The Existential Crisis Every Manual Therapist Should Have

if you have a lot of certainty in something that is potentially equivocal I could do this or this, and you'll get the same outcomes. But if I feel really confident in that, I have better outcomes. Than the person who's uncertain. So what I have come to lean into is

What if the thing making you feel like a fraud as a clinician is actually the thing that could make you great? Today I am talking with Richard McIlmoyle, a chiropractor from British Columbia who spent 13 years practicing with biomechanical certainty before everything changed. After discovering modern pain signs, Richard went through what he calls an existential crisis. On the other side of it, he became a better clinician, a better mentor, and someone who's now influencing how medical students learn about pain. In this conversation, we dig into how to mentor students without shattering their confidence, why intellectual humility might be your greatest clinical asset, and how Richard approaches manual therapy from a macro down perspective, starting with values and beliefs before ever thinking about tissues. We'll also talk about the tension between continuing education that sell certain and the messy reality of clinical practice, richard shares the story of how he audited UBC's medical school pain curriculum, and how he's working to improve how healthcare understands and treats pain. This is a conversation about transformation, humility, and what's possible when we choose curiosity over certainty. Now onto our conversation with Richard McIlmoyle

This is the Modern Pain Podcast with Mark Kargela.

I appreciate you taking some time I'd love to hear you'cause I have some good friends who are chiropractors and the journey. And I've also had, obviously a very heavy manual therapy background myself. I'm wondering how your journey evolved and some of the existential crises you faced along the way to, to get to where you are from like your initial chiropractic training.

That is it. Fabulous question. And everybody that I ever met down in San Diego went through that whole that whole process of shedding our former selves and emerging the other side, you know, from the cocoon of what we were. So I graduated in 99 from a school Logan College of Chiropractic out in St. Louis, Missouri. And you know, that experience of. Being thrust into a world which I didn't understand when I first went in. I had seen a chiropractor back in my high school days and he had done some work on me and I had some knee pain and he sort of assessed my pelvis and did some things and my knee pain got better and I thought, wow, that's really. Cool. I'd like to learn how to do that. And so that's what prompted me to go to school. And then I found out about all of the interesting stuff that happens in our profession. So, after graduating off I went, was practicing Ontario and then moved out here to the West coast and it was probably early 2010s. So I had been in practice for, you know, 12, 13 years. And I came across, actually it was Craig Levenson. Who's Cairo down in la he wrote the rehab textbook that I had used in school, and it sort of influenced and influenced my approach. Saw him on on Facebook and he was posting some interesting videos, posted the famous TED Talk from TEDx Adelaide that Lermer Mosley did. I saw that at the time I was also teaching neurology at our local massage college. And the way he described like nociceptive signaling. And when he does that video, there's so many layers to it that I, that really captured me. Like he speeds up his talk when he is talking about a delta fibers, and then he slows it down when he is talking about C five. So it doesn't directly articulate these things. But I liked the underlying messages and how complex it was. So that brought me in. And it triggered me to rethink everything that I knew that was the gateway into it. And at the same time, my business partner's wife was experiencing some chronic pain stuff. So it really sent me down the rabbit hole of trying to understand that better. And fast forward to 2015 and Lmer was speaking down in San Diego at the San Diego Pain Summit. And so my business partner and I went down and yeah, found our people. It was sort of like these people are all having the existential crisis crisises that we are, that everything that we've understood how what we do works. Isn't how we work. So you go into the nihilism stage where you say nothing works, and then you come out the other side and go, everything can work. And it's, it came to me pretty easily in that there was always a thing within my profession where, you know, like in school I leaned hard into biomechanics.'cause that seemed to be the only thing that was really. Based in hard research within my profession. There's a lot of the airy fairy stuff on the edges of, you know, well, you, you're aware of it, I'm sure, like fixing cancer by cracking joints and stuff like that. So this is where I leaned into. And then, so from a biomechanical standpoint, if I direct forces at a joint in the lower back and your back pain gets better, that makes sense to me. But there's some. Practices within our profession where they just treat like the top two vertebrae, that's all they treat. And you're thinking, well, that's crazy. There's no, and then, but then you meet people who've had gotten better with like low back pain issues or, you know, hip issues or knee issues that have just been treated here. So reconciling that from a strictly biomechanical standpoint was untenable. Then the door being kicked open by introduced to how what we do, probably more accurately works all of a sudden. That made sense. So there was multiple layers to why it really resonated with me. So yeah.

