WEBVTT 00:00:03.330 --> 00:00:05.192 Okay, welcome to the Hands-On, 00:00:05.312 --> 00:00:08.977 Hands-Off podcast from the American 00:00:09.077 --> 00:00:10.939 Academy of Orthopedic Manual Physical 00:00:10.980 --> 00:00:11.601 Therapists. 00:00:12.141 --> 00:00:13.122 I'm Amy McDevitt, 00:00:13.202 --> 00:00:15.726 and today I decided to bring on my 00:00:15.785 --> 00:00:17.547 good friend and colleague, Paul Minkin. 00:00:18.368 --> 00:00:21.172 Paul has been a therapist for over thirty 00:00:21.192 --> 00:00:21.551 years. 00:00:22.152 --> 00:00:24.934 He's been in academics and he's also been 00:00:24.975 --> 00:00:27.117 involved in entry-level education, 00:00:27.176 --> 00:00:29.297 residency education, fellowship education. 00:00:29.998 --> 00:00:31.579 And today I wanted to just have him 00:00:31.800 --> 00:00:34.322 chat a little bit about an article called 00:00:34.362 --> 00:00:36.162 the worst pain is an unexplained pain. 00:00:36.183 --> 00:00:39.125 And that was published in JOSPT just 00:00:39.246 --> 00:00:41.728 recently, but we've had some kind of off, 00:00:42.008 --> 00:00:42.427 uh, 00:00:42.508 --> 00:00:44.490 offscreen conversations about this topic. 00:00:44.570 --> 00:00:46.070 And I just wanted to bring Paul on 00:00:46.091 --> 00:00:47.472 to talk a little bit more about it. 00:00:47.972 --> 00:00:48.552 So, um, 00:00:49.033 --> 00:00:49.914 Paul, welcome, 00:00:50.015 --> 00:00:51.337 and thank you for agreeing to come on 00:00:51.356 --> 00:00:52.158 the podcast today. 00:00:53.201 --> 00:00:54.463 Well, thanks for having me, Amy, 00:00:54.482 --> 00:00:55.905 and you forgot to mention you're an author 00:00:55.945 --> 00:00:56.927 on that paper too, so... 00:00:57.898 --> 00:00:59.139 Yeah, yes, that's right. 00:00:59.198 --> 00:01:00.378 So I'm an author. 00:01:00.439 --> 00:01:03.399 And then we also have Jeremy Lewis as 00:01:03.420 --> 00:01:04.921 the senior author on this paper. 00:01:04.980 --> 00:01:06.822 And what was kind of fun, Paul, 00:01:06.841 --> 00:01:08.361 if you don't mind me telling the story, 00:01:08.421 --> 00:01:10.882 is the three of us were chatting at 00:01:10.923 --> 00:01:13.164 the AOMT conference last year and just 00:01:13.203 --> 00:01:15.105 talking about things that we're passionate 00:01:15.125 --> 00:01:17.066 about and work that we're doing and 00:01:17.126 --> 00:01:18.326 research and that sort of thing. 00:01:18.387 --> 00:01:20.326 And we kind of just made a little 00:01:20.367 --> 00:01:22.328 bit of a pact or a decision to 00:01:22.447 --> 00:01:23.948 write a couple of passion papers together. 00:01:24.269 --> 00:01:26.150 with each of us leading a paper about 00:01:26.209 --> 00:01:27.590 something that we were passionate about. 00:01:27.650 --> 00:01:29.292 And so it's this is kind of a 00:01:29.352 --> 00:01:31.852 fun result of a conversation that started 00:01:31.893 --> 00:01:32.632 at a conference. 00:01:33.173 --> 00:01:33.894 Paul, 00:01:33.974 --> 00:01:35.594 tell us a little bit more about why 00:01:35.635 --> 00:01:39.777 this is a passion paper for you. 00:01:39.837 --> 00:01:40.236 Well, you know, 00:01:40.277 --> 00:01:43.278 I have always respected Jeremy Lewis's 00:01:43.319 --> 00:01:43.718 work, 00:01:43.838 --> 00:01:46.379 and so he gave a pre-conference course at 00:01:46.780 --> 00:01:48.320 last year, which was outstanding, 00:01:48.361 --> 00:01:49.621 but he brought up this 00:01:50.406 --> 00:01:52.750 quote by Hillary Mantel that the worst 00:01:52.769 --> 00:01:54.450 pain is an unexplained pain. 00:01:54.471 --> 00:01:56.653 And that just really resonated with me. 00:01:56.974 --> 00:01:58.575 And how do we make sense of that 00:01:59.757 --> 00:02:00.638 to our patients? 