Whole Person Reasoning: Biopsychosocial Rebrand or Real Upgrade?

Okay. Welcome f- to this week's live episode of the Modern Pain Podcast. This-- we're doing something a little bit different. Couple reasons. Editing a podcast is no easy task, and it takes a lot of time, and I've been trying to spend more of my time building stuff. So we're building a lot of stuff for Modern Pain Pro and Modern Pain Cares community, some courses, a pain program, all sorts of cool stuff some AI-assisted things. So that's kept me in build mode, and with that said, I don't have as much time to edit a podcast, so we're gonna do it live. Ben, how are you doing this fine day? Nervous for the football- Nervous match with Mexico from England, I know, but how elsewhere, how are you doing?

All right, FIFA tried to disrupt our plans, didn't they, early in the week, and they planned to bring the appoint- match forwards, but here we are relieved that they changed their mind five hours later.

Yes,

they did I will be asleep when it happens. It'll be 1:00 AM here when this happens. Yeah. So I will be waking up at 6:00 AM to discover the fate. Yeah. Yes, this is just one of those World Cups where we the times aren't good for us. Like we were saying before, there's been other plenty of sport events, whether it's Olympics or other football events where you guys have to suffer and watch me the early m- very early morning or silly hours o'clock.

So you're just gonna wake up and let it rip and just find out? You're not gonna tape it and get up early? I'll

just find out, yeah.

Okay.

No, just find out 'cause I won't have time to... I have an hour to wake up and get out the door, so there's no point. Plus, it's stormy in Mexico apparently, so who knows what time it's actually gonna happen.

Very true.

And if it goes to extra time and pen- who... all that stuff. No. Let's just rip the Band-Aid off, and we'll see.

Figure out what the fate is. See if you live to fight another day. Good for you. All right let's get into this week's topic, and I w- I wanted to talk about it as far as whole person reasoning, and that's... Is it a buzzword? Is it not? Is it the new biopsychosocial? We're gonna kinda unpack that a little bit today, 'cause I... It's kinda where I've landed as far as how I think we need to kinda operate as clinicians, and not just when pain hits a magical 91 days that all of a sudden you have to think about the whole person, 'cause we've all had people, if you're working with people in pain who have an acute injury that might have a lot going on around it or might have a lot of significant anxieties and concerns and fears around it because we're humans and we do that type of stuff. So Ben, I'm wondering what do you-- when you think of whole person reasoning w- where do you see that sitting as, as far as that? Is that an upgrade, or is that just another giving, a f- our supposed embracement of biopsychosocial just a new name?

Yeah, is it just giving different words to something we should already be doing anyway? There'll be surely be certain scenarios that, as you said, if you're in a very acute situation, and you need to, I don't know, focus on a very specific tissue for some issue, fine. But otherwise, most of the time, I would hope whatever s- person you are, whatever profession you do, whatever specialty, et cetera, that yeah, it should be something you're doing regardless, right? Because we are trained to ask not just about someone's problem, whatever it is, but then also ask about their other problems, and we should be asking about their life and whether it's work, social, who's at home, all that stuff. And we should be asking about not just the physical issues, but the... et cetera. Is it the n- new term for biopsychosocial? Maybe. Are they two words for the same thing? Potentially. But I think it's something we should be doing anyway. I don't think it's something we should be like, "Oh, here's this extra special thing that," you know. It's something that sh- should be routine. Unfortunately if it was, we wouldn't need to make this resource and other stuff, would... Yeah. So sometimes reminders help. That's why this resource, you're gonna put a link to them, we'll talk about. But I think it's something we should be doing routinely for anyone. I realize there's barriers, right? Time what's going on, what the patient wants to talk about, et cetera. But it's not like this is a completely brand new thing that no one's ever thought of before. It's more of here's, extra reminders, extra resources But it should be, if I was a patient coming into a service, whatever that is, I would hope the person in front of me, unless I'm, there in A&E and I'm losing blood from my leg and they need to stitch it up, I'd otherwise hope whatever the problem is, that they're gonna treat me as a whole person Is my thinking. What do you think, Mark?