It's that video. I would definitely recall that TEDx talk. That's one. I remember when I first listened to it. I was fortunate. I was teaching some adjuncting at a college where I was able to teach paint science and that one was one I always like would clip pieces outta that and played it for the majority of my classes. Still a good video and really still resonates to this day, but you and I both have the op opportunities to mentor students who are going through chiropractic training or in, in my case, physiotherapy training. We both were speaking to this a little bit before we went on, but I'd love it's a delicate balance, right? Because I think what we see with modern science and things and how quickly that enters the classroom, you know, for us it's gotta go through accrediting bodies and then it gotta go it's like at minimum a 10 year process. So it puts as a clinical, like preceptor or mentor, puts you in a difficult position, right? Where you have a student who's learned all these things that in a very kind of. Yeah, categorical kind of this illusion of certainty, right? They learn often like A, B, C, or D or the rubric is very, yeah, very linear way of looking at how things are. And then we've been out for a while and we see how chaotic and non-linear and complex and emergent pain is and how. It's, there's no training that's ever gonna perfectly, you gotta get out there with people and just have some concepts and some frameworks to go off of and then figure it way your way out for yourself and all that good stuff. But I'm wondering how you deal with that tension. With knowing what you know and the bumps you've had, and I do wonder sometimes if we just have to go through our bumps and journeys, but how do you help students not completely shatter their foundation of what,'cause it's not like we need to completely shatter. They learn a lot of good things and some good orthopedic skills and exam skills and stuff. But obviously there's also a lot of things that are like okay, I understand that's how you've been taught, but here's the reality of what we see with humans in pain. How do you deal with that when you're working with students.

That's it's a delicate process. Well, I say that there's, I think I deal with it similar to how I deal with communicating with patients. I think there's an overlap there with a lot of the, well, not a lot. Occasionally you have people coming in to get treated looking for your help that have. These foundational understandings about how their body work, that are flawed or at best, flawed? No, at worst. Flawed, at best. Slightly misunderstood. And, you know, maybe they've been planted there by a previous practitioner that they saw, or just sort of the cultural zeitgeist of things, and you have to challenge those and it's pretty individual. How hard do you need to challenge them or how softly can you challenge them? So when it comes to students, I think I've had the good fortune of most of the students that have come to do their preceptorships with us at our clinic have a little bit of a leaning towards questioning some of the things that they were taught. So there's a bit, they're preloaded a little bit, but when it comes to. Challenging those, I usually lay out scenarios in front of them to try to reveal the questions to ask if that were true, then why is this? And when I'm, that's partially how I approach treatment. When we're doing, I dunno, like exploration of movement. If someone has a belief that something is. Inherently flawed, broken, stuck. And then if you can create a situation where that belief is challenged, then it kicks that door open. So like a lot of the psychological constructs of about creating cognitive dissonance and creating opportunity to change the narrative that they have. So it similar with students where, you know, we'll be doing something, some work in you know, an assessment with a patient. And let's say you're going through like shoulder girdle orthopedic testing and I'll mess around with people want you to do something to them. They like, as a patient you want an evaluation, right? And so as you're going through the evaluation with orthopedic testing, I'll mess around with that to try to show them what they can do. So if there's an orthopedic test that they fail or they have pain with that slightly modifying it. And trying to create a situation where they don't fail with it or they don't have pain. If you're doing like, just resisted range of motion stuff with somebody's shoulder and just have them, okay, I'm gonna have you raise your shoulder. I'm gonna have you retracted or protracted and load this again and see if that changes. When a student sees that, they're like, that's not how you do that orthopedic test. And and. Then you can have the chance to walk through how you've created that change.

