Chronic Pain Care: When Guidelines Don’t Fit

And I think that's the idea of a mind line and not of the guidelines. So the guideline informs. A mind line, but it is not like a slave that we follow them. That means also from a mind line concept. Then the moment that you have guidelines, then you have to understand from the guideline come from a population data, so we'll never completely probably fit with your patients. So you have also have to argue why should I follow or how should I deviate, modify based on the thoughts and are you able to ex make it more explicit where you're standing?

if you've ever felt the tension between what the guideline says and what the person in front of you actually needs this episode is for you. As clinicians, we're trained to look for patterns A plus B equals C. Measure it, treat it, retest it. But what happens when the patient doesn't fit the pattern? When the Oswestry score doesn't match the lived experience? When the complexity of a human life refuses to shrink down to a checklist. Today I am joined by Joost Van wijchen, physiotherapist educator, and deep thinker on clinical reasoning and professional formation. Joost brings a powerful lens to our work through the idea of mind lines, the implicit experience shaped frameworks that actually guide what we do far more than any guideline ever could. In this conversation, we explore why uncertainty isn't a flaw in practice. It's the reality of it. We talk about how clinicians can navigate complexity without defaulting to rigid certainty. Why patients aren't wrong when they don't match our models, and how a capability based approach can shift our focus from fixing impairments to expanding meaningful possibilities. If you're wrestling with outcome measures, educational models that oversimplify care, or the discomfort of not having clean answers, you're not alone. Let's dig into the messy human, deeply relational work of modern physical therapy.

This is the Modern Pain Podcast with Mark Kargela.

Love to get into the concept of mind lines because I think it's a good topic to kind of think of some of that complexity we see in clinic and and with even in education of course, as well. I'm wondering if you could kind of talk about what you saw in clinical practice or education that convinced you that. Mind li mind lines shaped our behavior more than maybe the clinical guidelines that we, you know, kind of rigidly try to assume everybody's adhering to. And it's, and obviously those might have some, some challenges as far as how they're developed with some research that kind of looks at some more population statistic norms versus some of the complexity and, and, you know, uniqueness that we see in the clinic.

Yes. I think that this is an interesting question. Now we go and something which I really are eager to talk about. I think that when we from, we have clinical practice and we have con concept of what is knowledge. We constantly know from how is the reality that we live in? Is it objectified? Can we measure it? Can we see it? So we have quite a lot of different perspectives or conceptions concerning knowledge in itself and the world around us. So when we go in clinical practice, we want to do the best for our patients. So it's a kind of an ethical element and the best for society, but then it gets the question, what is the best? So we try to. Make it more clear. So to follow a guiding rule book. And at the same time, there's quite a lot of contextual elements and situational awareness that we constantly talk about. Those are definitely a little bit hard to pick up when we have population data and this personalized elements. So we have to measure that things. For me, the moment, the first moment I started reading concerning mind lines when I got into. Touch with John Gabby and Andre Le May from England, which was a nice story then was for those who don't know two general physicians and they start to research the best GP practices in England, how they worked. And they thought, oh, that must be evidence-based practice to the heart. So that will be Bookman book map based, and that was 2020 2000, 2001. Then they came there and. A computer was never open though. They are thinking, how do they work clinically? So they did an ethnographical study and they start observing what is actually there and then they figured out when, okay, most of the people, they have a set of. Ideas in their mind. So it's acknowledged in practice, in context, and that they consider it as a kind of a mind line and then you collaborate with each other. Now your question, what I see in clinical practice, I think that we as clinicians are constantly working with a client, with a patient who lives in an environment and they're quite, we have a certain understanding of the variables that are influencing them. And we also know there are some variables that we don't know and they don't know, but. We also know that patients has some knowledge. We have some knowledge, and we have some, as, some assumptions concerning reality. The moment that we understand what kind of, how this whole messy element of all those thoughts together is the mind line in which you build up your logic and your structure, which is also you can ask questions about. And I think that's the idea of a mind line and not of the guidelines. So the guideline informs. A mind line, but it is not like a slave that we follow them. That means also from a mind line concept. Then the moment that you have guidelines, then you have to understand from the guideline come from a population data, so we'll never completely probably fit with your patients. So you have also have to argue why should I follow or how should I deviate, modify based on the thoughts and are you able to ex make it more explicit where you're standing? And I think that. That means also from clinical practice, we work way more with uncertainty as we have always done. So if we go back in medicine, healthcare over the last thousand years, I would say it is standing in this party uncertainty. We didn't call it uncertainty, but contextual elements. And then you see, okay, what is possible? How can we influence what's the effect? So there's a kind of a. A learning into it. But the moment we want to go more into a world, which is as it is as we can control, as we can say it is, then we go more, okay, if we have this guideline, then we follow as if there's an idea, the practice will get better and it'll get better because we execute more. But at the same time, we also see the downside that some people doesn't really fit within the guidelines, so we have to move on. So I think that for me, mind lines. It's actually the more implicit base on which you build up your discussions and also your rational in thoughts, processes, if

