Using Improv to Improve Your Practice.

Mark Kargela: 0:00

Research has clearly pointed out the effects the context we create in treatment have on outcomes. If you watch a master clinician in action, you will see if you look beyond the techniques. Watch how confidently they communicate both verbally and non verbally. Watch how confidently and comfortably they deliver techniques or exercises. The performance they put on in front of a patient can have a big impact on how well the patient will respond in intervention. This is why you can deliver the same technique or exercise and get different results, even though you felt you delivered it exactly the same way technically. If the performance matters, then it would make sense that we should aim to get better in our performance skills. Before you light me up in the comments, ideally, the context we create is around an intervention that has scientific plausibility and merit, but it should give us pause to consider that maybe some of the interventions out there function mainly, if not fully, on their performance aspects. So this brings us to this week's episode where I interviewed Logan Buckley. I got to know Logan in our Modern Pain Pro community and as we had discussions around ways we can improve communication, he let me know he was involved in improv. To me, the best clinicians are able to be master improv performers. They're able to adapt their conversations and interventions to the uniqueness of every individual. When explanations or interventions fall flat, they're able to adapt and adjust on the fly to find a positive road forward. In this week's episode, we discuss how improv can enhance our communication and how it's a huge help when we navigate the uncertainty and complexity we face in the clinic. Logan also shares how his focus on authenticity versus mimicking his mentors really helped him grow and improve. As always, don't forget to subscribe wherever you're listening or watching the podcast so we can spread a better message around pain to more people. If you want to go deeper on conversations around a topic like this, make sure you check out our community at modernpaincare. com forward slash community. Now onto the episode. Welcome to the podcast. Logan.

Logan Buckley: 1:43

Hello.

Mark Kargela: 1:44

Good to have you, man. You know, uh, got to know you a bit as you've kind of joined our community, modern pain pro community, some one of our founding alpha members. So really grateful for you that, but the nice thing about the community is I've been able to get to know you and some of the other members and kind of hear some unique backgrounds and one of your unique backgrounds we'll get into. But before we do that, I'd love if you could kind of, uh, introduce yourself kind of. Where you're at, what you're up to, how far along you are in your, your physiotherapy journey.

Logan Buckley: 2:13

Yeah, I graduated. I have to think back now. I'm at that point where I'm like, how many years ago was it? Uh, so I think five, I've been out of school for five years, graduated in 2018, uh, went into outpatient orthopedics, um, and was there for, did residency, maybe six months out of school, uh, with Upstream and then decided. I got a little burnt out and decided to leave. I did pediatrics for a year and a half, and then I kind of had this urge, uh, my passion's working with people with persistent pain, and I kind of had that urge keep on coming up. In the year and a half, I was in pediatrics and found my way back into outpatient orthopedics. Um, got my OCS. This past year. So that was a big benchmark. I kind of set a goal for myself. Um, just have been kind of fumbling along, like all people, I feel like my first five years and, um, working at Providence, uh, in Oregon right now.

Mark Kargela: 3:25

Awesome. Awesome. So it's interesting existential crisis, uh, journey that, you know, it seems to be everybody's some part of their, their career journey of where we, we have this like, man, I'm kind of burning out. I don't know if this is my gig anymore. And obviously you found your way back. You know, the thing that got us to this conversation is, you know, we, we talk a lot about communication and. And how crucial communication is as part of our, our, our work as, as physiotherapists and it's a skill, right? It's not this, you know, we call it a soft skill, but it's, it's, it's probably the hardest skill we learn. And to be able to be nimble and agile with your communication is, is crucial as well. Um, and then you said, well, Hey, I, you know, I do some improv and I've known some other folks. I want to say our friend, Sandy Hilton does it. And there's other folks I know in the physio profession who do, who've done improv and it just. Makes so much sense to me of why that is such a helpful thing to do to improve patient care. I'd love if you could kind of get into how that even came to be. Is that something you've done as, as somebody in high school or when, when did improv enter your existence?