00:02:00.697 --> 00:02:02.620 And that's always the challenge, you know, 00:02:02.659 --> 00:02:04.182 whether they come in with imaging that 00:02:04.201 --> 00:02:06.784 shows this is going on or, 00:02:06.805 --> 00:02:06.864 you 00:02:07.617 --> 00:02:09.620 know the the really tough one is the 00:02:09.659 --> 00:02:13.024 patient who has maybe symptoms and has 00:02:13.164 --> 00:02:15.247 x-rays and has an mri and doesn't show 00:02:15.307 --> 00:02:17.730 anything right and so like what's going on 00:02:17.770 --> 00:02:19.753 now and i see a lot of patients 00:02:19.794 --> 00:02:20.615 who have been to 00:02:21.808 --> 00:02:22.370 you know, 00:02:22.389 --> 00:02:24.431 chiropractors and physical therapists and 00:02:24.450 --> 00:02:25.072 physicians. 00:02:25.092 --> 00:02:26.633 And the physician tells them, you know, 00:02:26.652 --> 00:02:27.674 it's a disc problem. 00:02:27.693 --> 00:02:28.955 And the chiropractor tells them they've 00:02:28.974 --> 00:02:30.075 got a vertebrae out of place. 00:02:30.175 --> 00:02:32.057 And PTs are as guilty as anybody else 00:02:32.437 --> 00:02:34.080 of labeling patients. 00:02:34.099 --> 00:02:34.300 You know, 00:02:34.961 --> 00:02:36.701 your SI is out of place or your 00:02:36.741 --> 00:02:38.984 nominant's rotated or things like that. 00:02:39.104 --> 00:02:41.225 So they've heard three different stories 00:02:41.286 --> 00:02:42.526 from three different providers, 00:02:42.567 --> 00:02:44.609 and they don't know where to go with 00:02:44.628 --> 00:02:44.868 that. 00:02:45.189 --> 00:02:47.931 And just trying to make sense of that 00:02:49.152 --> 00:02:50.954 for the patient that's sitting in front of 00:02:50.993 --> 00:02:52.534 you can be challenging. 00:02:52.615 --> 00:02:56.817 So we'll get into talking about the ICF 00:02:56.856 --> 00:02:58.296 model and things like that. 00:02:58.358 --> 00:02:59.837 But as physical therapists, 00:02:59.858 --> 00:03:00.758 we treat human beings. 00:03:00.799 --> 00:03:01.899 We don't treat pathology. 00:03:01.959 --> 00:03:05.461 So shifting the focus away from trying to 00:03:06.221 --> 00:03:09.862 pinpoint the pain generator is a useless 00:03:09.923 --> 00:03:11.463 exercise for most of our patients. 00:03:12.014 --> 00:03:12.313 Yeah, 00:03:12.394 --> 00:03:13.735 and you said something that resonates with 00:03:13.754 --> 00:03:14.155 me too. 00:03:14.794 --> 00:03:16.496 It's kind of both sides of this argument. 00:03:16.536 --> 00:03:17.836 So it's whether the patient has had 00:03:17.915 --> 00:03:19.917 imaging and there's a whole plethora of 00:03:19.956 --> 00:03:22.337 things that were read by a radiologist the 00:03:22.377 --> 00:03:23.538 patient is reading, 00:03:23.578 --> 00:03:24.957 sometimes even before they have an 00:03:24.978 --> 00:03:26.838 opportunity to interact with the provider 00:03:27.158 --> 00:03:28.039 to get context. 00:03:28.680 --> 00:03:30.560 And it's the patient who doesn't have any 00:03:30.620 --> 00:03:31.781 findings on imaging 00:03:32.320 --> 00:03:34.502 That feels like something has gone 00:03:34.543 --> 00:03:36.746 horribly wrong because there's no evidence 00:03:37.086 --> 00:03:39.027 of anything that's problematic or 00:03:39.068 --> 00:03:41.751 explaining why they have certain symptoms. 00:03:41.790 --> 00:03:43.832 So I like that you called that out 00:03:43.853 --> 00:03:45.514 because it can happen on kind of both 00:03:45.574 --> 00:03:46.536 sides of that argument. 00:03:47.537 --> 00:03:48.798 So my first question is, 00:03:48.837 --> 00:03:50.879 what are some of your experiences that 00:03:50.960 --> 00:03:54.122 kind of shaped your decision to write this 00:03:54.203 --> 00:03:54.663 viewpoint? 00:03:56.663 --> 00:03:57.604 Well, you know, over the years, 00:03:57.704 --> 00:03:59.705 I've had countless patients who come in 00:03:59.745 --> 00:04:00.324 with pain, 00:04:00.344 --> 00:04:03.105 but there's no clear structural cause 00:04:03.165 --> 00:04:03.566 overall. 