Yeah, I love it. And then kind of brings up that tension between kind of. Our educational ways that we go after, we'll use physiotherapy.'cause that's obviously a common one that we share where guidelines in this linearity that we teach is, is kind of where, and it's hard, right? Because a lot of times we need to have some sort of objective measure for what, what's a rubber stamp of a physio who is, who is safe and ready to practice and, and will be a, a, you know, a, a valued contributor to the profession. It, it sometimes sets us up for this false sense of certainty. Maybe that that comes out. I know I, maybe you can speak to what you felt coming outta physio school where, you know, I, I know I felt there was gonna be these kinda linear A plus B, equal C, and then we get out, and yet we have all these contextual factors and things you speak of. I'm wondering if you could speak to a little bit of maybe how that kinda showed up in your journey where, you know, maybe this false sense of certainty was present yet. When you got in the clinic, we, we saw it was different. And then you work in some special populations, refugee health. You mentioned trauma-informed components of, of the experiences a lot of those folks deal with. I, I'm wondering if you could speak to how that kind of false sense of certainty maybe has evolved to a little bit more of a nuanced mind line approach where you've been able to kind of zoom out a bit to see that. Man, it's a lot more. You know, complex than, than what we've kind of maybe conceptualized it at. And we will get further on into how that gets into education. But I'm wondering if you could kind of speak to that and, and how it's kind of developed.

yes. I think there's an interesting element there because the moment that I graduated in 1995, I started in my first, I graduated in Netherlands, started my first job in, in Norway in a hospital. And then you got, you have this theoretical reality from this is how it's supposed to be. And then you see patients in a hospital. And for example, the first thing that I noticed growing up in the Netherlands and teach in the Netherlands, which is everything is flat and the whole world is two dimensional. So also the weather is quite. Stable so people can go home and they always live on the ground floor because there's no mountains. And then you come in Norway and then people live on an island. They live on the rocks and then announced we don't have rocks. So the whole environmental issue that the moment that a patient in a hospital is operated on an on a hip replacement, when you go home, it's not like they go on a steady surface. They go, maybe they have to go on a little boat, and then they have to go up some rocks to get there. So then you understand, okay, this doesn't fit. My perception. So there's more that meets the eye. So that was the first thing that follows. Then you also quite follow. Then even if you make a plan, then the patient don't follow the plan That was in clinical practice. The moment that you have with people with refugee experiences, then there are much more issues at large because that's also concerning safety, where understanding language elements beliefs concerning health con beliefs concerning sociality. So then. The whole reality of knowing goes from the body to being into the world and into the world, and most both the physical world, the social world, and the imaginary world that people live in. And you think, okay, this doesn't fit. That was the first thing for me that you have to navigate. So it's not like navigation. And the same time I was not so familiar with with philosophy or ontology or epistemology. So these were just words. Very far away from clinical practice, but the moment you start understanding from how do we conceptualize the world, then it starts to make difference. So when I started at physiotherapy education in Netherlands, I remember that one of my, one of the students came back from practice and she said, none of the patients. They're all wrong. They all come with a different pattern than actually should be with this problem. And then I think, okay, this interesting so that the student physiotherapy thinks that the patients are wrong. So what kind of a twisted world are we when we say patients are wrong because they have to follow the pattern, because the pattern, the ideas first, and then patients have to follow. Everything in clinical practice means that there's a lot large diversity. How it's behaving and we can we pick up this diversity because that's also where clinical reasoning is. Then it starts to make sense. We move more and more in a world in which we prefer to control because we want to understand, we want to make it controllable. So we know to have certainty. So we have, so we want to make it predictable. So we live in this kind of sense. And that was for me, for clinical practice. And then when I started working mostly with refugee patient, then you see there is not so much predictability'cause there are, there's a lot of stresses in parts that they don't understand. Especially when as a young physiotherapist you get what's happening also with manual therapy that you have a patient which has back pain. He was also the other part, but I noticed the moment that I had a patient with back pain and he came to me and I helped them to have less pain for three, four days. And then he come back and he said, oh, I'm so happy that I come back to you. And then afterwards I'm wondering, so I am becoming the solution and if I am going to be the solution, am I not part of the problem. So following. So there's a lot of ethical elements there that are starts to, to mess up in my head also, both as educator and as clinician. And I thought, okay, so what are the assumptions that we start with the world? And then they start to getting more into mind lines. So the way that we think and practicing. So the moment that we can understand as a clinician and also helping our students that the world is not as. Clear as we hope, because that's just an assumption. The moment that we understand that the world is also a bit messy, but there's some predictability in this unpredictability, the predictable is that there's diversity that we have to navigate this diversity. So that means also that we, as you say, there's some elements when it's life or death. We have to be very clear in the guidelines. So this is what we follow. And then the moment that we have excluded that one, it's getting more open. So the moments starts emerging for how do we work in this emerging field? That's not everything is either this or that. I think that this is something that for me, concerning mind, life, skin practice, in clinical practice, that we are so used to work in one concept. We vary the opposite. So it's either right or it's wrong. So you follow or you don't follow. That's probably the more spectrum, and I think most of the clinician also most of the guests, if I hear you and I hear the guest in your podcast, they make it more nuanced. So it's not either or. There's always some in between and. In education, we still have an idea in education, especially in the Western world, that education should be clear and boxed. Because then since we can measure what it is, but are we really measuring, for example, also in America, in the States now, when we use the, now we, maybe I go too far. When we go and trust the professional activities, when do we trust another person? That means that on competence is more than just following the rule book. And that means also that's a kind of an ethical dilemma, but now I'm connecting quite a lot of elements together. Yeah.

