From Telling to Guiding – Transforming Patient Communication

Ben Whybrow: [00:00:00] yeah, uni I, like many people was taught. What to ask, right? They teach you how to take a subjective, what makes it worse, what makes it better. There wasn't even the Peter Sullivan's line of, tell me your story. At that point it was just, how can we help? What's brought you here?

What happened, so to speak. Going, learning what to ask essentially. And you could have your template on your piece of paper at the time. This was before computer notes. And you just ask. And that was it. And that, I'll be honest with you, mark, that was it. For comms training, there was nothing about difficult conversations.

Mark Kargela: Welcome back to the podcast. Today we're diving deep into a topic that's at the heart of effective healthcare communication. How do we move beyond traditional, authoritative interactions to truly collaborate with our patients?

Our special guest, Ben Whybrow, joins us to explore the power of guided discovery, a communication style that fosters a shared understanding and empowers patients in their own healing journey. Ben, who has recently [00:01:00] joined the modern pain care team, brings a wealth of experience as a pain specialist, physio and host of the Clinical Communication Podcast.

We'll be discussing how to shift from a paternalistic approach to one that recognizes the patient as an expert in their own life and experiences. Want to put these principles into practice? We've got you covered. Head over to our show notes to download our exclusive guided discovery Clinical Companion.

It's packed with ideas, stem questions and dialogues to help you hone your skills. Now let's get into the conversation with Ben Wey Brow.

Announcer: This is the Modern Pain Podcast with Mark Kargela.

Mark Kargela: Ben, welcome to the podcast.

Ben Whybrow: Thank you, mark. Thank you for having me. I'm looking forward to this.

Mark Kargela: Yeah it's good to have you, man. I'm excited and I'm also excited because Ben has joined the modern pain care team. I've noticed Ben online and he talks and speaks in the same ways as far as, and has a definite similar thinking process. So that's what drew me to Ben's work.

He's got his own fledgling podcast that he's recognized as well as I have, that it's more work than probably [00:02:00] we'd like them to be. But Ben's joined 'cause he's gonna act as our community manager in a community course that we're soon to release here in the next month or two. That's gonna hopefully deliver some significant value of helping people really hone a pain practice in their own practice, be it with individuals and or be it with groups, and really have a structure and a framework to go off of that you can immediately start making impact in your community.

We'll talk about more than that as time passes on, but if you're interested, definitely check out the show notes. We'll have some ways you can sign up if you want to keep abreast of those developments and when things are released. With that said, Ben you're a second time appearance here on the podcast,

but if you can just kind give people an update where you're at, what you're up to.

Ben Whybrow: Sure. Actually things have changed a bit since we last spoke. So yeah. I still clinically work as a physio here in the uk for our wonderful NHS as a, we call a pain specialist physio. I'm doing this in air quotes that people might not see. Seeing people like you Mark, who have got persistent pain, whether it's in one place or.

All over their body and trying to support them. As part of a MDT team, we have consultants, nurses, [00:03:00] OTs psychologists, and a bit more. And we, like you were just saying about groups, yes, we see 'em individually. We have our own pain management programs as well where we support them in groups not just individually.

Also, as you kindly mentioned to me, mark there about a year ago, just under now, I started my own podcast, you. Grateful for mentioning that called clinical communication to help spread the word and improve the comm skills. Not just for physios healthcare in general. It's obviously most of the listeners are physios or physical therapists at the moment.

'cause I know about 40% of my listeners are American apparently. It's yeah, it's coming along 42 episodes now, but as you rightly said there, mark, it is a lot more work, like parenting. It's a lot more involved than you ever imagined. So yes I've learned a lot over the past year and still doing a bit of teaching as well.

Still work at the clinical school teaching that kind of stuff, but that's where I'm up to now. And also obviously gonna be helping you with this program.

Mark Kargela: We're excited. We're in the, I'm gonna throw of finishing the final touches on, I've been [00:04:00] fortunate to work with Bro Thompson. She's been a big support and advisor in developing this. And then you're coming on board with, again, clinical communications. That's what a big part of the program's about.

So it, it's a great fit and we're excited

Launch it, especially I. Taking a course beyond what we've normally had, where it's just, here's your recordings, listen to 'em, and then maybe do an exam at the end. This is gonna be much more an active learning process where you're applying it, basically designing a course that I wish I had when I was trying to learn out, learn how and deliver this stuff.

But one of the things we're gonna actually talk about in the course that we figured might not be a bad idea to talk about today is communication again, but more specifically a different communication style. 'cause I think as we come outta school, we're very much. Wired into more of a, an authoritative kind of, people will call it paternalistic, where there's this expert and there's this novice in the room and you're really dispatching your knowledge upon the novice to educate and don't get me wrong, there might be a time and a place for that style of communication when it's invited and when the context is correct.

We'll talk about maybe what that context is instead of, I think maybe traditionally that was the context. That was just the nature of the inter [00:05:00] interaction. It was very much. Prescriptive information coming from the experts to the person who doesn't have that expertise. So the whole point of kind of guided discovery is sharing the expertise in room. And you've, if you've listened to the podcast, we spoke to shared expertise.