I think it's like you're creating almost a behavioral experiment like you would with a patient, right? You're almost,'cause I honestly, I think that's a sign of you know, top-notch like mentoring, right? Because it sometimes, and I know earlier in my like coaching, mentoring, it was very much like. Like we say, not to be with patients, right? Where you're just I'm the expert, you're the student. You know? Let me just dictate down to you is like try to meet them where they're at a little bit and then create scenarios where it's not you telling them something. It's where they come up with their own answers. Through you giving them this is where you're approaching it, but yet there's this can you see the disconnect? What do you make of that? Right? Where you're having them. Unpack that a little bit. To me that's like the most powerful way somebody, you know can learn, right? Where it's not this just. Eviscerating mentoring, you know, dressed down because you know, oh, how did, what are you thinking with that versus allowing them to explore and be curious and you know, not always have the answers. I think some of that humility too. Do you find that being helpful from a, because I think I've come across some mentors who've been great, but I've definitely had some that maybe were. Overly certain maybe would be the words on things to where it was off-putting to me. And especially when I was reading things that are like, I can't really get behind that. But I think like some intellectual humility and goes a long way in that in that relationship with a mentor mentee, what's been your

I think, yeah, being able to say, I don't know, like similar with patients like. Why does that do that? Well, I'm not really sure, but here's a few possibilities. And I've, in the mentorship role I've always leaned into, you know, a good mentor mentee relationship is one, we're almost, you're riffing off each other. And there are things like those students who are just coming outta school. There's a bunch of stuff that they know that I wasn't taught or exposed to. So I've learned lots from students that have come through in that, oh, I didn't realize that. And then you go down a rabbit hole and okay, yeah, that is a better way to if you get look at strict orthopedic testing and you're like, oh, here's a triad of tests that if you do those and they're all positive, that gives you a better indication that might be like a source of nociception. And it's just not something that's in your. You can't know everything. That's where I lean into I can't know everything and I know that I don't know everything. So pretending that I do is a disservice to me, to everyone around me that's people are coming in to try to, you know, that's why people see us. They want to try to understand stuff, and if you don't understand it, then how can you help them understand it? I think that's, yeah. Yeah. I think that's critical.

Do you think there's a difficulty to, for the, that being willing to say, I don't know. Early in your career. I know for me personally, there's such a like clutching for expertise and belonging and worthiness as like somebody this person should trust and believe in. And there's probably a little bit of some lack of self-confidence and lack of belief in our ourself that we really have to establish ourselves as this expert in all knowing, which puts us in a situation where. Man, it was hard for me to even consider. I don't know.'cause to me, you're a failure. You don't know what you're talking about, different things. But now to me, I look at, and I've posted about this, like if I see a clinician out there who like, can, say, I don't know, to a patient that would be a person I would like, turn towards and Hey, I, I, what's going on here? Versus early in my career, it's well, this guy doesn't know what he's talking about. Is that, what do you think, like as far as was that your experience as a young clinician as

Yeah, like that resonates with me so much coming out of coming outta school. You know, thinking that you know everything, like when you're taught, everything you're taught in school is oh, there'll be this certainty when you come out. If the person has this, you're gonna be, you know, catching people's cancer because you are such a good diagnostician, you're gonna be able to. Feed through all of this, and then you come out and nothing looks like it didn't, so nothing's cut and dried. And then there's so much uncertainty and the sense of geez am I a fraud? Like I really don't know what I'm doing here, but I don't want anyone else to know that. I don't know. And like the layers on top of that, of being, you know, looking young. Like I graduated from Chiro College when I was 29 but looked like I was about 22. And so, you know. Wearing a tie to try to make myself look more authoritative. And then I had this conversation with my business partner now she is a chiropractor who graduated in 2016, I think it was. And like the added layer that I think of not only is she looks young, but she's a woman as well, and like the like. The lack of respect for knowledge that happens there that's fed through her entire career adds another layer to her. So we all come out, I think with this, if you don't, there's a problem If you don't come out and then start in practice and go, oh crap, I don't know what I'm doing entirely here. I think there's a problem with that. If you think you do know everything. A, you're not gonna grow as a clinician to try to gain the knowledge to know more about what you're doing, but also I think you're doing a disservice to your patients to, to think that you know exactly what you're doing.