No, and, and I love the, the story you have with your student.'cause that's such a common one I we hear too, like they come back from clinical placements and the eyes are opened of, and sometimes I've, we've had clinic students similar where there's this frustration of nobody's fit in this, this guideline or this pattern that I've was taught in school. How do we get clinicians? What are some practical ways for clinicians to kinda maybe expand their, you know, mind lines knowing that they're shaped contextually and there's all these kind of variables that when we try to teach in a very kind of narrow guideline, kind of, you know, just so people can get con conceptually again, maybe have some ways to kind of measure, you know, safety in these different things yet. It doesn't necessarily reflect, you know, what a mind line ideally encapsulates when we're thinking about some of the things you've already mentioned, some of the environmental components that a, that a person's navigating in and, and other components, our own biases and things that we're bringing into the equation. And just a lot of, you know, gray, I guess I would say were, were that, but what are some practical ways maybe clinicians or teams can kind of help develop those mind lines to con, to consider this complexity and, and manage it? And make decisions within, like you just spoke to, instead of this relentless pursuit of like this yes or no, or this right or wrong, where it can be situa, situationally something that people can take in a lot of this information and maybe form some, some dis some decisions that move this unique person that, again, may not fit perfectly this guideline that was developed, but it gives you some actionable ways to, to help move somebody forward.

Good question. And I think that's, first of all, most of, I think that most of the time we want our focus is on solution because we want to help. But in order to help that the solution is an answer to something. But so most of all, first of all, what is actually question? What is the dilemma? And here is something which is quite interesting because we. We structure already the solution in a certain frame without maybe knowing what is the question or before the question, what is the dilemma where we are standing in. So the moment we deal with each other to see if, okay, what is the trouble? There's a kind of troublesome ness where we standing in. So the patient comes to you, for example, in a clinical case, and they have a clear question. For example, pain. They want to get rid of the pain. But that's already a solution. So what is actually the question? What is actually the dilemma? Are the, can we discover together from what kind of what kind of dilemmas, what kind of variables are in place? Without moving too fast into the dilemma, I think that the moment that you have the dilemmas in place, the moment you dive a little bit under it is a team, for example, what kind of assumptions do we have concerning these dilemmas? So are we, for example, are we talking concerning these dilemmas? Okay. Are we are some bi biological system? Structures are some psychosocial elements, are some ecological here. Here's some digital health social environment. So we can have quite a lot of elements which are already conceptualization. So also have a knowledge base. So the moment you dare to explore with each other based on what's, which lenses. Are we using this? And it's not about right and wrong, but it's more to dare to be explicit. So this is my assumption. And by pronouncing that assumption for yourself, then at least you are, you're getting more explicit concerning your mind lines and others can discuss it. So something is in emergence and it's the same as patients also have, it's what is what is their assumption concerning it and I think overall. Overreaching this one, it's more instead of the different elements you go between the relation you're trying to search, what is the relationality between the different elements, which are the, which elements are on the playing field here? And maybe then we can even accept the app. Some elements at play, which we don't know and maybe will come to play. But then there's more an emerging element. And then already here I'm starting to push my mind line into the world. But first of all. Explore what kind of, what are dilemmas and how do we look upon these dilemmas? I would say I think that's the starting point.