The third space, things like Cohen Quinner coined in their writings, but also. Just looking at the patient as an expert in their life and all the context that we know. If we're looking from

a complex biopsychosocial model that they bring to it, that we need, that expertise is stuff we need to know about to help them hopefully connect the dots in a very complex experience. I'd love to hear from you, Ben, just how you. Were maybe taught communication in school, how it was portrayed to you and how you conceptualized it coming outta school. And then as you saw patients and saw how folks are working with people with persistent pain and maybe some of the complex bi soc factors we see emerging in interactions, how that may have grown or what's developed as [00:06:00] time has

Ben Whybrow: So I, it's, yeah, uni I, like many people was taught. What to ask, right? They teach you how to take a subjective, what makes it worse, what makes it better. There wasn't even the Peter Sullivan's line of, tell me your story. At that point it was just, how can we help? What's brought you here?

What happened, so to speak. Going, learning what to ask essentially. And you could have your template on your piece of paper at the time. This was before computer notes. And you just ask. And that was it. And that, I'll be honest with you, mark, that was it. For comms training, there was nothing about difficult conversations.

There was nothing about behavior change, motivational interviewing, act, all that stuff, nothing. And obviously at the time when you're at university, you just assume that's what you should do. And I'll be honest with you, my placements. How it was that kind of came across as well that there was still quite biomedical.

But the, all of the [00:07:00] bio-psychosocial stuff we talk about was still quite, it was known, this is, but it wasn't talked about a lot. Everything was still very structure, pathology, resolve it. However, I left Uni and I always credit my father-in-law a bit for this 'cause he recommended the book how To Win Friends and Influence People.

You ever read it? Yeah. Yeah. Great book. So I read that at 21 over the gap between leaving uni and then starting work and. My father-in-law, I'll be honest, he's the epitome of that book. Okay. He's got a bit of charisma, a bit of charm, bit of knowing the right words, how to be at the right time and that experience.

Along with, I will say my, one of the last educator I had who Al also, I didn't realize it at the time of being on the placement, but after reading the book and some other experience realized, he epitomized that too. [00:08:00] 'cause he had. A certain rela, whether it was relationship, rapport, way of being with patients that just got trust, got, I don't wanna say buy-in, a feeling of care, feeling of support.

Just immediately they felt they were with someone who could help them, even though he hadn't done anything. At that point, he was just you saying hello, asking him some questions. But the his presence, if we call it that. Made it feel that way. When I had those sort experiences, which were good and helped open my eyes a bit, but obviously, no, this was over, we're talking 11 years ago now, so still quite biomedical, still quite structural focused.

I read Louis Gifford's aches and pains books about a couple years into working, and I'll be honest, that was the thing that really opened my eyes to all this. I that, those are the books that I recommend to any, not even physical therapist or physio, just anyone who's working in a [00:09:00] musculoskeletal field.

You will get more from those three books than anything else that's out there. You read them at all, mark? I.

Mark Kargela: Oh yeah

Ben Whybrow: you have.

Mark Kargela: huge proponent of those books for sure

Ben Whybrow: Yes. And incredibly well written. And even though they are, I say 10 years old now, they are as relevant today as they were then. And like I say, so easy to read. It's not a big textbook, which puts you to sleep.

There really good reason. Like I said, that was really what got me to focus on. Actually, it's not just the structural bit, it's everything else that's going on with it. And over time, reading other things, speaking to people like yourself, many other experts, and just having the patient mileage and my own interest in it.

And that's what I think, that's what grew my interest, I think. Over time our at least for my social media bubble, it appears that we're changing. I of, we [00:10:00] can't say the same thing for the whole profession or the whole of healthcare, but I feel that it's slowly realizing the greater importance of not just communication to get it right, but also the biopsychosocial nature of people's health as well.

Mark Kargela: all those books and I will definitely will link 'em in the show notes for those who wanna read them. 'cause they're definitely worth in investing some time in

Ben Whybrow: Yeah.

Mark Kargela: Gifford books. Sounded like he was re rehashing a bit of my career with some of the mentoring issues and stuff where he had like Geoff Maitland mentoring him. Amazing contributor to our profession,

Ben Whybrow: Yeah.

Mark Kargela: Recognize these patients that some complex pain presentations in his practice. And I saw the same thing in my mentoring. So it was one of those shining light moments when I was down and having maybe an existential crisis in my own career to, to see that, okay, he went through this and he really had a pretty, profound way of putting it in words

Ben Whybrow: Yeah

Mark Kargela: a motivational way to say, there's a lot we can still do. And that definitely drove me to, and it's hard to believe those were 10 years that is definitely. [00:11:00] Books you must read if you're trying to help somebody who's dealing with some persistent pain issues, especially when you're tussling with how we were taught

Ben Whybrow: Yep.

Mark Kargela: and the shortcomings that we're seeing when we're make putting on that clinical mileage as you put, and maybe seeing that it's not really bearing fruit with some patients.