Do. Do you see con continued education as a clutch for certainty too? I mean, I've just been thinking about continued education.'cause there are so many gray-haired individuals, maybe more than just gray haired individuals.'cause there's some younger folks too who will sell you certainty, right? Just really just gotta do it. This system that I have it, it'll get a figured out. You just gotta do this. And then the certainties there, and then you grab the certainty, you get a little dose of it. And then we know all the non specifics when your confidence's high on it. And then the reality strikes. Has just fallen in line with the graveyard of other frameworks and systems that we're supposedly supposed to give you. This certainty has been, what's your experience been with the ConEd scene

Oh, the content scene has been an adventure over the years. Like I've. In school, did the whole a RT thing came out and when I came outta the fog of having kids, once my youngest was three, is when I'm like, oh, okay. I'm not just like rote in practice. Like I, I look back at that time and think, oh my gosh, I was just a robot, like going through and not having a lot of. Cognitive space to do anything.'cause you're sleep deprived. You're, yeah, you're pulled in every direction. But when I came outta that I became interested in DNS so dynamic neuromuscular stabilization because it was being sold as more of a framework of thinking rather than a process of doing. And that appealed to me at the time and it continues to appeal to me to like. If you're thinking about any process, have a process of how to think through things and like the critical thinking mode of things. We went through all of that, and then it's just, yeah, it's one thing after another of here's the system to go through. I haven't done there's a MDT that they call like Mac Bay Mackenzie. I don't know if there's a difference between those, but a lot of people that I find have a lot of certainty when they do that. That's a. And I don't know what is the latest one? I don't know.

Yeah, I don't know. I think dry needling and is a big push here and there's a few other things. Manipulation remains huge and always will, and again, I none of these I just look at things too as one more thing that can give you the certainty of maybe some short-term changes, which can be a helpful move to start somebody and nothing wrong with it. But again, when we sit there and that's where we anchor our practice and identify with it. God, you miss so much growth and you miss so much ability to be so much more than whatever system or intervention. You're like, take what's best outta those things. And maybe there's some song shoots to'em yeah, I think they can have

I use stuff from all of the different systems that I've learned in contented and then just use them for what they're worth, right? There's a big thing here, myo activation. Which I think is like an isolated to BC sort of technique that was developed that is basically a form of dry needling. But it's, there's a huge uptake from people and they're like, oh, we're changing fascia. And it's primarily in the medical realm. So it's MDs and nurse practitioners who are getting heavily into this. And, so all these, and yeah, there's a benefit. Some people have huge success with it. You know, you see patients go in and have it done huge success, and so you can't discount the thing that's being done. It's I think we've all talked about this in the past, like it's the framework, the understanding about how it works. That's probably not exactly how it's being shown. Yeah.

I I always have this internal struggle because I have this like maybe skeptical nature a little bit. Those, you know me, probably definitely know that. But, it makes me wonder, if I could just be blind to just drink the Kool-Aid and have the zest and the'cause, you know, if you have that going into an intervention, you're gonna be like selling it like you believe it, like the truth, gospel truth of what's gonna be, this is what you need, this is what's gonna, and I sometimes wonder if I compromise outcomes by not, you know, I just, with a good conscience, I can't. You know, propose the changes or MEChA, you know, the grandiose claims that some of these things do you find yourself struggling with that? Like you see folks out there who have their system or things, but, and it results in somebody who is massively confident, that has really a practice theatrical ritual around whatever their shtick is around whatever the thing is. That probably accounts for the majority of the mechanism of effect yet. And I sometimes wonder if I like miss out on that. What do you think?

yes. Yes. And I mean, there's a component of that, like the missing out on it that also emerges from like when you're trying to, I think when you're trying to practice the way that I hear you're doing it and the way that I try to do it. If you're in a system and then have the doors open or the curtains pulled back on, understanding the mechanisms. Almost everybody that I've talked to in San Diego and in other places when they've gone through that financially, you take a hit because because of the uncertainty and all of that, and you're not treating people within the system anymore. So there's a lot of chiros who fall into systems and they're just. Churning people through, you see them, you know, buying the yacht, buying the big cottage on the lake and all of that. So there's a little bit of feeling of missing out with that. But then you look, yeah, like Beloki and Bishop did studies on, you know, if you have a lot of certainty in something that is potentially equivocal I could do this or this, and you'll get the same outcomes. But if I feel really confident in that, I have better outcomes. Than the person who's uncertain. So what I have come to lean into is my certainty in a uncertainty, but B, that there's options, like we can find the things together to help move forward. So I'm confident in my ability to communicate with a patient. Or client, whatever you, whichever terms you wanna use to navigate. Like I know I have confidence in my skills, in communication, that we can chart a path forward, whether I will be the successful person to guide them or not. I know that we can uncover some things in some way to help them. Like I feel I I've. I've done this a few times with people just to sort of take the piss out of them is like I can with a hundred percent certainty tell you that I will help the person who comes through my door and sort of cheekily we'll figure out if there's something we can do or can't. Right. So, which is helping in some way, shape, or form.