Logan Buckley: 4:27

So, I was a senior in undergrad, um, and I needed a throwaway class for, to stay a full time student. I had gotten into physical therapy school. I needed a throwaway class. I had to take an acting class or an arts class. in my, uh, undergrad, uh, for my, uh, arts and science degree. So I was like, you know what? I know the acting teacher. She's really cool. She has this improv class. Uh, my siblings never thought I was funny, so I was kind of more also doing it to be like, I, I think I can be funny. Let me try this improv thing. Kind of just to stick it to my siblings a little bit. I'm one of five kids. So it was really more just like, screw you guys, I am funny. And I just took the class, and it was my last semester, and I really, really liked it. And I, fast forward to physical therapy, I had ten days between finishing undergrad and starting physical therapy school. And I remember I, our summer, um, semester at Maryland, we had to do anatomy and we did nine weeks of anatomy. So we were in the cadaver lab nonstop. I just remember getting out of that class and all of my classmates are, they would get stress relief from working out. And I never had that. I am not one of those people that gets a lot of stress relief from working out. And I knew, I was like, I need to, if I will stay sane during, uh, PT school, I need to find another outlet. And I did this improv thing my last semester of undergrad that was really fun. Let me look if there's improv classes in Baltimore. And I looked them up and joined a class. And at first I was like, ah, this is just gonna be a stress reliever. This will be fun. I didn't really think anything of it and it ended up not just helping, uh, just socially and getting that stress relief, but it led to some of the best friendships I've ever had. It gave me community outside of my physical therapy school classmates, uh, gave me something to look forward to at night instead of studying. Um, and then now as we're talking, like we'll get into it, but it ended up as someone who's socially awkward. Um, and is diagnosed with a learning disability. It has really helped and impacted how I communicate with people. And how, what is, was, or has been seen as a deficit of mine for a long time. I think now actually in my practice is probably my biggest strength.

Mark Kargela: 7:31

Yeah. I mean, just getting to know you in the brief time I've gotten to know you, I would have never like pegged any social awkwardness or any of that. And I think it's obviously a skill you've built and I can just, in my story a bit, I think I alluded to in some of our meetings we've had is like, I used to be. Have massive social anxiety and probably would say social awkwardness as well. And it was just one of those things. I didn't do improv, but it kind of got just to where, Hey, I got to get good at this. And just got buried into like doing enough of these things and public engagements and things to where, you know, now I feel a lot more comfortable with that. So, I mean, good on you for, for, you know, taking the bull by the horns there and really. Like you said, I would agree that this definitely something that comes across as a strength of yours. Um, now with when we, when we look at this as a, as a physiotherapist, I'd love if you can kind of maybe look back as a DPT student. Cause I think there's this belief as a DPT student and I'm, you're, I'm happily if you, you disagree with any of this thought, but I just know as me as a DPT student, I was like, the communication was kind of secondary. It was like, I got to find the. magical thing with my hands or, or, or, or with some, you know, major, amazing special test or exercise was going to just be the key to, to solving these issues that patients came in with. How, how has that looking at improv and it's kind of role in what you were going to do as a physical therapist, how's that maybe changed over time? How have you seen that be? Maybe in your and maybe you didn't have that. Maybe you saw communication early on was a crucial part of things. But I'm curious how that kind of is morphed in your journey as a physical therapist, where you've kind of viewed it. It's place as far as helping your skill set.

Logan Buckley: 9:11

Yeah, I, it's something I don't think I Thought about too much. I think in physical therapy school. I was just trying to learn as much as I could I Think I knew that I was a likable person and although like Having have a history of like learning disability and stuff that I got along with a lot of people But I don't know if I really We picked up on the importance of language and communication, maybe a little bit near the end of our second year of physical therapy school. We got a little bit of pain neuroscience education, like stuff. We got quite a bit of it and it was like, Oh, communication matters and like placebo and what is a nocebo? And it's like, Oh, we can actually affect patients with our words. Then you kind of go into clinical and you're just picking up everything that your CIs are doing and trying to survive in it. I think once I got out of practice, I really honed in on trying to be a better communicator. Like, I was so worried about, like, nocebo stuff early on in my career that I, there was points where I wasn't thinking about it, but then I got, like, way over thinking about it. To my detriment, um, and then over time, I've, I think it was actually coming back, now that I'm thinking about it, I think it was coming back from Pediatrics, where I had to do Virtual Pediatrics for a year and a half, almost, and then going back into Ortho That I really started to hone in on communication And we, I worked in early intervention and we had to, we were a coaching model. And so I had to make differences in kids gross motor skills with just talking to them over a screen and giving parents ideas. And it was way more about my connection with the parents than it was, I felt, I think I gave the best interventions that I could. But sometimes it was just being their support system. Um, and I really started recognizing how that helps and then going back into orthopedics kind of changing that and, uh, being, honing in on some of what I tell patients or how I was communicating, honing in on my pain neuroscience education and knowing that I can, and then having success with it. Um, I'm kind of rambling, but one thing that makes me think of was. I recently, I thought, I'm so glad I did a lot of manual therapy early on in my career because that was a way I could change people's pain pretty quickly. It was a way to get comfortable with getting buy in from my patients. And it gave me the freedom to work on my language. Gave me the freedom to work on how to say things, how to present an exercise. And. So when I was ready to or when I started to like drop like manual therapy or not drop it completely but like bring it less Into sessions. I was having more success with not even Doing manual therapy on a first visit and people coming in and saying oh, yeah This was great from just and I just presented an exercise. I think correctly to what that patient needed But I wouldn't have been able to do that without the manual therapy allowing my language and communication to catch up.