Yeah obviously we're similar-minded in this thought process, but I, I had posted about this earlier in the week is... 'cause I was talking to my student who's in university. He's in his second to third of his last clinical rotations, clinical placements before he will graduate here in November. A- and it's just, it's always helpful for me to mentor students 'cause I think sometimes you get in the clinic enough and you forget what it is to be a student and what you're thinking, right? And when you're a student, you're so thinking about what's the kinda clinical guideline on this? What's my test cluster that I need to remember? Am I executing technically the test like I did in my lab practicals? Am I remembering all the, qualifying things for these diagnoses? And of course, important stuff, right? But it's sometimes you're in such your clinic- clinician brain that it's hard to be present with the person who's sitting in front of you, right? To... And, like, when you're trying to determine if your m- position, if you're trying to modulate pain with mobilization is the patient receiving it well or are you just too caught up in your head trying to think about am I doing it right? And my hand position. Is the table height right? Am I doing all those things? And again, it's, these are just hard things to resolve, and I think we get snippets of, psychosocial. I think we even have a course in our curriculum called S- I... It's changed our curriculum, and I'm on the clinical side, so I'm not as in-depthly in tuned with the exact naming schemes of our curriculum. But I know we do have a psychosocial course, and which is g- great, right? But I think still students see it as like a, it's a sidebar to the real stuff of I need to find the problem and identify it- Yeah and, fix it. I- we don't use the fix it terminology, but, that's the thought process. Sometimes we think that it's gonna be this black and white world where we're gonna-- 'Cause that's how we train health professionals, too, right? We have A, B, C, D on a licensure exam that determines... And it's the best thing we can do, right? It, it-- We need people to have a good knowledge base and a test and make sure they have a knowledge base, but that doesn't always translate well to the clinic, right? And people- Yeah don't fit A, B, Cs, or Ds. Sometimes, maybe, but there are a heck of a lot of people that have complexity, and y- the famous statement in university training is that all of the professors come back with is, "It depends." And students- in our program have even made shirts with that slogan of "It depends" on it, because it's, it just is. And to me, it just furtherly makes it to where we have to understand what's the unique it depends about the person in front of us, right? That make those- Yeah factors that could... And it's, a lot of it doesn't necessarily always gonna be what the textbook told it, it was. Maybe this person... I just saw a patient this week who's got some very significant issues going on wi- merely at home, and she's also got some other very difficult situations from some nutrition issues she's dealing with, and just a lot, right? And- Yeah the student's natural tendency, as it was mine, was just to get in and let's really talk about your back and things like that." And It w- he, it was a great experience 'cause he kinda was able to see. We brought in our behavioral health service, who's our psychology program does a great thing with our students learning how to help people in that. But again, I think it's, it, to me, especially when we know what the research is saying, pain is involved, what is involved in a pain experience, and for everybody it's gonna be different, but that's the whole point. For everybody it's gonna be different. You need a process to not assume there's big psychosocial overlays with anybody, and not assume it's not there, right? You need to have a pr- a process to reason through that to determine with this person, whether it's a day old or a decade old, what's going on in their life that might be influencing this thing one way or the other. Obviously, a decade old, it becomes a little bit more challenging just because, bioplasticity and patterns have probably been more, physiologically wired into our system's behavior. Not to say it can't be improved, but I guess that's a long-winded answer. What, how do you see university training and as a young clinician when you're trying to grasp certainty, right? You wanna know that, holy, I need to know what I'm doing. I wanna feel like I belong. I wanna feel like I can be on the same level as my clinician colleagues. How do you feel this kind of fits into that kind of mindset?

I feel like it's better than it was, used to be. I remember many years ago being at is it the Maitland grades where you have a grade one to four or something? Yeah, you're nodding, so you can remember better than I can. And there was quest- they teach you ask about these things, but that was about it. Interestingly our student early in the year, he had been taught to think about these things, and then when he went on a placement before ours, basically didn't the, what he was taught, which was right, then didn't come to fruition where he was actually on placement And then he came to us and he had a g- the, probably the best placement experience he ever had. But he... It's, the problem is, I think it's a combination of what's being said in hi- higher education, but that's gonna vary. Because ul- ultimately, the, how can I say? The governance that they're told or the things they're told to cover is generally quite vague. They're not... They're told, "Cover these things," but they're not told how and in depth. They're just, certain things they have to hit, so to speak. And then, of course, you can go on a placement, but that experience you're gonna have and how person-centered or, all these things we're talking about is, will vary depending on the service and who your educator is. I've had students in the past tell me that some of the other MSK placements they've been on have been very biomedical and passive, and they weren't even that long ago. I don't think it's just a higher education thing. I think certain higher educations are actually trying. Obviously, it depends on who's delivering it and biases, et cetera But I think some universities, and I can't-- I can only speak for obviously the UK, and even then I can only speak for the ones I'm aware of, are really trying to push this. But ultimately, it also depends on the services. And you're aware of what your own service does to a degree but as I've discovered, you're not aware of what other people in other services are doing as well around... And that could be very variable, and that will then influence people who may come to you one day. So I think the ed- the higher education, yes, they have a role, and it sounds some are trying but it's-- they're not the only piece in someone's journey, so to speak.