I like it.'cause you're leaning into that uncertainty is like, this opens up options, right? It gives us, a lot of, ground we can cover to find out what works for you. And I think that's where I think I've landed on it as well. It's to me, it frees me from having to be beholden to a system. Right. And it, I still see, I have, colleagues and stuff where, they're gonna the same. Manual therapy conference year after year. And I think what a shame to limit yourself to, granted they'll bring in some lip service of some other, things beyond

We do biopsychosocial.

it. Yeah. If we do it we, yeah we have that in there. It's in the conference. We, this guy talked about it today, you know, blah, blah, blah. Yeah. I just think what a shame to limit yourself and I think just being able to lean into that uncertainty.'cause I think. When you like anchor to a group or a system you just, you anchor on a false sense of certainty that really limits your ability to navigate what the reality is

yeah. Well, when you talk about like

And I think it's a

the different people that you learn from, like this is in retrospect, one of the things about, I keep on bringing up San Diego Payne Summit because I. I loved what happened there in the breaking down of barriers, the breaking down of siloed education, right? No one knew who I didn't have chiropractor across my chest. You didn't have physio, so no one knew that your backgrounds, but also I was exposed to speakers that I would've never chosen to see. It's like a lot of the psychological constructs, A lot of the things from ot, like Bronny and different things I would've never chosen. As a standalone to go and learn those things. But being exposed to them in that setting revealed to me how much understanding that can make us better clinicians. And so I, yeah, I feel also sad for those people who don't go outside of their, you know, they're in their pocket and they, that's what they do. They just do that over and over again. So I think one of the things I like to try to do with continuing education. When I teach is, can I Trojan Horse this? Can I give you a course on manual therapy? But I'm really trying to break down some of your biases and understanding about that. So yeah, that's

I it's a tussle for sure. And I just would encourage you, if you're listening and you're considering, I'm gonna just go to the same manual therapy conference where I get my reinforcing dose of confirmation bias, that you just get unstable, get, go just lean into that uncertainty and go to a psychology conference or go to. Even an occupational therapist, like one of the greatest underestimated professions out there is occupational therapists as far as their ability to really work with people and move them towards what matters and not get caught up in, in the techniques and tools and really lean on what the human in front of you has as resources and all that stuff. One thing I wanted to touch upon is, what we talked a little bit before, before going on is how your system of, how you can decide on manual therapy and kind of your framework you use.'cause I it, I think it really is similar to how I think of it. And I was just having a conversation of, instead of going micro to macro, we go more macro and then see what needs to happen micro.'cause sometimes it's the macro stuff that if we handle that. Maybe we don't need to get as micro with a lot of the nitpicking on mechanics and things that maybe have been traditionally the way we look at it. I'd love if you could unpack your thought process around that and how you look at it now.