Yeah. No, I, I, I definitely agree. I'm wondering,'cause patients come in with their own powerful mind lines, right? Of kind of where, what, what's with, what's their assumptions they're making, as you mentioned in this scenario, I'm wondering how we kind of prepare clinicians or what are some things clinicians can do to maybe tap into that?'cause I think you, you nicely pointed out that oftentimes clinicians, we have this assumption of what the dilemmas and what's the solution needs to be and what question we're trying to answer without even knowing like what might be behind that and what might be. Are we jumping to solutions before we really truly understand what the context is and what might be the thing that we need to, you know, maybe best help somebody move towards, you know, what is meaningful to them? I'm wondering how we can help clinicians maybe and, and maybe it's obviously gathering this narrative in this story and trying to really deeply understand the mind lines that are coming into the room both implicitly within ourselves.'cause I think you've nicely pointed out. That almost metacognitive piece where we're thinking about our, our thinking and, and how we're conceptualizing what is knowledge and our understanding of the world. And having that as like this conscious understanding of how, what we're bringing to the equation, how do we then have this person in front of us and, and try to understand that component to the best of our ability.'cause I don't think, I mean, we get. Taught that in physio school where, yeah, you need to have a good patient interview. Yet, I don't know if we really still give a good conceptualization of what information that gives us to where we can then have this kind of co-constructed interaction with somebody to hopefully move somebody forward.

I think that you put it quite nice and I think one of the dilemmas and it sounds like that we have described this metacognitive reflection moment and at the same time being back in a realism, we don't have time to that one. So you have a patient and you probably have half an hour. So for the first time, so we had the constraints we have the tendency to look at constraints as a problematic element. And I would say we have to embrace the constraints that we are in. So the moment that we meet a patient, that patient, the patient, the person in front of us has some expectations the same as we have, and the moment we tap too fast in, in the expectation because we think that we understand them, then we can go maybe and Norwegian is a beer service. It's a bad service. Er so we have to be careful. How do we tap in? Because this is, now you're getting somewhere what I will call between patient C and agency. So for the patient, C is the patient is Im patient, is in, is has ency, so they don't have control. They are awaiting. So that's also in the old sense, and we want to help them to find agency that they have. They can do something, they can influence it. So that's something, some, a goal that we probably have. And the patient also wants to deal something with it. I think that in here comes one of the Ambigu ambiguities that we're standing in. So we want to understand the patient, and the patient wants to be helped. We have half an hour, for example, and to be very clear, okay, so we have to explore and at the same time we have to come up with advice because that's what the patient thinks of. And at the same time, the advice that we give provides also per perspective towards the future. So if, for example, we don't understand the patient's perspective and mind lines, we should be careful in the advice that we give. The moment we the patient wants to be is very clear. It is yes or no, and you don't understand that it's not a yes or no. Then you do a very bad service if you give a yes or no. So then you have to keep it in the middle. But at least if on, based on what I know now, I would give you this advice, but we prefer to see how this will fit out for the next three days. Can you come back and then we can discuss it and then we can explore a little bit more. Actually what we do in assessment and treatment goes a little bit hand in hand. I think in this sense, it's understanding the, I have to start thinking I the question of the patient and also your own ex, your own expectations come hand in hand here. Don't drop too fast in this conclusion. At the same time, understand that you need to give something because that's the expectation. Because not giving something is also a problem. And this was quite interesting the moment that we worked with refugee patients and the time I had refugee patient was quite a lot from Chena. That was the first time that was ROAR in Russia from Chena. And they get from a trauma, they were used to go to a physiotherapist. You get fixed or something. People do. So they at least. So we have to ask quite quickly. They are, they expect it to be touched. To be done with something. That means also I could try to do something and at the same time asking them what do they expect? And I have to be honest what I think is the effect here without going away from the placebo. So that means also you building this trust relationship that takes some time. And I think that's something for we can do with patients. If I'm. If I may change it in another example, that's more from educational wise, and that's why we work quite a lot of'cause in education. We try to make it first understandable. So we break down the complex is difficult. So what we do, we make, we try to make it simple, but the moment we make it simple of understandable. We go away from the complexity. So if we are honest in education also to patients, if something is complex, we can't make it simple, but we cannot try to make the complexity understandable. That's something else. So there's a total different concepts. No, we started education, we didn't an in the Netherlands, we, in 2015 we did a different way of education for first year physiotherapy students. And we started on a farm and they just arrived. The first question, what I ask the students, what do you expect of this day? And they said, no, nothing. So we did nothing. We actually did nothing. We had the time, so we just drink coffee and wait. So within an hour, one of the students got mostly several, got very frustrated and start asking, why don't you have a plan? So I said, oh, you expected a plan of me. Why didn't you tell me? In that kind of creating a kind of a confrontation. To make sense. Okay. We have to make, be explicit what we want, otherwise it doesn't work. That means also that in the rest of the educational process, we start to work if it is always relational. And that means also that students at the infant are just chaos because chaos is not so dangerous. Those were the students when we were in the COVID periods with a lockdown. Everything changes, but they were not so much. Think, oh no, we don't have education, or we had different responsibilities. So they created our own education. What I mean to say also with the patient, the moment that we dare to challenge in a good way, what do you expect from me? What can I expect you? What will be the possibility? Can we see what's the effect? Is that the effect that we want? Then you get into kind of a more co-constructive way quite quickly. But it asks something from us as physiotherapists because that you might challenge the patient on a good way differently than we used to have.