Mark Kargela: 13:10

Yeah, no, I think, you know, you sound very familiar as far as I definitely can relate to that journey with manual therapy as far as that was our in road to kind of communication with a patient. And like you said, gaining by and I think that still can be that for patients. I, I do agree that you bring up a good point to with like this. I think there's this implicit assumption that it just has to be. Part of the engagement, you know, especially first on like, we got to get that buy in and stuff. And it sounds like you've had a similar experience where, yeah, sure there are times where there's expectations, there's various contextual things that would make maybe hands on care, you know, a possible good choice first visit, but I think there's pressure to do it visit one just because it's kind of eroded. I think research has put it in perspective and it sounds like you've obviously put it in perspective to to where sometimes just a good therapeutic building alliance building session of like, Hey, you know, listen, validate what they're going through, come up with a game plan, show them that you're invested in their goals and that they, that you truly understand their why, what they want to get back to. And I find similarly, like it doesn't have to get so. hyper technical with manual therapy. I mean, again, there's a time and place and we can definitely examine to see if there's there's things that might be worth passively, you know, doing a symptom modification procedure. But yeah, I definitely have found the same thing. I'm curious with some of your persistent pain patients, because you mentioned, I think, I don't know if maybe the improv background kind of makes you more, you know, to me, I just see that population as an immense challenge of like improv, because you never know, What the context and story to me, it's like an improv where, wow, what's going to come in the door? How am I going to adapt to what that patient's unique story, oftentimes some very challenging stories that come in. I'm curious, like just specifically with that population of a persistent pain patient where, gosh, the story coming in and the context they bring that you have to improvise and try to fit yourself to. And then the session, a session fluctuations that can change pretty mightily with patients. I'd love if you could share how you feel this, that improv background has served you in that, in that role.

Logan Buckley: 15:12

So, this is actually a great setup, uh, question for all of that. I've been thinking about this recently, since you asked me to do this podcast, and I'm like, how, what is it? And I think I've narrowed it down to a couple of things. Uh, the first thing, Anyone that knows improv, or maybe even people that don't know improv, know that the fundamental rule, the first rule of improv, is yes, and. So, you say yes to your scene partner, and then you try to add something to the scene. And, I feel like when I have people with persistent pain, I kind of think of it like, I yes and as much as I can, so that I can but later. So, in improv, you're not necessarily going to, the rule is like, you don't want to butt, but in, when you're trying to change someone's mindset about pain, you're going to have to say butt at some time. So, for me, it's yes anding, or as much as you can and so you can butt, and that's something I think I'm I actually do quite a bit or I even when I give pain education. I say yes. I understand what you're saying Yes, like I um people with hypermobility. It's like yes, I know people with hypermobility have More pain, uh, and then my little and is do you mind if I give some education about it? So I'm yessing validating and then that and is then I give them the educate like pain neuroscience education See how they respond and I asked like how does like any questions like when I heard about this? My mind was blown and just being authentic with them. Like yeah, I it's wild. I don't I, it was hard for me to like comprehend at first. Like I just threw a lot at you. Um, and so then I, sometimes people are like, no. And then that's also where the improv is like, okay, they denied kind of that. How can I, now I need to continue to yet. I need to go back to yessing and just yes, yes, yes. So then I can try to introduce it again later when the time's right. Um, and I think that's definitely. And not having expectations too. I feel like early on in my career, I expected patients. Oh, like I gave this, they should come back and they should feel better. And you're kind of setting yourself up to not be flexible in that session. Um, this might be a little bit, I try not to, I do chart review to make sure there's nothing serious going on, but I try not to do like a. Deep dive chart review because I want to hear the patient's story, and I feel like I'm more adaptable There were so many times early into my career where I would read The chart review and I thought this person they are coming in with persistent pain I was like oh my gosh this person is gonna be this or that They're gonna this is gonna be it like a hard case and they come in and they're like the most lovely person And are so adaptable to change and like take everything so easily I was like, oh and I had like I went in with just this negative perception of what I was walking into And so sometimes I feel like there is an over chart reviewing. Um in a sense we can kind of get a picture of what this person is in our head and Have judgment on that and I think coming in with no judgment is actually really important, uh, specifically with those people with persistent pain. Um, so, um, so those are a couple of, like, that yes ending. And then another thing in improv, uh, depending on which theater you study at, there's this idea of game. So the game of a scene is the unusual thing. It's that funny thing in the scene. And it's your job to pick that up. So if my scene partner does something weird, it's my job to either match it, to like, increase that weird, or even state like, hey, that's weird. And then that's usually where the laugh comes from, is that pointing out. And I feel like in, uh, with my patients, I'm always listening for that weird thing. What are they actually saying? So, um, I'm trying to think of a good example of this. A patient comes in and is like, Yeah, I didn't do my home exercises. So what I actually hear in that is, I don't like my home exercises. So what are they actually saying? What's the way, or, um, You're trying to pick up things that are unique to them, uh, I think differential diagnosis, this helps a lot too. And it's like, oh, I've been coming in with knee pain. I'm a CrossFit athlete. I don't have any pain during CrossFit. And, uh, but I have pain when I'm sitting for long periods of time. And it's like, okay, is this a patella femoral issue? Is, or, that doesn't sound like it matches, like what else could it be? Is this a nerve issue that we're, like, they don't do well with long periods of sitting and we need to get the nerves moving a little bit? Um, I've had, I had a patient recently, uh, come in with like running and it was similar. They were a marathon runner and they, just, things didn't add up and then I, Differential diagnosis. I was like, let's check your femoral and saphenous nerve and like did some nerve glides and Felt better and they had been being they had been treated with quad strengthening Exercises before and weren't getting better. So like things like that with differential diagnosis. I think it helps Picking up on things that they enjoy Uh, you might, they might, you might not ask it, but they say something of, Oh, I used to, um, love doing this activity. And to me, I'm like, oh, that's interesting. Why'd you stop? Um, so I think that idea of game and like, understanding what the unusual thing is, or, uh, what is that, what are they actually trying to say, uh, is something I've really picked up with improv. Um,