00:04:03.605 --> 00:04:05.165 Maybe their imaging looks normal, 00:04:05.225 --> 00:04:06.866 but their suffering is real. 00:04:06.926 --> 00:04:07.806 So, you know, 00:04:07.826 --> 00:04:10.127 what moved me to write this piece was 00:04:10.168 --> 00:04:11.467 talking to Jeremy, 00:04:11.508 --> 00:04:13.429 but also reflecting on those patients that 00:04:13.449 --> 00:04:15.028 have bounced between providers, 00:04:15.169 --> 00:04:17.810 each giving them a different diagnosis 00:04:17.870 --> 00:04:18.269 overall, 00:04:18.290 --> 00:04:20.569 and it leaves them just confused and not 00:04:20.630 --> 00:04:23.011 sure where to go forward, afraid to move, 00:04:23.031 --> 00:04:24.711 thinking their back or whatever is going 00:04:24.752 --> 00:04:25.791 to explode if they 00:04:26.351 --> 00:04:27.072 if they load it. 00:04:27.153 --> 00:04:29.336 So in practice, 00:04:29.396 --> 00:04:31.377 I see that the worst pain isn't the 00:04:31.458 --> 00:04:32.658 one we can see on an MRI. 00:04:32.798 --> 00:04:35.843 It's the one that we can't explain to 00:04:35.862 --> 00:04:39.165 the patient in terms that they understand. 00:04:39.206 --> 00:04:39.567 So really, 00:04:39.627 --> 00:04:41.509 my goal is to help patients make sense 00:04:41.528 --> 00:04:42.089 of their pain, 00:04:42.670 --> 00:04:44.853 even when we can't pinpoint an exact 00:04:45.353 --> 00:04:47.536 anatomical diagnosis. 00:04:48.206 --> 00:04:49.966 Yeah, yeah, I think that's true. 00:04:50.007 --> 00:04:51.687 And I think it's something that I see 00:04:51.747 --> 00:04:53.968 in my setting because I treat, you know, 00:04:53.988 --> 00:04:55.430 a little bit of a different population 00:04:55.490 --> 00:04:57.850 working in a health care system for a 00:04:57.891 --> 00:05:00.233 hospital is that, you know, 00:05:00.273 --> 00:05:02.194 trying to describe to patients some of 00:05:02.233 --> 00:05:03.795 these things are normal age related 00:05:03.834 --> 00:05:05.375 changes and they may or may not be 00:05:05.415 --> 00:05:06.235 pain provoking. 00:05:06.276 --> 00:05:08.117 And so I think that's another kind of 00:05:08.156 --> 00:05:11.579 layer to this conversation is we don't we 00:05:11.598 --> 00:05:13.500 shouldn't have an expectation that imaging 00:05:13.519 --> 00:05:15.141 looks normal in people that are over the 00:05:15.221 --> 00:05:17.021 age of fifty or sixty or seventy. 00:05:19.026 --> 00:05:20.846 Or even younger individuals, you know, 00:05:20.887 --> 00:05:22.447 I treat a lot of college age students. 00:05:22.507 --> 00:05:23.348 And, you know, 00:05:23.367 --> 00:05:25.209 the research shows that especially with a 00:05:25.249 --> 00:05:26.430 condition like back pain, 00:05:26.490 --> 00:05:29.190 the individuals who have never had back 00:05:29.230 --> 00:05:31.031 pain are going to have findings very 00:05:31.072 --> 00:05:32.752 commonly on imaging. 00:05:32.793 --> 00:05:34.254 So, you know, 00:05:34.274 --> 00:05:36.095 saying that that's the cause of their pain 00:05:36.134 --> 00:05:36.814 is not valid. 00:05:36.834 --> 00:05:37.975 Yeah, yeah. 00:05:39.096 --> 00:05:40.596 And so I love this. 00:05:41.797 --> 00:05:43.656 This part of the argument comes early in 00:05:43.697 --> 00:05:45.278 the paper and there's a quote here I'm 00:05:45.298 --> 00:05:45.718 going to read. 00:05:45.778 --> 00:05:47.939 It's receiving a diagnosis carries a 00:05:47.999 --> 00:05:50.218 personal significance for patients as it 00:05:50.259 --> 00:05:51.920 provides a framework for understanding 00:05:51.939 --> 00:05:52.399 their pain, 00:05:52.860 --> 00:05:54.661 validates their experience and guides 00:05:54.680 --> 00:05:55.560 their recovery. 00:05:56.120 --> 00:05:58.201 So yet, you know, the article says, 00:05:58.382 --> 00:05:58.562 you know, 00:05:58.581 --> 00:06:00.242 the worst pain is an unexplained pain. 00:06:00.283 --> 00:06:02.963 So how do you balance the need for 00:06:03.083 --> 00:06:04.783 diagnostic clarity and 00:06:05.124 --> 00:06:07.225 with the reality that some musculoskeletal 00:06:07.266 --> 00:06:12.331 conditions lack a clear structural cause? 00:06:12.370 --> 00:06:14.153 Well, that's why I'm honest with patients. 