The, and it's, it's such a, sometimes a tug of war with, with how we kind of have been biased to be trained, you know, definitely here in the States. I, I think that was fascinating, the exercise y'all did in the farm there. I think that would be, I'd love to see our students navigate that too. It would be just interesting thing to experience, but you've, let's get into it.'cause I think this kind of bridges nicely into a, a, a little bit of, you know approach to help. Co-construct this narrative and take what you've kind of discussed as this capability approach, which kind of goes against maybe traditionally how we try to, you know, conceptualize a patient case where, you know, it's impairments and limitations, right? Not capabilities. It's a very different way of, of looking at patients, but I think it gives us a windows to move forward, right? You know, when we have, you know, some things that people can. Move positively into and, and might, you know, have some ripple effects on other parts of their, their, you know, their, their situation. I'm, I'm wondering if you can speak to kind of how that capability approach maybe changes our focus a little bit of, you know, and kind of gets more towards what, you know, as we talk about maybe ACT related things, this whole values based approach. Which to me has kind of opened up, you know, it's been very helpful for me clinically understanding a little bit more about ACT and this values based approach, which. Again, sounds pretty similar to this capabilities approach. Like let's, let's focus on the things that really are meaningful and matter to you and are, and are things that we can leverage that you might have some strengths in your situation, and then we can kind of move out into maybe some more, more difficult territory, more if you can speak to about to that capabilities approach.