It-- I definitely agree. I think when it comes to this too, I don't know if that classrooms can prepare somebody for to reason the whole person, right? I just don't... you can do simulated patients, and I know our faculty and our educators do the best they can, but I just honestly, I don't think it's a by fault of theirs that I don't think that's an environment. And I talked about this earlier in the week where that classroom lies in the clinic, right? That's where you're gonna learn from people. Yeah. And when you, especially when you see people who a couple rotations back, we had a, person who's dealt with a whiplash injury and really rocked the world. Wasn't able to do the things around the house that was important to them. Lost their car and their transportation, their independence. Just very distressing. And, the students were in their first placement, and I don't know how if you can harken back. For me, that's 23- First placement and four years ago, so it's been a minute. But- I just remember like heart beating out of my chest trying to get questions out and not sound like a bumbling fool 'cause I was so nervous that I wasn't gonna do it right, and all the things that we all do as young clinicians trying to figure things out. But, I'm looking at this and I can just see the distress and sh- she's very tense and things. And students are doing a great job asking all the things. They're like clearing out, like questioning that can help us, with their X-rays, clearing up her cervical instability 'cause it was neck and shoulder related things. And then I just popped in and just asked a question like, "You, you-- this sounds like it's been really hard for you. Like how are you coping with this? 'Cause it sounds like it's really kinda turned your life upside down." And she started crying and emotions came out and it was just, it ended up being a great thing for her 'cause we then, we t- I talked to her about, "Hey, this understandable, valid. This is a really tough situation." And she left very, like different. You just see sometimes just being heard and like being able to get l- unload that stuff Off your chest as a person, just it feels helpful. And it really helped her 'cause we taught her some mindfulness 'cause she was very anxious and stressful un- understandably 'cause she's a human dealing with a lot of difficult things right now. But she really found that helpful in working with some ACT-based processes and other things. But it was just i- is, it was just interesting to sit in that because I remember "Guys you're not seeing her. You're seeing your textbook and your your... the things." And I was right there with them. I'm not by any means saying they were not taught correctly or anything like that, 'cause I would've been doing the exact same thing in their shoes. But it just made me think that probably is one of those skills you just gotta get in the clinic, but you gotta give yourself some space to let the patient be seen, 'cause I don't think sometimes we're so concerned with maybe our perceived inadequacies or perceived like need, or maybe we're in one of those musculoskeletal settings where, you're lucky if you get a half hour with people. We're fortunate we get an hour, we can spend time, we can even go over and do whatever if it serves the patient. But yeah, I just I do think, it's just a, it's one of those skills that the classroom's not built to, to hone that with somebody, and you just have to get reps with people who are struggling and have some skills, and I think whole person reasoning skills to where you're not just holding tissue-based factors, which again, aren't bad to have in your head, but you should be thinking what else is going outs- on outside the four walls of this clinic in this person's life that could be driving, our systems into more dysregulation or more regulation. Maybe things are great. Maybe she's got amazing support. Maybe insurance has given her a new car immediately. Who knows? But, and, and- Yeah but you don't know till you ask, and you- Yeah you gotta have a process to make space for that stuff, because I will say, and I'd love to hear your thoughts, early in my career, I probably missed a boatload of that stuff and could have probably helped a lot more people, and not that obviously I was not trying to help people. I just wasn't bringing that information and that data that person held. And again, another post I made this week is we call it subjective as if it's less than information than the objective information. I'm wondering what your experience with that was to, in your development.