00:06:14.192 --> 00:06:17.857 And I do talk about the research that 00:06:17.896 --> 00:06:19.718 looks at asymptomatic individuals with 00:06:19.819 --> 00:06:20.980 whatever their condition is, 00:06:21.040 --> 00:06:22.761 whether it's shoulder pain, back pain, 00:06:22.800 --> 00:06:23.302 hip pain, 00:06:23.935 --> 00:06:24.797 you know, those kinds of things, 00:06:24.836 --> 00:06:27.199 the prevalence of pathoanatomy in 00:06:27.439 --> 00:06:30.221 asymptomatic individuals is through the 00:06:30.261 --> 00:06:30.600 roof. 00:06:30.661 --> 00:06:34.625 So just starting off, you know, 00:06:34.644 --> 00:06:36.745 with that and, you know, 00:06:36.846 --> 00:06:39.928 I tell them that it's very unlikely that 00:06:39.949 --> 00:06:42.511 I'll be able to exactly pinpoint what 00:06:42.591 --> 00:06:44.252 structure is causing your pain, 00:06:44.291 --> 00:06:47.074 but my job is to kind of listen 00:06:47.093 --> 00:06:49.076 to you as a human being and examine 00:06:49.115 --> 00:06:51.177 you and come up with all of the, 00:06:51.798 --> 00:06:54.120 contributing factors that may be playing a 00:06:54.160 --> 00:06:56.240 role in why you have pain, 00:06:56.341 --> 00:06:58.041 whether that's limited mobility, 00:06:58.101 --> 00:07:00.103 limited flexibility, limited strength, 00:07:00.624 --> 00:07:03.146 lack of sleep, poor nutrition, 00:07:03.206 --> 00:07:05.086 high stress, those kind of things. 00:07:05.127 --> 00:07:08.428 So just reinforcing to the patient that 00:07:08.809 --> 00:07:11.350 human beings are complex organisms, 00:07:11.411 --> 00:07:13.271 that there are multiple factors that 00:07:13.333 --> 00:07:14.994 contribute to a pain experience. 00:07:15.093 --> 00:07:17.375 My job is to tease out which ones 00:07:17.415 --> 00:07:20.137 can we identify, which ones can we modify, 00:07:20.317 --> 00:07:21.458 and moving forward, 00:07:22.218 --> 00:07:23.059 from that standpoint. 00:07:23.740 --> 00:07:24.620 Yeah. 00:07:25.141 --> 00:07:27.382 I don't know if the profession has 00:07:27.442 --> 00:07:29.764 evolved, Paul, or if we've evolved, 00:07:29.805 --> 00:07:32.286 but I feel like I also see things 00:07:32.326 --> 00:07:33.487 in a different lens. 00:07:33.588 --> 00:07:35.028 And I used to just think in terms 00:07:35.108 --> 00:07:35.629 of, okay, 00:07:35.649 --> 00:07:39.293 they have low back pain and this is 00:07:39.312 --> 00:07:40.793 the multimodal approach and these are the 00:07:40.814 --> 00:07:41.435 interventions. 00:07:41.495 --> 00:07:41.574 And 00:07:42.014 --> 00:07:44.315 Somehow now there's and maybe it's because 00:07:44.336 --> 00:07:45.636 there's been more work in the area, 00:07:45.675 --> 00:07:47.596 but I'm thinking and looking at so many 00:07:47.637 --> 00:07:48.276 different things, 00:07:48.336 --> 00:07:50.098 including what you just spoke to, 00:07:50.117 --> 00:07:51.459 which is lifestyle factors, 00:07:51.499 --> 00:07:53.319 but also what's going on in their lives 00:07:53.358 --> 00:07:55.600 and where they live and how they function 00:07:55.680 --> 00:07:57.461 and what kind of transportation they 00:07:57.521 --> 00:08:00.682 access and, you know, spirituality. 00:08:00.721 --> 00:08:02.702 And there's all these other dynamics that 00:08:02.762 --> 00:08:03.362 play in. 00:08:03.822 --> 00:08:05.622 that I never really appreciated before. 00:08:05.723 --> 00:08:07.303 So I don't know if we've changed or 00:08:07.343 --> 00:08:09.043 if the profession has changed and really 00:08:09.103 --> 00:08:11.345 decided to put a spotlight on some of 00:08:11.365 --> 00:08:13.384 these other more person-centered factors 00:08:13.404 --> 00:08:14.225 that really matter. 00:08:16.245 --> 00:08:17.125 Yeah, I think it's both. 00:08:17.225 --> 00:08:20.807 I think hopefully we continue to evolve 00:08:20.867 --> 00:08:22.867 and start to realize, again, 00:08:22.887 --> 00:08:24.468 that we're treating human beings. 