on the podcast. They were huge helps with me that for. So thank you for that, roger, and again Thank you for your time today.

Thank you so much, mark. It's been a pleasure, as always.

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This has been another episode of the Modern Pain Podcast with Dr Mark Cargilla. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincarecom. Also visit the Pain Masterminds Network on Facebook for free education and resources. 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.