I feel like I've turned I turned the pyramid upside down instead of going from a small, how we're taught, try to figure out what tissue is causing the problem and then work out from there and then understand, oh, are there any barriers, psychosocial things to, to create barriers to success? I think my approach, and this is how I'm trying to build out to. To teach folks about it is, you know, in, if you're doing an intake and you start having those conversations and you're really trying to understand their belief system, what are the factors that are playing a role in their life that might have brought them to this point where their pain experience is enough that they're seeking care? That's one of the things Ben Cormack. He said this once in a course that he was teaching here, was he asked, why do people come in to see you? And a lot of people say, well,'cause they're in pain. And he pointed out, they don't come in to see you because they're in pain. They're coming out to see you because the pain is now interfering in their life. Or they're worried it's going to interfere with their life. Oh, I wanna do that thing and this pain isn't going away. I wanna do that thing. So that's sort of. Part of the premise. So what do I have to understand about the person in front of me about what it is so you can understand goals. So understanding a lot of that and then understanding their beliefs about what is going on in their body. And then the fact that biomechanics and beliefs and if you want to break biopsychosocial, I really don't like that term'cause it does isolate everything it does. I argue that it's a model. It's really a framework. It's models predict things. And this framework is just, to me, bio psychosocial as a framework is how do we understand how humans work, right? So there's all of these different components that are wound together. And so when we start to understand what's going on with the person, we may be able to understand why they're moving a certain way, if their beliefs are. Their thoracic spine is crumbling because someone took an X-ray and told them they have degenerative disc disease and all these different things that they take on as meaning. They're falling apart. They're gonna move differently. So there's the tie in to biomechanics and thoughts and beliefs and cultural ideas that I think if we start from the top and understand all those cultural ideas, beliefs, and everything, then we start to get into some manual. Testing of people and we can unwind the parts of it that are, you know, fear of movement, habits of movement. Take those things away and see if we can change a person's beliefs about what goes on with movement. And then we can bring it down to go, okay, there is a tissue based symptom here. So we've gotten rid of the fear of movement, like someone's afraid of moving their neck. And let's say you get rid of all of their fear, do some passive stuff, and then you get to the point where oh, I can repeatedly put your head into this position passively. And you get a sense of pain in that area of your body. Oh, maybe there's something being pinched there. That is the origin of nociception. You became sensitized around it because you repeatedly triggered this nociceptive. Maybe you have some nervous system changes that expanded that. Now your body is bracing. You're now afraid that you don't want to trigger that painful experience. You think something's broken. And if we can unwind all of that first stuff to get back to the original or the tissue thing, we've gotten rid of all of that other stuff first. And it makes it so much easier to then get in to treat this. And you can explain it as you go with the patient

Stay tuned. We'll be right back to the Modern Pain Podcast.

Alright, real talk for a second. Your complex pain patients aren't getting better with the same old approaches and you know it. Pain practice OS is my eight week program that finally bridges the gap between knowing the bio-psychosocial model and actually delivering it in real sessions. We get proven frameworks, practical tools, and peer support from clinicians doing the same work right now. Check out modern pain care.com/os to get more information now back to the conversation. That's that whole making sense of pain that, you know, Peter O'Sullivan's group does such a good job of I, and I think some you're I a hundred percent agree. I think sometimes it allows you to get a lot of the compensatory or the kind of secondary, you know, changes that happen from, you know, dorsal horn to the brain and all the movement patterns and different things and emotions and thoughts and beliefs and all that stuff. And sometimes when you address that stuff, you're left with yeah, very kinda specific mechanically patterned pain behavior that would suggest. Nociceptive things that would benefit from maybe more specific things, so. Lo and behold, you might treat very locally and specifically at that. I know that gasp from the audience where you might actually do a manual technique at the spot now, and that happens, right? And, but I think obviously we don't go with the assumption that it needs to happen. But I think coming, the other interesting thing that I've seen and I love to hear, is sometimes you take care of and that's, I see this with Peter stuff and I definitely see it in clinic, where you take the fear and the and you work with some of that, you know, movement behaviors and different beliefs and stuff. And behavioral experiments, and all of a sudden there is no need to do anything in tissues.'cause things are moving and doing great and then life's good. But I think having a process that can go from that, big macro, what's your values? What's the thing that this person's, like you said, limited in life that's, they want, and then go back, well, what are the things that are getting in the way of that and not getting immediately to, so micro tissue level of look in big picture, because you can start knocking those things down. Maybe it's through some pain, neuroscience, education of course, coupled with other things. Maybe it's through some other, things that exposure based work or some behavioral experiments that. You knock those things down and then man, the tissues, why monkey with them, the person's happy as a clam, they're moving. Great. Has that been your experience too, where it gives you a little bit of a filter of when do I need to worry? No susceptibly tissue wise versus making that assumption. It's just needs to happen from that, like you said, impairment specific tissue, then go to the big picture