00:08:24.507 --> 00:08:26.468 We're not treating pathology, 00:08:26.649 --> 00:08:27.168 especially as 00:08:27.733 --> 00:08:29.615 as physical therapists and that kind of 00:08:29.634 --> 00:08:29.795 thing. 00:08:29.855 --> 00:08:31.355 And then one other point I wanted to 00:08:31.396 --> 00:08:32.297 comment on, you know, 00:08:32.336 --> 00:08:34.738 I also teach in fellowship and I had 00:08:34.758 --> 00:08:37.479 a fellow say once, you know, 00:08:37.538 --> 00:08:39.059 if a patient comes into me and brings 00:08:39.100 --> 00:08:40.221 their MRI, I tell them, 00:08:40.360 --> 00:08:41.761 I don't even want to see it. 00:08:43.283 --> 00:08:44.443 And, you know, for me, 00:08:45.024 --> 00:08:46.966 that is like slapping the patient in the 00:08:47.005 --> 00:08:47.326 face. 00:08:47.365 --> 00:08:48.748 They've spent this time, 00:08:48.788 --> 00:08:51.149 this money to get this image and you 00:08:51.169 --> 00:08:52.291 won't even look at it. 00:08:52.410 --> 00:08:55.052 Now, we've talked about how, you know, 00:08:55.214 --> 00:08:57.355 pathoanatomy is prevalent in asymptomatic 00:08:57.416 --> 00:08:57.916 individuals, 00:08:57.956 --> 00:08:59.898 but you need to validate that patient's 00:09:00.818 --> 00:09:01.318 experience, 00:09:01.359 --> 00:09:02.760 what they've been through and that kind of 00:09:02.780 --> 00:09:02.941 thing. 00:09:02.980 --> 00:09:04.481 So I will take the time to pull 00:09:04.522 --> 00:09:04.721 it up. 00:09:04.741 --> 00:09:06.303 Let's look at this and go through it. 00:09:06.943 --> 00:09:09.004 And then I will look at what they 00:09:09.044 --> 00:09:10.605 find on the imaging and I will tell 00:09:10.645 --> 00:09:12.386 the patient my job is to see if 00:09:12.947 --> 00:09:15.107 what I find in my clinical exam correlates 00:09:15.148 --> 00:09:16.528 with what we see on the imaging. 00:09:17.028 --> 00:09:18.750 If it does, great, we'll move forward. 00:09:18.889 --> 00:09:19.671 If it doesn't, 00:09:19.791 --> 00:09:23.032 then there are some other things that we 00:09:23.052 --> 00:09:23.613 can treat. 00:09:24.113 --> 00:09:24.753 And again, 00:09:24.793 --> 00:09:26.953 it is common for individuals to have 00:09:27.494 --> 00:09:30.076 pathoanatomy on imaging that does not 00:09:30.135 --> 00:09:32.456 correlate to symptoms. 00:09:33.136 --> 00:09:33.376 Yeah. 00:09:33.517 --> 00:09:35.437 And I find myself having that conversation 00:09:35.518 --> 00:09:37.618 actually quite a bit with my patients 00:09:37.658 --> 00:09:40.499 because most of them present to PT with 00:09:40.558 --> 00:09:42.519 imaging in hand because we're in a 00:09:42.538 --> 00:09:44.539 hospital-based system and that's just how 00:09:44.559 --> 00:09:45.480 that system works. 00:09:45.899 --> 00:09:48.340 So tell us a little bit about how 00:09:48.379 --> 00:09:51.061 the ICF model and maybe using language 00:09:51.081 --> 00:09:52.941 surrounding a functional diagnosis might 00:09:53.041 --> 00:09:55.182 help some of this situation with our 00:09:55.221 --> 00:09:55.761 patients. 00:09:58.250 --> 00:10:00.511 again we're trying to identify things that 00:10:00.712 --> 00:10:02.754 we can treat you know we're not going 00:10:02.774 --> 00:10:04.894 to go in and fix somebody's disc or 00:10:04.934 --> 00:10:06.775 if they've got a torn labrum in their 00:10:06.796 --> 00:10:09.057 shoulder or something like that so you 00:10:09.076 --> 00:10:11.139 know i'm going to be identifying uh 00:10:11.178 --> 00:10:12.659 impairments to movement you know you look 00:10:12.720 --> 00:10:15.520 at the mission statement for uh the apta 00:10:15.541 --> 00:10:17.322 you know optimizing human movement and 00:10:17.341 --> 00:10:19.384 that type of thing so my exam is 00:10:19.423 --> 00:10:22.565 really focused on barriers to the tissue 00:10:22.585 --> 00:10:24.407 that whatever tissue it is that they've 00:10:24.547 --> 00:10:24.927 injured 00:10:25.687 --> 00:10:27.788 uh making a complete recovery so that 00:10:27.888 --> 