Yes, and I think that kind of fits, as you say, quite quickly in the previous question, what we talked about. So the moment we are so occupied where with functioning that we go directly to the functioning of the person's phone. This is what you want to do, this is what you can, but having the capability approach is having the freedom to choose to bring it into functioning. And to bring also into function the elements that you value based on your culture and elements. So here we get capabilities, are cons, constantly connected with the values that people have and personal or in their society. So that means that instead of asking what is the solution that you ask for? Now we go back. So you meet a patient also for a clinician from what solution do you want? But actually it's the question. Why do you want that solution? What kind of freedoms, which kind of capabilities do you need? Do you have the capabilities to bring it into functioning? So because not having the pain, for example, if you talk about pain or is one thing because that pain is limiting something else, or there's, that's a kind of a functioning. So when you go in the values, what people have. So they make sense of being social engaged or being able to to transport themselves in a certain environment or experience the garden or going to the movie be quite simple or if they have the possibility to show emotions. The capability approach from Nusbaum described means that we go more and more does do this person in front of me or with me. Does that person have the freedom to choose to bring into function what they want? And if we can help people in that sense to have that. Possibilities. Again, that means also that we go in to search together with them. What kind of values, what do they value? And it goes also from very concrete and what kind of function do they value? And it means also to when we go, what you say, for example, also an act in the acceptance one. Okay. What is the current function that I have? What kind of values do I really prefer? What kind of conversions can we make to bring it into action? Because we, it's not like we can fix things. That means also that you can accept more. This is the elements that we have. What kind of additional elements can we do to bring it into functioning? I think that to talk about the capabilities that people have or don't have brings also way more in the equity, health equity elements. So what we are working on, and people are not so familiar with that because they see people bringing in function that they want also of that they had before. But it is here is the thing. You're not always that you can't have what you had, but we have to re. Conceptualize it in a way the same as what we do with act or with conversations and fighting change. We change the narratives of people so that they can stay closer to their values. So it's a kind of a shift in mindset because the moment we focus too much on the functionings then we have a problem. For an example, the moment that I live here in Norway and imagine, I'm really glad of walking in the mountains with my door. So this is really something that I constantly do. I had an radiculopathy in my left leg and I get less and less problems. I get problems on walking in the mountains, and this, the worst thing for me was not able to be in the mountains so I pushed quite hard and was afraid and I won that functioning of walking in the mountain. So it was very. Clear, but when we started talking more concerning the capabilities, it's not to be possible to be in that mountain, but to explore being with nature, being with others, being able to transport myself and here gets the question, do I accept also that there are constraints?'cause now I'm 53. I have constraints. I can't run as much as I can 20 years ago. Or maybe I can if I train, but I have to start training. So there's always constraints in life. So the moment I go more to the capability, bring it into function. And if I want to have this going into the mountains. I want to do then I go, okay, do I have the capabilities to focus myself, to train, to to be perseverance in different things? Then you get a whole different storyline building up, and I think that's, for me, that makes the capability approach so them important to move to the next level and also to shift focus a bit from both us and from the patient.

This brings up an interesting question one of our community members had, because in, in school he's a exercise physiologist, trained in Austria, great, great guy, but we're trained like if you, if you're not measuring, you don't, you're guessing is kind of the thought. Like, so, and we have these outcome measures. You're a sweaty score. You are, you know, these things that, that really try to reduce this complexity to some, you know, just some quantitative number. And I wonder if we think about this capability approach, how does it change how we might define a good outcome? Because sometimes, like there's examples I have in my practice where I have patients who are ecstatic. They're, they're back doing things that are valued to them. They're, they're, they're, they're really tapping into their capabilities and moving towards values. It may not look like what they were prior to this pain situation or this injury, but they're, they're happy'cause they see life returning in a, in a mode that's. They're happy with yet. Their O Sweat street score may even be worse. I've had some patients where their score actually dropped on some of these measures. Yet if you talk to them, they're, they're happy. They're, they're ecstatic. They feel like they've really had a, a, a, a great, you know, interaction and a great time in, in physio. Do we need a little bit of a of a revamping of what we define as a good outcome or, or as a clinician who's struggling with that, where my o history score's not different, but man, look at my patient's life, which I'd argue the latter is much more important. But then when we have these systems that rely on reimbursement and payment for your, your, your statistical outcome measures and, and all these different things that again, sometimes move us away from. What really is meaningful to the person in front of us? I'm wondering how you would recommend somebody navigate that tension.