100%. I can't tell you how many times I've had somebody come and see me. We walk through all of this and I could do nothing to them, and they would be fine. There's no need for me to do any sort of manual intervention to them. The testing and everything that I did, touching and moving their body around is probably enough. The secondary layer to this is. Again, you think about like bio-psychosocial. The social construct that we exist in Canada when it comes to healthcare is it's free, but they have to pay to come and see me, right? I'm not covered under our provincial plan. And so there's expectations that they come in with. And because I have this title of chiropractor, many people come in with the anticipation, with the expectation that I'm going to do something to them. Unless they've been referred from somebody who's had the experience with me where we haven't had to like, or the main benefit has been not what I do to them, but how I've coached them through things. I end up, I do something to pretty much everybody, like I do some sort of manual therapy to pretty much everybody because of that patient expectation. But it's always couched in, we're gonna do something to try to change. How you feel about this part of your body for a period of time so that then you can go and do all this stuff. But this is like a temporary little change. And one of the things I like when I, one of the things I was teaching, just doing this new sort of course on the weekend was my question to the audience was, what is the goal of our treatment towards people? It's a room of chiropractors and so get rid of pain. You get all these different answers and I would assert. That our goal is to change the person's perception of their own body or their perception of self, right? Like even moving from, one of the examples I used was, there's a woman who came to see me several months ago, was having some ankle pain. It had been going on for a year and a half. She had seen a few different people. Someone said, go see Richard. She came in to see me. We did an assessment. She identified as a runner and hadn't been running for about a year and a half. She had a daughter who's about five, no, five or eight years old, somewhere in that ballpark who was getting into running and she wanted the patient wanted to be able to run, there's a local race that's a marathon, or sorry, a 10 K, and they have a kids race that's like a one K race, and she really wanted to do that. And so we assessed her ankle. All I did was say, there's no re everything I'm seeing here, there's no reason why you shouldn't be able to get back running. And that was the treatment. She just needed the assurance that her body would be able to do the thing that she wanted to do, barely did anything. Most of it was assessment and just said, yeah, you, I don't see any reason why you shouldn't be able to do this. Maybe did a little bit of mulligan type stuff just to make her feel a bit better. And yeah. And she, she got back running I think I saw her again three, four months later. She had done the run with her daughter and the reason she was in to see me was because her and her sister had gone for a trail run and gotten a little lost. So they ended up doing like a 10 K run instead of 5K. And she's I think I overdid it a little bit. Can you have a look to see if I'm okay? Those stories are many, right? Yeah.

It's a great example. I think sometimes we have this preconceived belief that we need to go in there and intervene and do something right? And I think sometimes our best treatment is reassurance that you're safe, you're okay. You have been thoroughly the ritual of thoroughly being looked at and thoroughly being examined and feeling like you know the no stone has been left unturned and you have given me all systems go. I am safe to engage. How many times do I and I'm just hearkening back to my career, I wouldn't even have thought of that. Like it was immediately like, what are we gonna do? Right. And I gotta imagine there are people I have missed along the way that simply needed reassurance and a good solid physical examination that really signified thoroughness and that things have been really exhaustively checked. And you're okay on with life. And do you feel like you've

Oh,

of those along the way?

Like I can. I can probably stop and think about three or four, just off the top of my head, much less the dozens and dozens that I've probably forgotten about. And yeah, that, that reassurance, the thoroughness of exam. And then the other component, I can't remember who used this term, but a durable narrative for them. Here's the story that we've co-created about what? Like why you were experiencing that.'cause they've been experiencing something in their body that has brought them to see you. And so I think if you just do the exam and you're like, yeah, you're all good. There's no reason why you have that pain is can be unhelpful, right? It can be. Disconcerting to people be like, oh no, it's probably you were moving to I'm just making something up, but you're probably moving differently because you were afraid that you were gonna hurt that, so you were probably putting more strain on this tissue or that tissue, but you should be fine and you can just move more freely and giving them, again, the permission to move freely and without protection. Then hopefully that narrative is durable, that when they go out into the world and sort of challenge. That narrative, it holds up,

that definitely is awesome way to practice and definitely resonates with kind of, you know, obviously that's why we got you in the show, man. We've we jive with many things. I'd love to hear'cause you had an interesting experience recently, and then we'll land the plane here. You, you were able to,'cause this is one thing that I'm trying to find my ways into our medical school, evado school, that our, that's in our university that. Str, I think could probably do a little bit better on the pain front, it's still very much a structurally dominated narrative around pain, but you had the opportunity to get behind the scenes of medical education and really hopefully make some changes or recommend some changes. I'd love to you share what you did,'cause I think that's a great thing that I think if more folks like you could kinda get involved and see if you have some inroads too. Just, politely suggest taking a look behind the scenes and auditing things a little bit and seeing if there's some room for