00:10:30.668 includes physical factors like you know 00:10:30.969 --> 00:10:33.409 strength flexibility mobility those kind 00:10:33.429 --> 00:10:35.190 of things but also those other lifestyle 00:10:35.909 --> 00:10:38.071 uh things that we talk about so i 00:10:38.250 --> 00:10:39.471 tell my patients at the end of the 00:10:39.491 --> 00:10:40.392 exam look 00:10:41.192 --> 00:10:41.952 You have back pain. 00:10:41.993 --> 00:10:43.573 I don't know exactly what the structure 00:10:43.634 --> 00:10:43.754 is, 00:10:43.813 --> 00:10:46.135 but these are the key impairments that I 00:10:46.176 --> 00:10:48.697 have identified that I think are barriers 00:10:48.738 --> 00:10:50.259 to you getting back to doing what you 00:10:50.298 --> 00:10:50.820 need to do. 00:10:50.840 --> 00:10:52.942 And we're going to focus on treating those 00:10:52.981 --> 00:10:54.763 because the research would suggest if we 00:10:54.802 --> 00:10:55.903 improve those things, 00:10:56.323 --> 00:10:58.326 it's likely that you'll feel better. 00:10:58.385 --> 00:10:58.686 Yeah. 00:10:59.086 --> 00:11:00.707 And we speak to in the article a 00:11:00.727 --> 00:11:03.190 little bit about using words like pain. 00:11:03.788 --> 00:11:05.751 things are irritated or sensitive, 00:11:05.932 --> 00:11:08.754 or I find myself with patients using, 00:11:08.855 --> 00:11:09.917 you know, you're not really, 00:11:10.356 --> 00:11:12.038 you're sensitive to load right now. 00:11:12.580 --> 00:11:15.923 And those, those resonate with patients. 00:11:16.565 --> 00:11:17.866 Like your nerves are irritated, 00:11:17.907 --> 00:11:19.649 things like that, instead of using, 00:11:20.129 --> 00:11:20.289 you know, 00:11:20.330 --> 00:11:22.072 more of that pathoanatomic language that 00:11:22.091 --> 00:11:22.592 we know can, 00:11:23.171 --> 00:11:25.011 can in some patients be harmful, 00:11:25.032 --> 00:11:27.734 but I do feel like patients understand it 00:11:28.014 --> 00:11:29.615 when we break it down in that way. 00:11:30.916 --> 00:11:32.616 Have you ever had trouble kind of 00:11:32.657 --> 00:11:34.298 implementing some of that language and 00:11:34.337 --> 00:11:36.038 talking about, you know, 00:11:36.058 --> 00:11:38.159 mobility impairments or movement 00:11:38.201 --> 00:11:39.541 coordination or things like that with 00:11:39.581 --> 00:11:40.022 patients? 00:11:40.042 --> 00:11:41.403 Yeah. 00:11:41.543 --> 00:11:43.744 I mean, that's, that's always a challenge. 00:11:43.923 --> 00:11:44.384 I mean, 00:11:44.403 --> 00:11:45.825 a lot of patients come in with the 00:11:45.865 --> 00:11:47.346 thought that pain equals harm. 00:11:47.385 --> 00:11:48.486 Every time I feel pain, 00:11:48.854 --> 00:11:51.397 causing damage to the tissue overall. 00:11:51.437 --> 00:11:53.759 And so that's the first thing we need 00:11:53.778 --> 00:11:54.720 to kind of straighten out. 00:11:54.919 --> 00:11:57.943 And I'm a big advocate of pain science 00:11:57.984 --> 00:11:58.504 education, 00:11:58.524 --> 00:11:59.485 but I think a lot of it has 00:11:59.504 --> 00:12:01.527 gone way overboard that we don't need to 00:12:01.567 --> 00:12:03.769 get that detailed with our patients 00:12:03.830 --> 00:12:04.149 overall. 00:12:04.190 --> 00:12:04.610 Look, there's 00:12:05.171 --> 00:12:07.572 these things that are contributing to the 00:12:07.592 --> 00:12:08.514 symptoms that you're having. 00:12:08.533 --> 00:12:09.234 And like you said, 00:12:09.653 --> 00:12:11.076 your tissue just got overloaded. 