I think it can really open your eyes to. helping maybe connect with those patients. So let's discuss a little bit about the guided discovery approach too. 'cause it, it gifford's way of talking about, communication stuff just meshes well within this, where this collaborative stance you're taking with a patient, and it's this Socratic questioning where you're having the patient you're almost sequencing questions that they're very open-ended, where the patient can notice

Ben Whybrow: Yeah.

Mark Kargela: Thoughts, test their assumptions and reevaluate their assumptions as you're and it really also fits well with behavioral experiments and exposure based

Where you're ha where you're really guiding the patient to say, what do you notice with that?

You tell me your pain's constant, can you talk with it? Are there any times where it's not or where instead of these open or these shut closed ended questions, which sometimes what to ask at uni is [00:12:00] sometimes what those questions were, what's your number on a zero to 10 scale?

Ben Whybrow: Yeah.

Mark Kargela: I'm wondering how you see the collaborative stance of guided discovery questioning and how you aim to have that kind of stance within a discussion with somebody versus maybe that more lead or. More directed, authoritative, paternalistic communication style.

Ben Whybrow: I think you alluded to it just what you were saying there about the open native, open natured, Socratic style of the questioning. You know what or how, essentially questions that start like that. You can't end with just one word. You have to. There has to be a bigger answer to it. And there's a lot of things that has already been said that helps us with this.

I mentioned earlier about Peter Rose and says about, tell me your story. Now. That's someone's, when you ask that question, they're gonna give you their version of their story, okay? What they've taken away. You may have in your notes or things you've read that actually something else has happened that they either haven't said or is [00:13:00] different to what they've told you.

So that. Open. Questioning that. Finding out from them what they've grasped really gives you an insight into them and you know where you need to guide them. Now, there's no guarantee, of course, that when we're doing guided discovery, they're gonna end up at the location we want them to end at. It may go a different way because they may interpret things.

Differently to how we perceive them, whether it's past experience, whether it's things that's been said either from us or from other people, but the power of, as you rightly said, those open questions, especially questions to ask about feelings I think as well. How, when this happened, how did that feel? How did you feel when you were able to bend down and pick up that pen, which you were fearful to do in the past?

What do you feel like when you can't. Put on your shoes as easy as you could previously. Feelings are very powerful 'cause it's more than just an output, if [00:14:00] you will. It's more than just a function. It's the emotions. It's there. These other psychosocial bits that we want to harness, want to get an idea about that add into it.

So I think that's key, to be honest. The first thing is open questions. You can't. Say, you have to be careful. You can't always ask every question open. Sometimes you have to be closed, and that sometimes helps you get to the point a bit quicker. But I completely agree with you that style of questioning really helps us first understand where someone's at, and then also then helps us try and guide this discovery you're talking about where we want them to experience.

Mark Kargela: Yeah, I think, there's such, nuance to every conversation we have. So there's not really guide or a guidebook, although we're gonna give you the opportunity if you wanna download a, a guidebook that will have listed, that just gives you some ideas, some stem questions you can ask, gets into the [00:15:00] how to ask, what it might sound like.

We'll give you some different dialogues that you can get and some. Some common issues we have where we want to slip back into advice giving and go into maybe or traditional way

maybe digging into some discussions with that. thing that I've found helpful is showing up and as far as when you're asking yourself to bend and do something to tie your shoes, what shows

that? And obviously a lot of people are gonna default too. I feel tightness in my back, or I get this pinch, in my hip or whatever it may be

and those are good things. Okay. Yep. That's understandable. What what shows up in your head? I'm just curious, is there any, do you have any, some people might mention they're a little bit fearful or anxious.

You have anything that shows up in your head when you're doing that?

How do you work to get to the 'cause? You're right. A lot of these questions can get into the depth of the experience where it's not just, you know what's the. Lumbo pelvic rhythm or things that maybe traditionally we were worried

to look at what's, what is the whole context that's showing up for that patient, not just physically and physiologic sensation wise, although that's important.

We Yeah.[00:16:00]

kind of sensations are showing up. 'cause then we can teach people skills things to, to respond to those sensations and maybe ways that don't ramp things up and move things more in a fruitful direction. But other strategies you use Ben to get to the. Cognitive feelings, emotions, thought you mentioned a little bit of earlier, but I'm wondering if you can kinda expand on that a

Ben Whybrow: Yeah. Yeah. So I think the first thing is to say that. You are, you can do this in multiple parts. So you've got different points in your assessment where this can come up and anyone who's a bit, I say undergraduate or fresh graduate, they'll, you will just 'cause of it all being fairly new or still getting used to it.

You will naturally probably go through the questions in order but as you gain experience, I'm sure you're the same. You learn to bounce around your questions. You can answer them in different ways depending on what they say. I always, first of all, and I think this should be routine, but it isn't in a lot of [00:17:00] places.

Ask as part, we do our past medical history screening, right? We ask about weight loss, we ask about fractures, we ask about surgeries, all this jazz. But I've yet to see a template that says, how is your mental health? I've yet to see it. And it's very simple. It's one question again, it's open, it's Socratic in a way, and it gives you an idea, first of all, not just where they are now, but you could follow up by asking maybe how it was in the past if they've had any other input.