Mark Kargela: 22:24

Yeah. No, I love the fact to like, you know, there's this, you kind of allude to it a bit as far as this almost like scripted way of, especially when you like do a big chart review where you're almost just reading the script and the plot line that's led up to there. And then sometimes it like weaves you into that bias of like, this is what I should expect. And you know, as a. You know, young physio, you're going to use that to really, and it's still good to have hypothesis

Logan Buckley: 22:47

oh, yes.

Mark Kargela: 22:48

trying to rule out like red flags and all those things, but I do think, and you point out very well that it can sometimes preconceive and it almost biases your conversation, you know, and it should to an extent like, hey, we need to ask certain questions to rule out certain things. But again, this, this, this pursuit that we have as like traditional. biomedical minded clinicians is to kind of really have this A plus B equals C. So I just got to question out as many of the A's and B's as possible to see what's causing C. Um, and yet there's obviously we know pain is such so much more complex and the ability to go Unscripted where you, you go into this encounter with almost purposeful curiosity. And like you said, not just taking that, that answer for like, what's behind that? What's behind this patient saying, I didn't do my exercise because you can, what do we do as clinicians earlier in our career, non compliant patient, patient, not, you know, patient failing failed boat of therapy, but you know, it all gets lumped on the patient where obviously there's something behind it. You, you point out some, some good thoughts on it. Obviously the patient doesn't value them enough or something. Not going right enough to where they feel like that's worth their time or obviously there might be some other things going on in their world, but to have some purposeful curiosity of not just assuming, you know, there's something wrong with this patient. They're not compliant. They're just not listening to anything. Somehow that your interaction hasn't given them the reason to want to do it. So what's what's the missing piece there? So have you found that kind of really Okay. Uh, improv skill set really generates that purposeful like curiosity and your willingness to kind of delve into that muddy gray area. Cause I mean, improv kind of is the whole point of it. It's muddy and gray and you just see what comes out and you make some, you make some, you know, interesting. Interactions with the audience and with your fellow cast members and things. Now you're doing it with, with patients. Do you, how do you feel like that helps you navigate that muddy, uncertain gray area that as much as we want to paint and in school, we paint this very black and white picture of, well, you're going to put this on the ABC or D on your scantron and your board exam. And it's going to all be this black and white way of, of looking at the human in pain. And yet it is not what we see in the clinic. So I'd love to hear what your thoughts are as far as where you feel that improv is. served your ability to be comfortable in these type of situations where it's it's muddy and it's gray.