00:12:11.135 --> 00:12:14.518 If you are a sedentary individual and you 00:12:14.538 --> 00:12:16.240 help a person move and you expose your 00:12:16.259 --> 00:12:17.941 back to loads it hasn't seen in ten 00:12:17.980 --> 00:12:18.301 years, 00:12:19.302 --> 00:12:21.683 we would expect that you would be a 00:12:21.703 --> 00:12:22.423 little bit sore. 00:12:22.484 --> 00:12:24.365 And it does all come down to load 00:12:24.446 --> 00:12:26.908 and building the tissue's biologic 00:12:26.947 --> 00:12:28.428 capacity to tolerate load. 00:12:28.448 --> 00:12:31.750 And if you explain it in those terms 00:12:31.770 --> 00:12:32.351 to patients, 00:12:33.852 --> 00:12:34.913 it tends to resonate with them. 00:12:35.389 --> 00:12:35.671 Yeah. 00:12:36.211 --> 00:12:37.433 So do you mind if we go off 00:12:37.474 --> 00:12:39.458 script for a minute and I play the 00:12:39.499 --> 00:12:41.582 patient with my imaging in hand and you 00:12:41.623 --> 00:12:43.226 kind of reframe the conversation? 00:12:46.440 --> 00:12:46.779 Sure. 00:12:47.179 --> 00:12:47.900 All right. 00:12:47.921 --> 00:12:49.322 So I'm going to, for a moment, 00:12:49.361 --> 00:12:50.903 pretend that I'm much younger. 00:12:51.163 --> 00:12:52.964 I'm a thirty five year old female. 00:12:54.125 --> 00:12:55.005 But, Paul, 00:12:55.025 --> 00:12:56.986 I've been having all of this pain going 00:12:57.006 --> 00:12:58.628 down my right leg and I had an 00:12:58.668 --> 00:13:00.830 MRI because my doctor thought that would 00:13:00.850 --> 00:13:01.629 be the next step. 00:13:02.191 --> 00:13:04.972 And I have disc herniations. 00:13:05.133 --> 00:13:07.695 So I have disc herniations that they said 00:13:07.894 --> 00:13:10.015 L three and four, L four, five, 00:13:10.496 --> 00:13:12.357 both on the right and the left side. 00:13:12.498 --> 00:13:13.879 And I've got some disc herniation. 00:13:13.979 --> 00:13:16.101 decreased disc height is what the MRI 00:13:16.142 --> 00:13:17.143 report had said. 00:13:17.263 --> 00:13:19.004 And so, you know, 00:13:19.024 --> 00:13:20.147 what are we going to do about this? 00:13:20.167 --> 00:13:21.509 I don't know that I think physical therapy 00:13:21.808 --> 00:13:23.350 is going to work because we talked about 00:13:23.390 --> 00:13:23.991 injections. 00:13:25.908 --> 00:13:27.269 Yeah, so first of all, 00:13:27.408 --> 00:13:29.410 I want to validate that your pain is 00:13:29.750 --> 00:13:30.030 real, 00:13:30.071 --> 00:13:31.631 and I apologize that you have to go 00:13:31.652 --> 00:13:32.072 through that. 00:13:32.113 --> 00:13:34.354 And I understand that may be difficult for 00:13:34.374 --> 00:13:36.174 you to be going through that. 00:13:37.056 --> 00:13:39.118 Again, with my exam, 00:13:39.158 --> 00:13:40.899 I'm going to be trying to correlate what 00:13:40.938 --> 00:13:42.440 we see on imaging with some of the 00:13:42.480 --> 00:13:43.441 symptoms that you have, 00:13:43.480 --> 00:13:44.642 and they may correlate with 00:13:45.481 --> 00:13:46.701 what we see on the imaging and they 00:13:46.741 --> 00:13:47.202 may not. 00:13:48.123 --> 00:13:49.682 But we do have some good treatments that 00:13:49.702 --> 00:13:52.844 we know that can decrease the load in 00:13:52.884 --> 00:13:55.565 the region here and optimize the mobility 00:13:55.605 --> 00:13:56.684 of the tissues around there. 00:13:56.725 --> 00:13:59.166 But really our goal is to create the 00:13:59.326 --> 00:14:01.485 optimal environment for your back to 00:14:01.525 --> 00:14:03.927 recover from whatever is going on in that 00:14:03.966 --> 00:14:04.246 region. 00:14:05.047 --> 00:14:07.028 There's likely with the imaging findings 00:14:07.048 --> 00:14:08.629 that we're seeing some inflammation, 00:14:08.669 --> 00:14:10.611 some overload in through that area. 00:14:10.631 --> 00:14:12.072 And if we can get that calmed down, 00:14:12.113 --> 00:14:13.313 then the tissue can heal. 00:14:13.693 --> 00:14:14.914 As soon as that starts to heal, 00:14:14.975 --> 00:14:16.216 your symptoms will improve. 00:14:17.197 --> 00:14:18.738 There may be flares as we kind of 00:14:18.758 --> 00:14:19.578 go through things. 00:14:19.739 --> 00:14:20.240 Obviously, 00:14:21.240 --> 00:14:23.481 if the imaging is showing all of those 00:14:23.542 --> 00:14:25.224 things overall that are going on, 00:14:25.884 --> 00:14:29.027 we want to be respectful of that as 00:14:29.086 --> 00:14:30.128 we're progressing through. 