Oh, I'm sure. I think, I'm saying there's all... In the beginning of everyone's career, there'll be things you miss and don't see. That's par for the course, I think in a way. We'll all- whe- whether it's... It c- it could even be serious things that just slid under the rug and you didn't know what to ask at the time. I, it's just, yeah. There w- I'm sure there's certain things I didn't ask that I'd ask now. There's certain things they may have said that I'd have skipped over 'cause I was just too busy about making sure they, knew how to dorsiflex their foot somehow. I think, yeah, of course. And then over time you hopefully know kind of other things to consider, and then maybe keep an eye out for, ear out for. I think that's natural for students and new grads. The main thing you wanna do is not harm someone and try and help them with what you know. And you're focused initially on what you've been taught, right? And depends on where you've come from, but that's okay. It's okay that you won't always spot the extra stuff. Of course, the other thing we should say is because pain can be influenced by anything What that means is you can't have a giant list because anything will be infinite. So it's not a case of just, ah, do they, I'm gonna be a whole person but I'm still gonna have these six bubbles of what I'm gonna think about. 'Cause anything can influence pain. You can't... It's, and it's, it requires a bit of flexibility and open-mindedness to think, just to be li- to listen and then to see what comes without, as everyone says, listen without trying to plan what you're gonna say next, right? So just see what comes. You never know. I've had someone in the past who said their neck pain got worse after an election result. Fine. The weather, re- relationship changes, all sorts of things can change and affect people. So it's not a case of, yes, we're being whole person, but it's not a case of just still having just a bigger checklist. It's more a case of being open to seeing what comes. And there may be things that come up on that assessment that are actually well controlled. So someone could be let's say diabetic, right? But that diabetes could be well controlled. They could be losing weight intentionally. They could be trying to turn things around and control that. And so yes, it's there. It's something to be aware of. But you could have two people with diabetes. One could be well controlled, another could be not well controlled at all. So again, you're weighing up the individual and seeing what comes. Sounds very cliché, Mark, see what comes in the story, don't you?

Yeah. We, and that narrative piece is a big part. And, so we've, as this whole person reasoning framework, we, and this isn't, I'm not obviously inventing some sort of new trademarked thing. This is things I've heard Tim Beam's good, great clinician over there in the UK, and other folks speaking about Bronnie at Thompson, obviously a good friend and friend of Modern Pain Care and mentor. A lot of us have talked about it, right? But I've think trying to operationalize it into some sort of, and again, not just more checklists and boxes, right? But to train clinicians to have the space to see what shows up, right? And not just, filter yourself to where you're only l- your ears are only picking up, and your eyes and, you know- Yeah 'cause we obviously can see the person's emotions and state and things and when we're looking for it. And that's pretty much what the framework's there for, is to have people have a little bit of a wider net that they're casting. Yeah. Of course, they're gonna come across people that is just a basic ankle sprain. They're adaptive, they're supported, they're, everything's doing great in life, and don't need to get into what's going on with their relationships and things like that. But you should have a process to determine it and not assume it too, 'cause I've seen Ankle sprains where this person's well on their way to CRPS, and I've had kiddos with, well-meaning parents who are building, bubble wrap around the ankle and a fortress of protection and, again, all motivated on amazingly good things. They love their kid, and they wanna make sure everything's great. But that sometimes doesn't really w- bode well for the healing of an acute injury when we're really hyperprotective and very fearful and making pain seem to be nothing ever to be experienced. So with that said, we The whole point of the framework that we're trying to, discuss is this whole overarching thing of the story and the narrative of that person, right? It all needs to fit into that, right? Whatever domains you're thinking of, the local tissue, the immunol- immunological pieces or system biology is what we've broken it down to, where the immune, the endocrine the gut, and all these other kind of lifestyle factors sit in. Metabolic health factors, I guess you could sh- could say sit in. There's the psychological factors, right? How is this person thinking, believing, behaving, all these things around their condition? Again, gotta make space for it. I don't know how people think about it till I ask them, "Hey, what do you think's going on with your back? What do you think is, the-- What-- Do you-- Can you see yourself getting back to where you were after this?" Just so you get an idea of where their mindset is, and again, having a process to not just checkbox it, but have a good empathetic, validating conversation to see where somebody's at. And then there's obviously the context of a person and where were they at social culturally, context-wise, social determinants of health, all those things that we know are important influencers of it. And that's a lot to hold in your head at once, but that's kinda why, we're trying to, put together coursework and things to help clinicians be able to hold those things and then have, maybe, some reminder checklists or some things to just, "Hey, am I really thinking whole person?" 'Cause we've all had it. I've had my times where I had my little clinical cheat sheets with me to remember to do X, Y, and Z in my exams and- Yeah and all those things. It's just helpful things to help us be more efficient clinically. Then I'm wondering 'cause y- you see primarily in your service from, and correct me if I'm wrong, you see a lot in the complex pain realm. But y- from a systemic biology, right? I don't think I think of Jack March with his rheumatology things. Obviously, that's systemic biology and the immune system and all that really coming to the forefront of the practice. I'm wondering where you see kinda like systemic biology how it fits in y- in your reasoning. Obviously, it comes up and down depending on the unique person in front of us. Like how do you look at where that is with a person?