So it gives you an idea of, I guess that's more general than specific for pain, but perhaps how some of those, what psychological elements in this case would be involved. I think also when they're telling you their story about what's going on, we said about feelings earlier. You gave some great examples as well.

So what were your, if someone says I went to a consultant who said I have the back of a 80-year-old. Hopefully they [00:18:00] don't say that as much anymore, but you still hear it occasionally. How did you feel after that happened? What were your thoughts about that? I. What did you think when they said this?

What effect has that had on your, since all open, as you heard me there? Say that All open questions. You can use it there. You can, as you hopefully ask if we're being, and the social side of things, we're asking about work, we're asking about hobbies and interests. We're asking about who's at home, what effect is this having on your, life at home.

What about your relationship? What help is your other half providing? Are they having to care for you? You are getting, and like I said, the last one wasn't open, now it was closed, but we're getting an idea of not just where it hurts, what makes it worse, what makes it better, but also get an idea of the effect because you're then gonna finish your assessment.

And when it comes to then. Having to do some [00:19:00] explanations, having to discuss about what's going on. And Peter O. Sullivan has touched us in the past as have others that when we're trying to where it's appropriate, explain back, then you use the story, if you will, of what's been told back to them in a way to, and then you can add in some, depending on what they know or whether you can add in information about, sensitivity and nerves and whatever you feel is relevant, but because we're being personal with it and because we're using information they've provided, it's more personal term, it's more relevant rather than just some generic spiel. As you said, we don't just wanna sit there, we don't just wanna throw information at the wall and see what sticks.

Because I'd also say, I'm just thinking of what you asked as well, when we come to explain it, if we want to avoid being the. The person taking charge, the person just solving said problem. We wanna know [00:20:00] what they know and we wanna know what they want to know. Potentially, they may know a lot people have come to see me.

I've probably seen a pain consultant, peanut pain nurse. They may have seen someone else as well. They may have been to some educational stuff. They may have done their own reading. 'cause use AI these days and all that jazz, they may know a heck of a lot. I'll be honest with you, mark my, the days of me giving some long explained pain spiel, the long gone I find now, I dunno if it's the same for you, that the amount I explain about pain has gone down rather than up.

Is that the same for you, do you think?

Mark Kargela: Yeah, no, definitely. I think the, to me it was another almost example of us trying to lead and really, to me it gives an option and I think contextually it can have its place. Definitely. It's much less than where I. I think it was early on where, if you had pain and you were in my presence, you were gonna get some form of pain or a science education.

There Yeah.

of major deciding factors outside of that. [00:21:00] But yeah, I think the explaining that stuff, I, being able to get to the whole breadth of somebody's experience and you get all these puzzle pieces of. What do you make of that when can bend in certain situations and bend

and it doesn't hurt where instead of this is where the effects of a contextual experience show up in, in your

and you start getting into this like long winded, drawn out thing where I think you can help patients more apt, aptly discover and lead themselves to that.

Maybe it's not. True because then you, you get into what makes you think that? What are, what's the

where are you getting the information to think that you might your back might, I don't know, go out or whatever it may be that the negative things are, but yeah, no, I, getting back to the neuroscience education it's much, much more nuanced and very,

I would agree rarely, I haven't drawn a and gotten deep into the alarm system or done too much of that Yeah.

Find that there's some benefits of, as we do these kinda discovery processes, really get to the. Breadth of all the complexity and we have the patient and I look at, kinda [00:22:00] summarize all this using some motivational interviewing have that have been going on around this. And then I sometimes will try to just loop in a little bit of discussion like when in perpetual distress all these challenging things that I reflect back to the patients you've been going through.

Would you be okay to say how, if I, we discuss a little bit of how that can affect. your stress systems can affect how you experience pain in your

then get into a little bit about it can open some doors, especially if they have overlapping pain conditions where other body systems are so in dysregulation because life has become a very challenging distress. Anger, emotion filled, frustration filled experience for good reason for some of the experiences people have, but it sometimes can open that door.

But outside of that, these days, I don't really get, I have not explained an ion channel to somebody and. although I got really deep into it for a while, so I agree. I think overprescribed as many new interventions are

and they're new and shiny and our biases is present and fully on, on blast.

But where else do you think some of the guided [00:23:00] discovery approaches have helped you in practice? There's been some things we spoke about before and maybe we get into this now where. Before we went on and we talked about how it's easiest for us to explain when there's a, somebody tears an ACL or

relatively concrete explanation, right? There's an imaging finding, there's a concrete diagnosis.

Ben Whybrow: Yeah.

Mark Kargela: That doesn't take much for us to figure that out as far as, and the patient to get on the same wavelength with the patient.

But then we see patients where. There isn't a diagnosis or many coming from many different people that are often sometimes conflicting in a nature, and then the patient, I'll ask, does that make sense to you?

Do you feel like any of those diagnoses makes sense to you? And they're like I, no, they don't. I don't know what's going on

but I. How do you navigate that difficult discussion? I know maybe a little bit off where we just were, where do you feel we can make some headway with patients when there isn't? Because this is where I know clinicians definitely have had this discussion with me as well, and folks I've mentored as far as like they feel like patients want to have this black and white [00:24:00] answer. This is it and this is and that's not gonna happen with a lot of these cases. I've found if you're very honest and open with a patient, they actually respect that just as much.