Room for improvement. Exactly. Well it stemmed from a talk that I did. I did it twice. I did it one at the once at Pacific Pain Forum over in Vancouver. And then I had a friend ask me to come and do the same talk at the Alberta Pain Society conference. And it really was about siloed care and how do we integrate. What's the pathway forward to help create true interdisciplinary care?'cause we know that's gold standard for chronic pain. And right now we treat in silos. And my assertion is that we should all learn together and have a common language enable would, which would enable us to then integrate care together. And so part of that talk was I went and looked at. What is the pain education that we have in our pre-licensure for the different professions? And what I came across was in Canada, in the med schools, dedicated hours to pain education. The highest number in their entire curriculum is 10 hours. I don't know which school it is, but one of them actually has 10 hours of dedicated to pain education. So in my ridiculous boldness of being a chiropractor, actually contacted the University of British Columbia Medical Program and asked them what they were doing for their pain program, because this is what I become aware of. And would they be open to having a chiropractor come in to teach? A course about paint and got a response from the curriculum folks and she said, well, let me send you some things that we use. And so she sent me a couple of links at first, and I watched some videos that they utilize and it was mostly good, but there was some sort of outdated ideas and some challenging. Sort of narratives. And so I got back to her and I said here's a summary of what I saw in that, that here's the research that supports something slightly different. Then she got back in touch with me and said, Hey, why don't you audit our second year this, they do pain during this week. So I was able to virtually sit in,'cause they do a mixed program of in-person and virtual on three lectures that they do that are focused on paint. Over the course of that, there was three minutes on musculoskeletal pain in, so this is in their entire second year. I don't know how much they get in other years, but in their entire second year, they had three minutes on musculoskeletal pain, which felt horrible because I think 80% of. Patients come in to see doctors at least here for a pain thing, and a lot of it's musculoskeletal. So anyways got together with a friend of mine who's a physiotherapist, who's working with pain BC as well as with pain care bc, which is a provincial arm of the government that's been created to try to help, increase the uptake of interdisciplinary care for pain for people in the province. And yeah, with her knowledge of how to write things well, and with what I, the notes I had taken, we formulated a recommendation plan for some potential changes to the pain program or the pain education in UVC MED program. So it's. There's a benefit to knowing people. I've made some relationships, Tori actually was in San Diego for the last year, I think. But to make those connections with different people in different professions, which I've made through our adaptive mentorship network that we're doing with pain BC as well, with, you know, MDs with occupational therapists, with physiotherapists, with nurse practitioners. Having those personal connections opens doors for opportunities like what I got there. So, yeah.

Folks in, in this kind of thought process with pain and more modern ways that you need to be making those networking efforts and starting to make those connections. Because I think those type of opportunities, like you had can, I mean, and if you, if that changes like the education of physicians in bc I mean, I can have a massive ripple effect. So good on you for doing that, man. I, if folks wanna reach out to you, like if there's chiropractors like, man, I wanna get mentored by this gentleman. Sounds like he is forward thinking and somebody I'd like to learn underneath. How can folks get in

Website is www Dr. Richard mcm oil.com and that has all my information on there. I'm also relatively active on Instagram and Facebook. And I think I gave you the links for those things. So, I can't remember what the handles are'cause I just use them all the time. I don't actually tell people what my handles are, so,

we will, we'll have him in the show notes.

Excellent. Yeah. And yeah, anybody ever wants to reach out to me in Victoria? Just my clinic is Achieve Health, so.

Yeah, we'll link his clinic and all the areas where you can get in contact with Richard in the show notes. Really appreciate your time tonight, Richard and thank you so much for what you're doing up there in bc. Also, a beautiful area to visit if you get a

Come and visit.

up there. I mean, you can't beat. Yeah, absolutely. Alright, we're gonna leave it there this week. I appreciate everybody listening. If you haven't subscribed to the podcast, we'd love you to subscribe to the podcast, share this episode with somebody. We need more of this information out to more people. We'll 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 Karula. 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.