You said it there. The... Everyone always says, Mark, we have to make sure we don't forget the bio in the biopsychosocial, right?

Baby with the bathwater.

So everyone's gonna have their story, as you said. Everyone's gonna have their own individual situation. And it's not like for an individual that it will be, I'm throwing numbers in here in the sky, but I don't know, 40% bio, 30% psych, whatever, okay? 'Cause that's just not how humans work. And that will change, obviously. For persistent pain, the one-- you said rheumatology, the ones we see are the ones where they've got the drugs, the inflammation on the imaging is under control, in theory, but there's still a lot of pain. So in theory, the bio bit of it is being controlled by the drugs, but that, they're more okay than, as you're saying what's the rest of the person? What else out there? What other systems? What are the other bits involved in their life? There are people out there who've got very... That, that bio bit could be the big driver, right? There are some people who've got relevant tissue changes that for whatever reason can't be changed. And you could even ex-expand that. So we think about the classic nociceptive pain, but actually you could expand that to neuropathic pain, couldn't you? Because I'm thinking of regardless of the cause, whether the cause is active and it's an active compression of some form of nerve, or whether it's been a compression that's been released, but the changes have happened long enough thinking of even the rare stuff like vacuinoiditis after surgery and all that stuff, there's gonna be changes there I think it in a way, how that is phrased to the individual, not even by us, but by how they've interpreted it along their journey. If you've seen X amount of certain professionals, especially if they have professor or doctor or consultant in their top job title, and they say, "This is damaged. This is it," then you're much more likely to buy that and dare I say accept, but even think, "Oh, this is it then," compared to giving some, even the vaguer answer or nothing so direct. So I think it's the bio of it and the influence of it, to a degree, will be influenced by how much the individual believes it is part of it. That make sense?

No, 100%. I we see it too. Some of the stuff around, rotator cuff a little bit different of course, but like some of the best predictors of how somebody's gonna do with conservative management of a rotator cuff problem is how well they think they're gonna do with conservative management- Yeah or like their expectations, right? Yeah. And I do think there's, there are some people who, "This is what I'm dealt and I gotta learn to move and work with it," and then there's some people, "This is what I'm dealt and, things are gonna stop right now and there's no hope." And sometimes a lot of messaging around some of our conditions can be not the most helpful to have somebody feeling like there's hope, and then some of the way healthcare navigates people through the systems that understandably people can lose that hope. But I think, hopefully getting in front of some clinicians who are well-versed into s- ye- yes, you may be left with the biologic, 'cause we can see people with some pretty severe, car accidents. I think of Keith Meldrum with his accident where, he had a pretty severe, surgery, lost, had internal injuries and pretty severe stuff that's permanent, right? There's not necessarily, and he's left with some neuropathic pain that's there. He's managing it well and has really gotten in touch, and he's obviously a leading advocate now with helping folks, be able to s- still live well with maybe some difficult conditions that, you know, when surrounded with some of the negative messaging and healthcare folks that maybe aren't giving the whole picture, and then not purposefully. I think it's just from... I know I didn't really... If I ran out of mobes to do or ran out of soft tissue work to do, eh not much else we can do for you. I think this is where you're at. But now we know, again, if you, especially with that whole person approach and you can learn psychological skills like, with ex- acceptance commitment therapy, cognitive behavioral treatments, those type of things to start. And honestly, that's physiology changing, too, when you're working with- difficult thoughts, difficult sensations, how we're, how are we're reacting to what our in- internal experiences and external experience for that matter. That stuff shows up in physiology, that, that nociceptive apparatus isn't just sitting in a vat in a vacuum not being impacted by the world and context it sits in, right? And part of that is psychology 'cause psych- thoughts are physiology, right? And fears show up in stress systems and all these different things that humans do. But it just goes to say again that you have to have a process to figure it out. With the system biologics, I just think there's so much with chronic overlapping pain conditions and things that we see, and you hear these kind of constellations of symptoms showing up in whether you call it fibro or chronic fatigue. And I know s- they definitely there's different components, and some have a little bit more concrete diagnostics, and some of it is just you have this constellation of symptoms. But again, I think right now especially, too, we see a little bit more understanding and people being a little bit more able to, the metrics and the ability to track and the ability to understand your own values. And not everybody's there as a healthcare consumer, I get it. But I think the ability for people to manage their holistic health has been n- never a lower hanger in fruit than it is right now, where people can get all sorts of stuff, apps and different things to, to support themselves, to hopefully see their health from more than just... And I think as physios we have a huge opportunity to do more than just damage control when the wheels fall off and help, definitely help people when the struggles hit, to maybe get them back on the other side. But how do we keep people well? And how do we even get people that are well staying well? But we just tend to, and it's, I know there's obviously financial and systemic barriers, which is a way longer podcast than we have time for to go into the depths of that with. But I'm wondering too 'cause the la- the last piece that we try to help y- your students with and our folks in our community is, and the last part of our framework is that social culture or context, right? 'Cause, and I've spoke to this already, where the wonderful world of the four walls of your clinic are nothing like the walls of the world that person lives in day after day. And I'm wondering how you, maybe a couple things. How do you help students have an awareness of that? Like how do you help clinicians maybe open their eyes that, yes, you can test, treat, retest, and needle, scrape, tape, cup, slap, whatever it is that you're doing to somebody, and they could feel better after it in your session. But they go out into a world where you're not there, and they have to be able to modulate their experience when you're not there. I'm wondering how you work with clinicians who are trying to figure that all out.