I'm wondering what your experience is and how you kinda maybe approach that where this ambiguity and uncertainty that exists in the room, but how do you still make a beneficial interaction out of that?

Ben Whybrow: Yeah, I think you're right. It's, especially, it's, I'd say it's actually harder, yes. When you've got multiple different diagnoses being thrown around. I. That is often harder when nothing is found in a way because they're still having to juggle different thoughts, different expectations, different prognosis in the air.

There's still that uncertainty is almost more prominent than if they've been through the battery of tests and whatever else, and it came up clear. At least that bit's done, and then hopefully, and then you can move on to the accepting and managing and moving forwards bit if there's still different diagnoses.

I, I will first often, I'll be [00:25:00] honest with you, unless it is bond or obvious, which in those situations it probably isn't, then I'm not gonna go and add another diagnosis into that and try and confuse the matter even further. I would say that if you've got. Someone who's going through the journey at the moment of different diagnosis, different clinicians trying different tests and different procedures and blah, blah, blah.

Let it roll. Let the process go on because a lot of this comes down to timing. Sometimes someone has to be ready, not just acceptance ready, but also ready that the diagnosis or whether it's does get labeled or if or nothing. Now, is it ever truly nothing? Then we do have terms to these situations like fibro miles or the general chronic wise per pain now and chronic fatigue and stuff like that.

But let it be the right time. 'cause I think timing is something that we just [00:26:00] don't think about. We think about obviously the structure bit, but we think about words that we say, we think about a bit more about how to say them in our tone. But it needs to be the right time for this person. I'd say if someone's coming in, like I said, if they've got multiple diagnosis, multiple procedures going on, let that all roll.

But find out from them, how can I help you at this time? What help would you like from me? What did you, the classics are a question of what you want to expect from us. What matters to you at the moment, because. If we are being, I'm gonna be a bit act here, but if we're being values driven, right? We're working towards what's important to them, even while all these other things are up in the air, and you may then just have to move along with it, wait for other things to fall in line, and then in time it'll be the right time for the someone who's been through the mill of testing and there's [00:27:00] nothing else to be found.

And they've now sat in front of you. Then I'd be saying again, what's your thoughts? How did you feel when they said your scan was clear? Your blood tests were all right? What's your thoughts about moving forwards now you can be a bit more optimistic in those situations. 'cause we can say we are, we're happy.

You're not gonna break anything. You're not gonna call yourself any harm. I'd say there's, yeah, there's space for, there's a lot of space for optimism in that. We want them to be less fearful, right? Now sometimes people will take that the wrong way and they will think here, great, I'm not gonna cause myself any problem.

I will go for it. I'll go start running my 10 ks tomorrow, get back on the bike, blah, blah, blah, blah. And then wonder why they've had a flare three days later. So there needs to be a bit of I guess safeguarding in that aspect, making sure they're not just gonna go. But, sometimes we look at these people who've.

With their fiber mys or whatever, and the tests are all fine and we sometimes get a bit worried. [00:28:00] But actually I think, as you heard me say that, I think there's, we can be optimistic because there's no restrictions and sometimes for some people that can really like a fire under them, that can be the bulb that.

Says, actually, you know what? Okay, tests are fine. There may be some other factors involved, which you can discuss depending on what you hear and what you wanna discuss and what they know already. But actually that can then set them up for this kind of positive spin on if nothing needs to be done, let's get you working towards your values and goals and what's important to you.

What about you? What do you think?

Mark Kargela: I think it's, I agree with where you're at. I think difficulty is when the person's in the midst of a lot of mucking about, you would say, with pain and doing all these different things where old me and ego driven me would maybe get a little bit. Kinda abrasive towards those other folks who are, but I was one of those other folks too that, [00:29:00] where I was trying to, manipulate it away or do some sort of MDT that was gonna get it, to go away.

So I've had to pump the brakes I understand, when folks aren't there yet in their clinical journey to understand that maybe there's a time to like switch gears and this isn't something that even though it feels good for a day during the session, it's not giving them resulting changes in life. I don't get as much confronting on the other practitioners. I just help people lead themselves through like, how's it working? How's it lasting?

And ideally at this earlier on in the discussion, I've gotten to what's meaningful or maybe a few sessions, and I really get this values clarification that's been done to where I know what it meaningful to them, what matters to them. Cause in a formal pain program. Where the person's been through it all and they're docs are finally hopefully saying, there's not much more I can do for you, be it a pain physician or somebody where we need to get you in a pain program. And this is where we're gonna try to help our physician colleagues around our pain program to recognize these patients and that this isn't giving up. This is just giving them another option where we have a pain program that's gonna give them a different approach that can hopefully give [00:30:00] them some success, but in the midst of when they're in the merry go round around medical merry go around of trying all these different things. You have to be able to respect where they're at.