Oh, I love your question. In this one, I think this is both in probably also a philosophical question, and it is also an ethical question. First of all, we, if you can't measure, it doesn't exist. It comes from a certain perspective on what we know of the world. It's a worldview. It's a very positivistic or an objective fight worldview that the world ex exists outside of the world. World exists also outside our senses, so we can only, what we sense is there. So that's a worldview. And also our whole allocational system is built upon, and it's also based on reimbursement accountability that we have. That one. But the problem is that we put that worldview or that ontology, that paradigm as default, that's the only one that exists and here gets the first problem. So we have to acknowledge that it exists. So that's. A reality. It's not the reality. That's a reality that comes into place, which we definitely have to work with, but we also have this more interpretive reality. That is co-constructive. How do we construct the world around us that makes it less objective so that it's more interpersonal? We have a critical reality. What are the elements that we, that makes injustices? So how do we work with that one? We have an ecological reality of different paradigms, so all have a different way of knowing. So the moment that we look upon the methodology to make sense of the world. This measurement comes from one way of ontology, which is more, I would say post positivistic. So this is the objectified world, and that makes sense there. So then it's a consistent line, but the moment we start, as you say, how people experience their life, something that is more a constructive world into the patient, then the epistemology, what can we know of that reality is differently? So then. The same logic to measure that one, that's quite hard. So we are going to use the tools from one paradigm into a different paradigm and then to start to make, we have to make sense. So we have to be consistent with the way of looking at the world in that sense. And that makes something hard for us. Physio, therapists our clinicians. We have to navigate those different levels. What is there and what is meaningful for the patient Because what is meaningful for the reimbursement agency is maybe functioning That is that person is able to work again or doing so much hours or can be able to have so many meds during a day because they had five meds and now they come to 10 meds. That's. That's the, that part. But for the patient, it might be we go more into the sense of coherence like we have in Kinesis that we have is comprehensible. Is it meaningful, is it manageable? How is their own understanding? That's even a question. If we have patient reported outcome measures, who can pick it up? And here we get into this thing that we are cons No, in here. Let's stop it here.

Yeah, it, it's, it's a challenging tension. Like it's, I've just had my own struggles with that as well.'cause I think, you know, we're, we're trying to balance being a more whole person, centered clinician and some of these systemic barriers that are imposed upon us that, that, you know, sometimes try to take such complexity. And objectify it into this linear experience, yet we know it's so much more depth than that. And for clinicians that can be a struggle, right? Where they're, they measure their success. Am I really making somebody better? Am I really moving somebody towards what, where it almost puts us in this existential crisis as a, as a, as a physio. Like, am I making a difference when my O SwRI scores and my, you know, my efficiency of how many visits it takes for me to get someone? From point A to point B in their journey. Yet, to me it almost becomes surrendering a little bit of the control of the situation and letting the, the, again, it it, it becomes this like, well, if, if I'm just becoming this guide and coach, am I really surrendering my expertise or my position in this situation? Which honestly, I think we can interject. Obviously they're strategic when we have some knowledge that might help somebody move forward towards something that, again, that is meaningful to them, not just us. Can still, our expertise still can exist and coexist in a very co-constructed manner. It doesn't have to be imposed upon people. Yeah. It's, it's just it, it's such a struggle for physio. I'm wondering like, how do you help physios who are to understand that early on? Because I know you've been talking about in some of your educational approaches to how do we get complexity, and you did a little bit of that with, you know, some of the exercises you did for day one there. I'm wondering what do, how do we get clinicians to start being comfortable with the fact that there are these layers? And it is complex because I, you know, we still have systems and especially Western education where it's A, B, C, or D on a, on a sheet that you're gonna, or checkbox on a, on an exam. And we're trying to really objectify such a difficult to objectify experience. I'm wondering like, how do we navigate that in education be it both in academic and clinical education.