We I guess we, we encourage by demonstrating, because I can't remember if I've told you or not, we, as part of our questions now for the past 18 months, two years, apparently it's part of the NICE guidelines that one should ask someone, "What effect do you think your culture has on your pain?" Or, "Do you think your cultural background has an influence on the pain you feel?" Or something like that. So you would, l- because we ask, hopefully other clinicians see us ask, and then something to consider that, they may m- more like to ask 'cause they've seen us ask, if that makes sense. They feel inspired, hopefully. We... it's very tricky 'cause it also relies on the individual being able to identify the effect of their culture on their pain, and vice versa. Some can. A lot of the time, I would say 90-plus percent of the time, the answer is no, which I get. And to be honest with you, I'm more thinking about, at least where I am, other cultures that aren't the classic generic white British whatever. It's gonna be other cultures we think of where pain is, whether treated or thought of in a different way. That will depend on the culture and what it is. We have a large not large. There's a cohort of clients from certain parts of Europe who expect very passive care, if I call it that. And that's the culture there. That's what their experience is of. Everything is imaged first before you try and support them and all the treatments are very passive, and you have things done to you. There are other cultures where if you have a pain or a problem, everyone else tries to care for you, especially if you are a certain member of the family of a certain age as well. A, it become someone needs to be able to identify it, and B, then are they willing to change it? Because if it becomes part of your culture, and that's been the way of-- that's almost becomes your identity, then it's particularly tricky for someone to try and change because it's part of identity, so we don't wanna usually give it up. I'd like to tell you there's an easy answer, but the answer isn't easy. Ideally, the the ideal solution is you f- they can find other people in the same culture who are managing their, in this case, pain, whatever the problem is and then they hopefully feel inspired, and they feel, "Oh, this person's managing. They're part of my culture. They're doing this. Hope- I should do this too." I don't think it's too hard of a question to ask, clinicians to consider, and I think I, I think that when you've had a lit- not even a lot of experience, just a little bit of experience, and you can see how certain people from certain different cultures will feel about pain management or not or managing their issues differently to others. You'll be able to identify it, and we should say the same for all, a lot of these things. It's easy-- Sometimes it can be easy to identify if it's glaringly obvious in front of you. The harder bit is what you do about it.