Like you said, contextually, they're maybe not ready to make a different jump, but

if you help them explore what's they're doing, how's it working, it given or are they moving closer to their values, which is this creative hopelessness exercise that's part of Acts exercise that's would be weak one in our pain program you help people in either in an individual or in a group, you help them walk through everything they've tried.

What's worked, what's not long short-term benefits, short-term costs, long-term benefits, long-term costs, and then often with people, especially if they've spun through the system and they're not in the midst of the medical merry go round they can see that there's a, maybe a bunch of things lining up in the short-term benefits, like felt good, felt great, might be some few things.

Cost a lot in the short term, costs different things. But a lot of times the, as you help guide people through the exercise, you'll see a column that fills with. Things that gave a lot of short-term gains, but then when they go [00:31:00] to long-term benefits, there's just not much going on there.

Like they're not closer or anywhere to it. And that can be a tough thing for folks to come to terms , a lot of what we do is Hey, when you look at this patient or group, is this a matter that you're not trying hard enough? Where are you? Can you look at that and say you haven't tried hard enough?

And most, I don't think anybody can look at all these things you've been doing.

And medicine's been pushing you to do all this, and I've often recommended a lot of these things for people, it's, you're still where we're still not where we want to be. Like what, what shows up with, and then I'll have folks like, when you look at this what kind of is showing up for you right now?

To see, and oftentimes it's, some people get emotional, be it, teary-eyed or angry and it's you, yeah, these sort, this is real. This is a struggle. And that's where you hopefully open up an opportunity for them. Would you be willing. To try something different, but in the midst of the person that's in the not there yet, they're still maybe line packing their short-term benefits, column full before they're ready to look, that it isn't getting 'em the life they want. Then I just said, let's [00:32:00] focus on getting the life you want. If it's still people that are, spinning the wheels of, Nope, this needs to get fixed, this needs to get fixed and I've had to have some of those conversations. Maybe I'm not the person for you right now. And, you leave that open invitation for somebody that if it gets to the point where you feel like you've tried these things and you're still not getting to the life you want, then I'm gonna be here for you and I'm happily we'll start this thing, we'll get you moving maybe in a different approach. How do you deal with that too? Where folks are still No, I wanna be fixed. No, I wanna be fixed. No, I wanna be fixed.

Ben Whybrow: I think we have a mutual friend in in Jerry Durham. And he said something to me once, which I completely agree with in that things often go wrong when expectations aren't asked because you can. Say, you can clarify expectations and then you can either say, you can try and beat them or not.

And if you don't, if you say, oh you can't, this, being able to meet their expectations or actually what you're able to [00:33:00] achieve is maybe not in line with what's gonna be possible. That's much better than a false hope. And then wasting everyone's time in a way. Obviously if you can meet the expectations, great, go for it.

But. Setting the expectations early on, first time you meet them, but at some point during your, probably at the end, towards the end of your first session, and then, if this, in this case, we've got someone who's still looking for a fix and you're telling them that it looks like you've been for all these tests, been for all these things here, bad surgery, injections, what have you.

What I from ask them, actually, this may be helpful for some people. What have you been told by the others, the other people you've seen now? What did they say? 'Cause I have a my boss has a great phrase, which is sometimes people are told but they don't hear and they may not have. Now [00:34:00] the reason they don't hear may be because they didn't actually hear it, which is rare.

Or they chose not to hear. That in a way, if they've been, if you can clarify from them what they've been told. They may have been told nothing else we can do. This is gonna be long term, but there isn't a fix. They may have been told that already. And then we get back to your great point and questions about, so what your thoughts on that, what's going through your, what was going through your mind when they told you this?

What's, how you've been feeling, what you been wanting to do about this since I. If they're still wanting to find the third, fourth opinion to see if they get a different way that can fix it, let 'em go for it. As you rightly said earlier, if it's the right time, great. If it's not, that's okay too.

What you don't wanna do is set a false expectation that then doesn't come to light, and everyone's frustrated. Not just them, but you, the [00:35:00] service, et cetera. They. That's okay. Sometimes, we have that and all other aspects of life as well. You may have a problem with your, I dunno, let's say electricity, which you think is a minor problem, but then actually electrician comes down and says, oh no, sorry, that's gonna need a lot more than what you thought.

You may get another opinion that says the same thing. Or someone's totally different. We have this at all aspects of life. It's no different in healthcare. Obviously it's affected. In this case it's pain. But if you ask clarifying expectations early and finding out what they've been told and where they're at with it and see where they wanna go is, and then this is more closed question, but is this the right time to try and manage your pain?

Or you still want to try and find the fix? And we've got, we've both seen plenty, not, I'd say it's less than it used to be, but there's still people who just, it's not quite the right time. They can, [00:36:00] if you've built, even if you've done nothing and just assessed them and clarified, it's not the right time.

If you've built some rapport, built some, a good, decent relationship, when it is the right time, they'll hopefully come back to you. How do you manage it when they come in,

Mark Kargela: no, that's exactly pretty much how I would go about it for sure. As far as help them unpack where they're at. Some people you know, are in the midst of still trying to fix and, you have a open discussion and have them kinda explore what they've been doing, how's it working? And there's, you can just see that it's not working and they office.