I think that this is both in education and in clinical practice. We are, first of all we live in a world which have constraints and rules and all the things that we are, that's part of our society, and we are part of that system also. But there's more than just that system. That's, that would be for me, that would be the first goal also with students. When we first go to students. So the moment we have learning outcomes, those are just, that's the only part where they get credit for. So they learn way more, but that is at least a kind of the the ring they have to jump into. But there's way more. So that's first of all. So we constantly have to say, that's only the tiny little bit that the system ask of us. That's first of all. Second, I think that in assessment that we use in clinical, in education, we constantly have to think of, we can only look upon the competence of a person based on proxy. We use quite a lot of products. So based on the product we look, we say that's a competent or not. Even the word competence is quite interesting when you look upon the word competence in different countries. But let's put it this way, what we see now more and more to say something concerning the competence of a person, you need to see a product, some process, some practice, some performance, and that's the same as the patient. That's, it's a whole thing. So you can't put just one element. And to make a high stake decision, that person, yes or no is able to go for physiotherapy. That's the same as looking at a patient. And we have only this Oswestry score. And that's the threshold. You have to pass or fail. Even though the system may save on, there's enough. That doesn't mean that clinically and ethically, morally for us, that's enough. So those are the two things in here. When I would say for students in the beginning, we have to help them to understand there is this objective reality from the generalized elements that we have, and that kind of provides a foundation for us. To help us. So that provide us into the world. The only thing is that's not the only thing that we have. So we have also the understanding of patients as a living creature, of being part of a world. So that is also connecting there. Our job is not to be in either one, so not one is better than the other. We have to navigate what is necessary. So the moment we dare to navigate and also see that there's a connection. Then it's useful at the same time. And this is what I sometimes is the problematic part also in explaining it's not either or. So also when physiotherapy or healthcare practice in the US or Norway, or the Netherlands or the UK is different because we have different system elements and we can say there's a constraints, but happily we can live thanks to the system and at the same time, we can also challenge it so we can do more than just that one. So we have to use those constraints. I see that provides a kind of security and it keeps also a way forward, but at the same time, we have this reflective trend. Why do we do what we do? And can we do that discussion openly with our colleague without saying this is right and this is wrong. Because the moment we go on right and wrong we lose it. We have to say, okay, how can we emerge? How we can we go better? Long answer short, I think it's about navigating the different realms of understanding that we work with and daring to help each other. Can we go a little bit away from, I'm writing you wrong, to, what is your right? There can be more than one truth present at the same time. Within a certain bandwidth and here gets a problem. Not everything is able, there are things who becomes into unjust or directly foul, or you create an iatrogenic problem, that's not where we have to go. So there is this code of conduct provides a kind of a frame in which we can navigate with each other, but we are so focused on doing the best practice. But can we talk with each other concerning where did we fail? Where did we learn? Are we opening up to where is the most learning experience? Because the best practice is one thing. That's not probably the way that we learn most. We learned most from where we had challenges from. Can we share with challenges the dilemmas that we think of. That's also what we do with patients, and I think that in clinical education, when we move from physiotherapy, education, from telling the answer and focusing on the answer, we focus on the question because every answer provides a new question. If we are able to stand with the questions we be, we'd be more happy and more curious, I would say.

Yeah, absolutely. And I think you, you put it very well there. I think it, it, it's a challenging balance and I think, you know, like you said, it's learning from the question more than the answer and what goes behind that question. And if we can kind of zoom out with. And, and you've, you've done an amazing you know, job with some of your content you've put out as far as helping us see that. As far as being able to see that there's much more layers and complex layers that are on that. And, but it, the more we can kinda reflect on what's behind a question and what, what's the data? And, and maybe it's more than just, you know, this, this, what's within this body.'cause this body is embodied a lot contextually, ecologically, and all these different things that we know. Can impact things. Joost, I'd love to talk with you for another two hours, but I wanna respect your time and maybe we're gonna have to have a part two because I've, I've really enjoyed this conversation. Where can folks, if they wanna follow your work and or get in touch with you, where can they find you?

So I have a, just reflections on Substack. That's the first bit which is quite easy. I'm quite easy to find on both LinkedIn and the Facebook. Or they can connect me at Western Norway University of Applied Sciences in Norway, Bergen, which is on the website there. I'm always happy to start com communicating or talking with colleagues interested people. I love conversations and

That's the whole reason I, yeah. The whole reason I do this podcast is have great conversations like this, and I'd highly recommend you, you look into Joost work, it's, it's, it's great stuff and it has you, to me, the, the best work is ones that really make me think and, and merely make me consider things I haven't considered. And Joost work does an amazing job of that. I know he is been influenced by David Nichols and I mean, there's, and we've had David and you know, Matt Lowes. Mutual colleague and, and folks that just help us think more deeply about what it is that we're doing when we're interacting with another human and trying to move them towards what matters. And hopefully you've gotten outta this conversation that there's a lot to be thinking about that can help us be more whole person centered, you know, clinicians and not as much of a clinician centered practice, but a, a, you know, more holistic centered practice. So you also wanna thank you again for your time and thank you for all the amazing work you're doing.

Thank you, mark. It was a pleasure to be here and lovely to have a conversation with you.

Yeah. And we're gonna make sure we get in, in touch in person eventually so we can, so we can sit down and, and have a coffee or something and, and, and talk over some of these dilemmas that we have in our, in our world and in our practice. So, uh, looking forward to that. And for those of you who are watching, we'd love if you could share this episode with somebody else who might be, uh. Tussling with this tension that we spoke about with some of the, um, difficult topics that hopefully we shed some light on today. Wherever you're listening to the podcast, we'd love if you could, uh, you know, subscribe and share it with any of the folks you know who might benefit from this conversation. We are gonna leave it there this week. We will talk to you all next week.

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 modern pain care.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.