Yeah that's for certain. And I even think cultures too, not just like ethnic culture, which is obviously part of it, especially when you're not a member of the patient's ethnic culture and just, in your culture, how do people usually manage these type of things? And, d- like you said, those type of questions can be hugely helpful and to get a window in on where kind of expectations are out of the get-go, 'cause I do think, there's a lot of oh, the m- hands-on manual, so you're just wasting time. And then but you got a culture of a person, that's what they're coming in expecting. I'm not saying we always have to- Yeah completely cater to 100% to it, but, in the end, they're gonna probably look for somebody that meets them somewhat in their belief and expectation system. So you can choose to be no, that's stupid," or y- it's not have a discussion, "Hey, yes, but yes, and let's see if we can also do X, Y, and Z." So I, I just think there's so much complexities in the social cultural things, and then there becomes you can get us into the social determinants of health, which obviously some folks I think, Matt Lowe had a good paper recently, or maybe it's coming out. I don't remember. He shared it with me. But anyway, it's was basically to you can have the most guideline-based treatment, right? Where it's completely- checking the boxes of perfect, guideline-based treatment, yet this human may not have the social and economic resources to do your program, to do the walking, or to do the things you want that are part of that guideline. They just simply don't have it. So how do you tailor it? And to me, that's not whole person healthcare. That's evidence, consumed healthcare, where you're forgetting that people have to fit the evidence too. And not all evidence, even the most well-designed guidelines, those are designed by population studies oftentimes, where a lot of the patients with a lot of complex health things are well within the exclusion criteria of m- much of the data that went to form them. So and again, it's not to say they're not helpful. Of course, they give us guardrails and all that good stuff, but just something we need to be mindful of. So with that said if you are interested in getting deeper into the whole person reasoning frameworks and developing yourself a a framework to use and to cast that wide net over your caseload so you're not missing things that you could be catching up, or if you're somebody early in your career where I wish I was thinking whole person early. I was just very much in the facet glides and things for about five to 10 years of my career, which-

Oh, no, Mark. Oh, it's about 10 years.

Yeah, that's so easily. I just thought it was the next manual therapy CEU that was gonna get me there, my friend. But- So Ben and I are-- Ben's our community manager at Modern Pain Pro, so we're starting our Whole Person Reasoning Framework class, or Whole Person Reasoning Approach class, which is gonna basically walk through these frameworks, and it's g- and you'll see it on the Modern Pain Care's website if you wanna check it out. But there's a guide you can download on Modern Pain Care. Just check it out, see if it's something that you think would help you in your practice. I just... My firm belief is we all need to learn how to practice this way, whether you're in a sports setting where, "Oh, yeah, I just need to see the ACL and the surgeon and the approach who, was at whatever." And I'm not saying... Obviously, certain settings lend themselves to more or less need to get into the comp- But I've definitely seen some athletes. I just recently finished one post-meniscectomy that had a ma- massive, was also dealing with a massive anxiety struggle with physio school and really almost CRPS-type behavior that took a lot of, significant tailored care to, 'cause they did not fit any of the timelines that docs or ph- other physios thought she should, but they also didn't see that she's dealing with a massively distressing experience and struggling right now with anxiety and all of these things with DPT school and the fire hose you drink as a grad student. So anything you'd wanna leave folks with before we finish up for today here, Ben?

Download the guide. Sign up for Modern Pain Pro community. Let's 'cause it's really good. That's what I'll leave people with. I think it's easy to say, I think, and this guide will give you ideas. There's the link But there should be, we said this at the beginning, for every person yes, there'll be very acute situations, but again, that's mostly people in A&E and life and death situations. Otherwise, for everything else outside of that, whole person, there's a guide there to give you more ideas, and then sign up for the community.

Yeah. We'd love to have you in the community. That's all I need

from you, Mark.

Yeah. Hey you're a master, man. I appreciate it. No, it's, I think we'd love to have you in the community. It's-- we're trying to get a g- a group of clinicians. We got a good group right now who are doing some great stuff in their communities. We just had Sam get his pain program just finished up in Australia and had some great stuff going on with some of his patients there. That's the kind of stuff... Good pain care just should be something that the world-- That's just commonplace, right? We shouldn't have to like- Yeah go searching for someone who practices whole-person healthcare. I know it's a... Sometimes we say biopsychosocial and whole person, but do we truly embody it? And hopefully, check out the guide. If it resonates with you and it's something you think that would be worth pursuing further, reach out to us. You're more than welcome. You can check out the community for 30 days. If you don't like it, then fine. But you don't know unless you check it out, so we'd love if you'd check it out. But if you don't wanna join the community, that's fine. Just keep tuning into the podcast, checking out the content. Hopefully, it's something that'll help move things forward in your practice. But we're gonna leave it there this week. We hope you all enjoyed. I didn't see any questions come in, so I didn't have any to pop on the screen, Ben, but maybe next week we'll- It's fine advertise these more and maybe it won't be next week, but- We'll organize ourselves we'll see if we can't get a little bit more viewership. But thanks for your time today. We will talk to you all next time.

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