I've had people point blank say that and I'm say I it's, we see a lot of patients where they've been trying all the things, and I can hear your experience that you've been busting your tail to get this thing to, to improve. And unfortunately it sounds like it hasn't gotten where you wanted to. We have a program that kind of helps folks in your situation maybe take a different approach that we found can give you some significant [00:37:00] benefits in life, would you be willing to try a different approach that maybe works on that and then introduce, some of the things that, like our pain program and or maybe it's a cognitive functional therapy type program or whatever it may be.

There's plenty of things out there, but one that no longer sitting on the sidelines. Until pain's fixed. This is get off the sidelines into life and learn how to keep pain. We respond to pain at a way that keeps us on task with our values in the person we wanna live by versus again. I have a patient right now, she's talks about how she's like a full-time patient.

Like her weeks are pretty much planned on medical appointment.

She doesn't have any time to 'cause for her to get outta the house is just, and to get prepared and to get ready. That's a massive undertaking for her. So she's doing making some big changes just because she's permission to not seek to fix and it's liberating for her, right?

That I, and she, we've talked the drop the struggle analogy and there's been the struggling in quicksand analogy and things we've used where sometimes the struggle is the problem [00:38:00] and it's this constant tussle with symptoms and there's nice, some nice ways you can kinda. Structure some conversations to have people explore that there's exercises and act and various other things where people can explore that. But if, what do you think are the kind of skills or resources out there? Or how would you recommend, obviously, selfishly we would love, have folks, 'cause my thing is we need to get people better able to have these conversations to help people. There's a lot of good people teaching it, Joe tatta, ourselves Peter o Sullivan's group's doing some good stuff. There's many others. So what do you think, if a clinician wants to get better at these skills?

There's not really a textbook. There is a textbook, there are texts that can help people in these type of communication skills, but where do you sit with and then just get in reps and that you can only read so much before you

get in there.

And I always say, you gotta suck to get good at something.

Ben Whybrow: Yeah. Yes. And then I, yeah, the textbooks, I agree. The irony that some of, [00:39:00] and these are more medical ones, but the prominent medical communication skills textbook is. I'll be honest with you, mark. So we were talking so much praise about Louis Gifford's book, I would say, and that's so easy to read. It is so hard to read some of the communication textbooks given the, what's being discuss discussed in those books.

I think yes, you're right, there's a combination of reps certainly that's probably the biggest player in it. If we were to put obviously our excellent resources in this, project we're putting together as well. Put that to one side. I think we can also learn from other industries as well. Things like marketing, sales in a way.

Not that we're trying to. Sell per se. And I realize that word makes people sound a bit uncomfortable or feel uncomfortable at times. But there, if you were to go to a car dealership and try and buy a car these [00:40:00] days they'd be asking you a lot of open questions as well. Things like, what do you do for a job?

How often do you need to drive it? How many miles do you need to do a year? What kind of pack, they're doing a similar thing, like we're doing to end up with a situation where hopefully we're getting to a point where the customer is choosing or selecting what's, and they're guiding the discovery towards whatever car it is.

So I think there's a lot we can also learn from other industries. I'm not gonna have, I don't have a specific salesman or marketing person. I'm gonna say, you must go and check out this person. But, medicine has learned, has taken things from piloting, for example, there's things they adopted out to increase safety standards.

We can learn from these other areas, which in turn can make our practice better. I feel I, I think that's where, especially with the future and how we're talking about we are get, we're pretty good at hopefully getting better with the words and we're very, [00:41:00] we as clinicians, we're trained to be logical and use science and data, but we have to remember that not the rest of the world is like that.

And just throwing facts at people and saying, Marjorie, your disc degeneration here. If you are in your seventies we can see that 70%, 70% of people in your age will also have disc degeneration or more, and they don't know about it. Marjorie may not care about that. Okay. That may be nothing to her, but what may be important, as you rightly said up, and we've both said actually is about what's important to you.

What do you want to get back to? For Marjorie, it may be playing with her grandchildren. She couldn't care about. Her MOI report, but that, but being able to look after her grandchildren while her daughter goes to work could be life altering for EV many people. What do you think?

Mark Kargela: I would agree on the marketing sales. That's something I dug into de Deeply for the last, I think I mentioned on a few podcasts recently, where mainly to [00:42:00] help clinicians recognize that they got a problem, that traditional education and they, learning more manipulations and more ways to in something isn't gonna solve this issue.

They need to have a framework and that's kinda what spurred on, development of this well, one, I guess backing it up, I do think. owe it to our patients to have some skills sell. And I'm okay saying sell, trying to take people and see how much I can empty their something to show that we have a valuable solution to what they're dealing if we have something that there's legitimate science behind,

There's legitimate, obviously anecdotal, we got patients that I'm, that are, can serve as social proof that our work, especially with people in their shoes.

Why wouldn't we learn the skills to be able to confidently help guide a patient to make a decision?

I don't think it has to be high pressure sales. We've all probably been in those

but let me hear about your problem.

Ben Whybrow: Yeah.

Mark Kargela: you make of that? All the things. Let them really put it all on the table and different things.