Logan Buckley: 25:08

Yeah, I think that's a really good question. Um, when I think of those muddy I think it, like when you With improv, you have to be willing to fail. And you've The amount of times I've done improv for I think now like seven years, the amount of times I've gone on stage and ate shit is, like, infinite. I, like, I You go swinging big, you think you have this great idea, and it just falls flat, no one laughs. And I think when you're coming in with those muddy situations, you just can't be afraid to fail. I think that's what it is, like you, you, and also coming in pretty, knowing that like you might not have the answer, you're not, I think that's really good. Uh, there's sometimes in scenes. The one, the scenes that I feel, there's sometimes I just don't know how to respond. It's like, yeah, I'm making this up on the spot and that's okay. And giving yourself freedom to be like, yeah, I didn't know how to respond to that. I did my best. It did not go, get a laugh. And then I, but I'm not going to dwell on it in the next scene. Uh, you can get informed by it. So the next time you are more prepared or you feel like you can practice. And I feel like it's those muddy, uh, conversations. You just have to have them. And you just have to go in with open mindedness. You have to go in with, uh, a sense that it might not work out. You might get a patient mad. Um, But that, that's, that's

Mark Kargela: 27:02

part of part of part of the

Logan Buckley: 27:03

part of the game. Um, and if But maybe it can turn into something where that patient recognizes something they've never recognized.

Mark Kargela: 27:13

Yeah, and it only happens if you if you're willing to put yourself out there, right? It's only happens if you're willing to get in those uncomfortable conversational spaces that exist in a clinical encounter that again might shine light on something that is a major Shifting point. It also might land completely flat. Like you said, um, I think we can all probably relate anybody that's had any conversations clinically with somebody, you know, has had them fall flat and fail. I'm sure we could have a whole probably season of episodes of our, of failed, failed efforts and attempts, especially, you know, with pain science and the thoughts of like, I'm just going to educate people's pain away. And that's how, you know, how I think some of us think about it early on. And then we realize, okay, Pump the brakes on it. It's part of the part of the discussion and it's part of the you know The plot but it definitely is not as with anything. It's not going to be a standalone One one shot and where the patient's making these 180s rarely Um, if ever so, no, I I appreciate you sharing that. Um Oh god, there's so many places we could go with it. Uh The, the, where would you recommend somebody as like an early career clinician, somebody who's really, maybe there's somebody who has social challenges and, and some, you know, we spoke to our individual challenges on the social front. Uh, how would you recommend somebody, I mean, maybe it is improv, but what, what, what do you think are some things people can do to get more comfortable having these type of conversations and getting into some of these. Muddy waters and trying to find comfort with it.

Logan Buckley: 28:48

Yeah. I feel like, for me And I was actually thinking along these lines of possible questions you would ask, and for me, it's really finding out who you are as a person and who you are as a clinician and what you're comfortable doing. Um, I, like, so I, I think back to when I first was, uh, uh, coming out as a physical therapist or at a grad school. I was, uh, like, I was in the closet, like, I was gay, but I wasn't out. Um, I wasn't myself. I was depressed. And that shows up to clinic. And the more in the last, like, five years I've become more comfortable with myself, the more comfortable I've been in those conversations. So, for me, improv was a great way It was something I found joy in. It's something that resonated with me. Something that I used to love doing theater when I was in middle school. So it brought something back that I enjoyed. So it was authentic to me. But I also know there's a lot of people that that's not authentic to. And I would be naive to be like, Just take an improv class and it will be perfect. And you'll be better at communication. I don't think that's I'm not naive enough to say that. It's finding, like, working on yourself and working on who you are. Uh, I really feel like in the last year and a half, I've really become a better physical therapist and I've really become a better, actually, improv comedian because I've more and more had my own voice. I'm no longer trying to mimic others. And I'm actually informed by others, but now the voice is my own. So like when I give, when I have those tough conversations, it's coming from me. Uh, and I feel like the only way to get better at it and find your voice and what makes sense to you is actually jump into the discomfort a little bit. it's, I think, I know me, I am an open book, I am a pretty honest person, I don't try to hide my emotions that well. You're talking to someone who, if a patient asks, how's your day, and I'm not having a great day, I'll actually say, yeah, I'm not having a good day. but I recognize that's not everyone. So my, I think that part of me allows me to have those conversations a little bit better. Um, but I think it's finding what works for you. Who are you as a person? What makes sense to you too when it comes to pain neuroscience? Like that's a hard thing to conceptualize. So as a new grad, don't beat yourself up if you don't have the perfect words for it. Try to like find what makes sense for you. And if it makes sense for you and you can educate it, um, and educate patients, like it's going to make more sense to them. If you try to do it a way, like you can be informed and you can mimic definitely early on to help find your voice. But it's, um, I would say as much as you can try to just be yourself. And I know that's a dumb, it might feel like a dumb answer, but being yourself really helps in those situations.