And you say here's, what we can offer. Here's, it's a different approach, type thing. And

I just [00:43:00] there's so much. To be said to, to just develop skills and not persuasion in a non-ethical way, but persuasion to persuade them off of the, just to even look

The fix approach and that there might be something else, even if you can open up the window for them to consider, that might give you another session to try and move them forward with something I think is worth learning those skills.

Ben Whybrow: Yeah.

Mark Kargela: As far as how we teach it, I think our focus is on, and I think we've all learned things good this way. Give people a scaffolding, like a framework, when we're building a house or something like we're building this this persistent pain, psychologically informed, well-rounded pain clinician house.

You need a framework or a scaffold to go around it so you can have something to give it some structural support as you're building this thing. And that's how we would look at program is given people. An eight week, it'll be a relatively defined framework with

And different things that people can kinda lead patients through.

Of course, those who you're out are very experienced. You might be able to go off script and off play because we've all learned things where it might have [00:44:00] been a framework of, and we've probably all learned, like you mentioned in uni the questions we should ask. And that

Ben Whybrow: damn.

Mark Kargela: very scripted and we might even had 'em written out and asked them in a specific order as we learned them.

But then eventually we went off script and we went in whatever order fit the situation in front of us. So that's how we would. Look to, to help people with this type of thing is give them a structured way to help people get through this. And then you'll be able to take that and then learn skills.

And that's probably, and also the reason we're backing it up with the community a mentorship community. Because that's one thing to learn this and then just go on your own and try it. This is why. Learn it, try it. Come back to your peer group, come back to your group mentoring sessions, and let's go through what's going well, what's not going well, and how do we help you.

Ben Whybrow: Yeah.

Mark Kargela: of navigate that. 'cause that's one thing I've, even when I was in fellowship, I mean there was a little bit of some online discussions and things like that and some meetings, but a lot of that was not where, it was this like peer learning, group learning, social learning activity where we're trying to help each other.

'cause I think it's also reassuring to see that the struggles you're having are struggles that many others have had. Ben and I have

Some of them we're still having, I don't think there's anything [00:45:00] that. that this game is gonna be something where it's ever easy.

Hard. Life's messy pain's, hard pain's, messy.

Ben Whybrow: Yeah.

Mark Kargela: a lot of difficult emotions, difficult sensations, difficult situations that. Some of our patients face, but man, I feel so much more comfortable and confident to, to navigate those uncertain situations that I have some sort of framework to go off of and community like. Part of the reason I do this podcast is it's like a support group for myself to talk to other clinicians and researchers

Support me in my kind of questions of what I see in the clinic and I can pose 'em to researchers and other clinicians who are dealing with the same things.

So any thoughts you have to leave folks with today here, Ben?

Ben Whybrow: Tell you what I was thinking about earlier when we said about, from the explaining side of things about, we, we've both been explaining pain less, I. We used to finding out what people know, what do they wanna know? I think we also should be clear that the last thing I've recently added to this of this is now a three.

What do they know? What do they wanna know? [00:46:00] What do they need to know? Someone may not want to know much. They may just wanna move forward, but they may need to know about certain strategies, whether it's mindfulness, whether it's pacing, whether it's certain type of exercise, whatever. It's to help them then get to that, where we, where that discovery and to help them get to where we're both aiming for.

You can make your values, you can set your goals, you can build all the great relationship and trust. And most of the time what they know is enough. But occasionally just I don't want people to take away here that we should never explain anything ever again. Because sometimes you, it is appropriate and it will help that person.

And I really like to point at that. You said about sometimes it's data and sometimes it's anecdotes because for some people the anecdotes is what will help guide not the data. We need to be, we'll talk about this more another time, [00:47:00] but there is room for both. I know as clinicians we're wired and trained to think about the logic and the RCTs and the systematic reviews and blah, blah, blah, blah, but not everyone thinks that way, and sometimes an anecdote or a story is more appropriate.

I think that's a good cliffhanger to leave people on before the next time.

Mark Kargela: we'll expand on these topics as we go, and we're gonna have a little bit of a topic series just to help folks kinda see. Just some just help. 'cause I think there's I've, we're trying to position these episodes as ways, things we would've liked to hear other clinicians talk about when we were coming up and growing into our, current situations, clinicians.

And we're still growing, as we said, I'm 21 years in Ben's not that quite that far along, but, still, we're still navigating difficult situations to learn how to better interact with people. trying to create a community of folks that are on the same boat. And we're fortunate to have folks that listen on the podcast.

I know, Ben, you got folks that listen to yours, that are on the same journey with us. So we appreciate y'all for joining us on the journey. If you have any questions, don't [00:48:00] hesitate to reach out to you either, Russ. We'll have contacts in the show notes. You also will put links to the books that Ben had mentioned earlier, the Gifford books and the other book we mentioned earlier on. And for those of you who are interested in possibly being involved in our pain program, we're gonna have it launch in here, like I said, within a few months to really give you guys the framework and all that stuff.

There'll be a little bit of a interest list, sign up in the comments as well if you want to get notified when that's gonna go off and all that good stuff. So we'll leave it there this week. We'll talk to y'all next week.