Mark Kargela: 32:42

I mean, that definitely resonates with me because I'll just kind of go back to my journey with like pain science, for instance, like I took a lot of it, you know, gobbled up Gifford and Mosley and Butler and then was was with Adrian Lowe's group for a bit. And I remember having those flashcards and having Adrian stories and stuff. And I felt like I was being Adrian trying to be Adrian Lowe in the treatment room with And nothing wrong with those stories and those metaphor metaphors and things, but I didn't feel like I was being authentic or organic. It was something where I felt like I still was pulling myself trying to be something that wasn't necessarily my normal natural self. And I agree. I think patients sometimes read that where I, you know, I, I, I get the premise behind the why you hurt box. I think it's definitely has been an overall help, but my only knock on it is, is it's just this, this kind of weighted kind of to be this unauthentic. Non organic stripped from the context of a conversation with a relationship with a person and get into this. Well, your car, your nervous system is a car alarm and you point to the picture and you still have this scripted way going. And so I, I love the fact in the discussions around authenticity and it's, I, I would agree too. I think we do mimic just to kind of mimic our mentors and mimic, mimic the people that we kind of model ourselves after. Probably our parents as well as we grow up and we can probably look at a lot of people who we've mimicked along our journeys But in the end we have to find our own voice you know, we have to kind of fly the nest a little bit and kind of get in that discomfort that is Life and definitely parallels more than just the treatment room for sure But I love what you said as far as really feeling like you weren't mimicking anybody you're being your true authentic self and that really has allowed you to really Uh, you know, grow clinically and have more success clinically, I think I would agree to patients see that and they see the authenticity of somebody in front of them versus somebody who's struggling to mimic and figure out their own voice. And it's okay. I agree. You got to lean into that discomfort. You got to lean into that mud and you will find it. You just got to be willing to put yourself in a discomfort to find it. It will heal. B failed conversations. It will be pain science stories that just make no sense to you. Even reflecting back that I know I can reflect back on some of my attempts at Metaphor and things that like, ugh, that did not go well. Um, but man, I'll tell you, those are the priceless parts of your journey to, I mean, you look back and you cringe, but man, if you don't have those, you don't grow. I'm just, I'm sure you have probably a litany of, of your, of your own, you know, challenges and, and, and missteps along the way. What, what would you. Say to some of those clinicians who are struggling to, I know you've already talked about the authenticity, um, part, but, uh, I mean, when it comes to pain science education, for instance. What have you found helpful to kind of, and you've alluded to having your own voice, but I'm curious, any other pointers you have for folks who are trying to kind of find their own voice versus the flashcards and the, the, the canned metaphors that are out there?

Logan Buckley: 35:39

so something that helps me One I've just I Try to give it a lot like I the amount of times I attempted to give it for people with acute pain for people with chronic pain for people with subacute like I I tried it a lot, uh, tweaked it, modified it, see what response, if a patient recognized it, like I tried to pick up, like, in my subconscious brain of like, okay, this person responded well to how I said this, maybe let me say it to this person, um, oh, this type of personality doesn't respond well to this, how, which, which one should I use, um, um, Reading body language, uh, trying multiple ones during a session. I had one recently where I tried the car alarm, didn't, and that's, or I used the alarm system, didn't work. I switched, uh, going from a dark room to a light room and something clicked. And I just switched the analogy. And, uh, I didn't give up, but I just switched it and like something clicked in that, with that one. Not being afraid to try multiple ones. Uh, I would also, I think also trying to tie it back, this is going back to that unusual thing or that game, tying it into a patient experience really, really helps. So being able to listen to what a patient is saying, and then being able to pick that up, and maybe they didn't fully get the, Analogy you've used the first day, but they say something where they're stressed out and they're in a flare up or they Had a loss in the family and now their pain is significant Being able to pick up on that quickly and like hey remember that alarm system analogy I used a couple sessions ago Yeah, do you think this may be impacting that right now? And they're like, oh my gosh, yes. I didn't even think of that. And then being, so being able to, maybe it's not your first attempt, but as you continue treating, being able to pick up on what your patient's saying, being able to pick up on things, and tie it back to what they Experience is where you probably have the most success and what I've gotten better at over time.

Mark Kargela: 38:21

great points. I think the one thing you talk about there too, is just like you're, you're kind of using, we call it like, I remember in fellowship, it's pattern recognition. You're trying to see what works with what patients in what context. Normally, traditionally, like what technique and what special test or whatever, you know, type of thing, but you can see, and I've stressed this over and over again, when we teach, as far as you got to look at communication, like your most powerful intervention, you mentioned not even just the, uh, you know, verbals, the non verbals, you being able to read it from a patient, but also how you're portraying yourself to a patient non verbally and all those things. I think it's, it's, it's powerful stuff that we take for such granted. And, but I think if you watch, Master clinicians or clinicians who are really good with with they're often amazing with people and they've developed some probably these improv skills kind of implicitly just through experience and things. I think being more explicit with understanding the role of these skills, these soft skills, which again, I'm not a fan of that term. But, um, and if you can just look at that as like, man, I need to hone this part of my craft because it's I don't know about you what I'd love to hear your thoughts on because for me, I feel like when I've really prioritized that my need to be this toolbox laden, you know, 15 million techniques to do things really kind of got stripped away to like still do some of the basics well and some of the you know, get people moving back to ways they want to move and calm things down, build them back up. That's about as complex I do. There might be some manual therapy stuff in there to, you know, to maybe help that journey along in the right context. But what's been your experience with the The complexity of your communication versus the complexity of your interventions.

Logan Buckley: 40:00

Oh, yeah, I think it's like, so I have a hard time or even when, um, I have like students shadow me or I had a physical therapy assistant student, uh, last year and It's hard to even, like, put into words how much I'm thinking about language, uh, when I'm with a patient. There, I might implicitly, on purpose, leave a portion of my pain education completely out. Not because I completely forgot it, because I didn't think it would be good for this patient at that time. But it doesn't. It comes off. Like, smooth, and like, nothing was, like, I didn't make any different choice in what I was gonna say. And it's hard to teach that. And it's hard to be able to, like, Oh, so, you know, during that pain education talk I gave, how I didn't do this, well, it's because of this and that, and It's just over, I, reps, and over time, uh, recognizing it, I feel like, better with my communication, the more simple my, even, exercises are. I feel like I don't even I feel like I actually had my PTA student, one of I giggled at this when she said it, when she was, uh, with me treating. I think it was her first week. She's like, oh. I didn't even think to bring exercises I do into the gym, into working with my patients. Cause most of the exercises I were giving were just modifications of squats, deadlifts, um, like front raise, lateral raise, overhead press, like nothing crazy, nothing like over the top in her words were like, Oh, I didn't even think that I could bring in exercises that I do. Into the clinic. I didn't think of that as physical therapy exercises. And I was like, oh. And I even think myself, as I've gotten better with communication, more and more of my exercises are pretty, um, like they're not crazy and they're pretty simplified and they're effective and we get the job done.

Mark Kargela: 42:25

Yeah. No, I would completely agree. I think, you know, the, you know, a lot of times too, is we're getting an act with brownie in our, in our group right now, as far as this whole values based and really point things to values. And then, like, to me, it's like, what are your values? What do you, what does life need? Would life look like if pain was less of a barrier? Once we identify those things, it doesn't need to be simple. If somebody wants to. You know, just do things that look like the thing they want to get back to and then do more of the thing you want to get back to. I think we, we make this, this assumption that there needs to be some sort of complexity. And I think to me, it just goes back to where we misplaced the complexity of pain. You know, we used to think it all lied in tissues. Therefore, tissue narratives got so overly complex and went into all sorts of. Fairytale stories of things we could feel with our fingers and, and, you know, rib flare, you know, all the, you know, things I'm sure we could all have a support group discussion about the things we were used to think we could do with the body. And then we missed the real complexity, which was that human being in front of us and how they're navigating this pain situation. And then how we can weave into that and I think it's probably a lot more about getting a human and especially the research still kind of tends to show that expectations, psychosocial factors, all these different things have such a more mediating effect. Not to say there can't be some times where mechanical treatments can't be very important. I definitely, when I had my herniated disc, there were certain mechanical things that were not happening for me and certain ones that definitely made me feel better. So. But it's just obviously we're talking in certain contexts, oftentimes with some patients, but we don't know that until we get to have these communications and discussions with unique people and get to see. And not make any assumptions with that chart review you talked about early on that it's going to be some mechanical problems strictly where we're going to give the patient a stage and are undivided attention and that purposeful curiosity that you, you bring to an encounter that you're, I think your improv career has really, you know, helped you develop, you can hear it in the way you talk about how you interact with patients, that there's that purposeful, um, um, Curiosity and I one more thing and then I want to kind of wrap it up and let you kind of finish off with anything you want to mention. But you mentioned this kind of I always feel guilty with students because we have students that come in twice a week with us. And I early career mark would just wow with like, look at this manual therapy technique and look at all these fancy exercises. And I feel like I'm so proud I don't want to say vanilla, but it is, it's not special, but I try to get to the across the students and I don't feel like they're in a space. I know I probably was definitely not in a space where I wanted to learn how to manipulate man. I wanted to learn how to do these amazing sports medicine exercises that when I would, if I were to go went to see or shadow me, I would think this dude is so basic and he's so like old school, like he doesn't do anything. Anything sexy or fancy and I mean, I occasionally manipulate still, like, you know, oftentimes more expectation based stuff, but, um, yeah, it's, it's, it's interesting how our practices shift over time and when we prioritize kind of the things that we tend to be the secret sauce that really move the needles for people. Um, I'm curious, anything you want to kind of leave us with today as we, I want to respect your time and I really appreciate it. I've enjoyed this conversation immensely.

Logan Buckley: 45:30

Um, one thing, just I'll piggyback off something that you said. I think it's also important to recognize when exercise isn't the answer, and I've been even doing that more and more. I specifically remember a case where, um, the exercises flared my patient up and, but when she didn't do the exercises, she was fine and could do her daily life as she needed. And I said, okay. And she respected me so much for it. I was like, yeah, this doesn't work for you. Right now, exercise is too much. It's not your priority. We don't need to do it. Uh, when you feel like you're ready, and you need some exercise, uh, education, and you need to get back to it, let me know. Here's my card. And she, we had a great rapport. There was nothing wrong with that, uh, interaction, and she actually left happy.

Mark Kargela: 46:26

Yeah. Yeah. I think we have this like implicit or just assumption that it has to be part of the gig. We're, you know, in a lot of the research manual therapy and exercise where it has to be part of the gig, but I think, you know, you obviously being a person centered clinician can hear that well, exercise doesn't like it and it makes everything worse. And can we structure some things, you know, and I've gotten creative with maybe it's not technically exercise, but it's the person pursuing the things that make them happy and feel like they're, you know, more of the person that they want to be, that pain's not stopping them from being as much anymore. Um, and I find that stuff to sometimes be more powerful than probably any exercise I've ever prescribed in the past. So, man, I really appreciate your time tonight. Anything else you want to leave us with?

Logan Buckley: 47:07

I think, uh, for me, what really helps, I think I put it is trying, mimic your mentors, mimic them at the beginning, figure out what's, but then really spend time and enjoy the ride of finding what works out for you. I don't, I think I stressed out too much, uh, about not doing things right. And now that I like, look back, uh, In my practice. It's like, oh, like, no, that was all, it was fine. I was just finding my voice. I was finding who Logan practices as, like, what, uh, makes sense to me. I'm still doing it. Uh, your talk about, we're learning about ACT here in our group. And, uh, I'm in the same process of like, okay, I think I understand what ACT is, but I don't know how I need to frame it. I want it to come more casual because I have more of a casual conversation approach. How do I do that? I have no idea. I'm feeling this is formal. I have failed quite a bit trying to implement it. Uh, so I'm still on that journey with like a new, uh, different method to think about. So, uh, just. Don't beat yourselves up too much. I wish I could I still beat myself up too much, so I'm gonna tell others not to.

Mark Kargela: 48:30

No, that's, that is great advice. And I think, um, words we could all probably take to heed or take heed of just because I think we do tend to be our harshest critic and feel like we always have the answer. And you've already talked about like being willing to be authentic. And I don't know, being a word that comes out of your mouth. I know I've, Got more comfortable saying that and I would agree. I think patients respond actually strange strangely really well to that I think they respect it that you're being a real person and not somebody who's this, you know Paternalistic, you know dictator of all that is right and the patient's all wrong type of so it kind of levels with the patient So again, thank you so much for your time today Logan really appreciate it. It's been awesome getting to chat with you I'll probably pick your brain more in our group about some more improv skills and Um, we'll stumble our way into getting better at act together.

Logan Buckley: 49:17

yeah, thank you.

Mark Kargela: 49:20

No problem, man. Well, you have you guys who are listening. We'd love to have you subscribe on wherever you're listening to the podcast. If you're watching on YouTube, we'd love to have you subscribe and, and maybe like the, this episode so we can spread it to more people. But again, we want to thank you for listening and we'll talk to you all next week.

49:34

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