00:14:30.168 --> 00:14:31.928 But the goal is to get you back 00:14:31.969 --> 00:14:33.350 to doing the things that you want to 00:14:33.370 --> 00:14:33.811 do and 00:14:34.571 --> 00:14:36.432 you know not laying around we know that 00:14:37.251 --> 00:14:40.313 bed rest and things like that just tend 00:14:40.354 --> 00:14:42.154 to make these symptoms worse on on 00:14:42.254 --> 00:14:44.174 multiple levels both from a healing level 00:14:44.215 --> 00:14:46.336 and a psychological level so you know i 00:14:46.355 --> 00:14:48.496 don't want to dismiss what we see on 00:14:48.537 --> 00:14:50.697 the imaging but you know there's plenty of 00:14:50.738 --> 00:14:53.399 people out there who have really uh 00:14:53.740 --> 00:14:55.900 terrible looking backs on on imaging who 00:14:55.921 --> 00:14:57.961 have no pain so there's no reason why 00:14:58.001 --> 00:14:59.623 you can't get back to doing what you 00:14:59.643 --> 00:15:00.342 need to be able to do 00:15:01.331 --> 00:15:03.351 Yeah, that was pretty good, Paul. 00:15:03.371 --> 00:15:05.033 I'll give it a nine out of ten. 00:15:07.953 --> 00:15:09.154 Maybe a ten out of a ten if 00:15:09.174 --> 00:15:10.755 you inserted a little teach back in there 00:15:10.775 --> 00:15:11.235 or something. 00:15:11.275 --> 00:15:12.476 But no, I'm joking. 00:15:12.496 --> 00:15:13.037 That was great. 00:15:13.157 --> 00:15:15.817 I think you covered so many bases. 00:15:15.837 --> 00:15:19.519 You talked about maybe decreasing some 00:15:19.559 --> 00:15:22.280 catastrophizing if that's present because 00:15:22.301 --> 00:15:23.581 you kind of normalized a little bit of 00:15:23.601 --> 00:15:24.142 the imaging. 00:15:24.162 --> 00:15:25.222 But then you also talked about 00:15:25.783 --> 00:15:27.504 contribution of lifestyle factors and 00:15:27.563 --> 00:15:29.344 other things that we'd be doing together 00:15:31.004 --> 00:15:32.904 in physical therapy in order to mitigate 00:15:32.924 --> 00:15:33.666 some of that pain. 00:15:33.706 --> 00:15:36.267 But I think it's great to just give 00:15:36.287 --> 00:15:37.986 people an opportunity to hear what a 00:15:38.027 --> 00:15:39.467 conversation might be like that you would 00:15:39.508 --> 00:15:41.207 have with a patient. 00:15:42.269 --> 00:15:43.568 You started to talk a little bit about 00:15:43.629 --> 00:15:44.249 lifestyle. 00:15:44.269 --> 00:15:47.830 And so the article did cover some and 00:15:47.890 --> 00:15:49.711 highlight some of these lifestyle factors 00:15:49.750 --> 00:15:51.751 like sleep and stress and nutrition and 00:15:52.392 --> 00:15:54.456 How do you kind of integrate those into 00:15:54.476 --> 00:15:55.839 your treatment plan? 00:15:56.120 --> 00:15:58.183 Or maybe you titrate them in over time 00:15:58.245 --> 00:16:00.308 without overwhelming the patient or maybe 00:16:00.349 --> 00:16:02.033 stepping out of our scope of practice? 00:16:03.899 --> 00:16:05.760 yeah so that's a great question you know 00:16:05.841 --> 00:16:07.302 one of the things i'll use especially with 00:16:07.322 --> 00:16:09.222 somebody that's had symptoms for a while 00:16:09.263 --> 00:16:11.004 going on is i'll have them watch that 00:16:11.945 --> 00:16:14.186 youtube video explain pain in five minutes 00:16:14.225 --> 00:16:15.986 because it does such a nice job of 00:16:16.047 --> 00:16:18.628 going through all of the different 00:16:18.788 --> 00:16:20.929 lifestyle things that may be contributing 00:16:21.009 --> 00:16:24.471 to symptoms such as sleep and stress and 00:16:24.511 --> 00:16:26.432 nutrition and activity levels and 00:16:26.873 --> 00:16:27.613 And that type of thing. 00:16:27.633 --> 00:16:29.894 So I like to really frame lifestyle as 00:16:29.994 --> 00:16:30.894 part of recovery. 00:16:30.933 --> 00:16:32.054 It's not an add on. 00:16:32.414 --> 00:16:34.995 And I explained to patients that pain is 00:16:35.034 --> 00:16:36.015 like a dimmer switch. 00:16:36.056 --> 00:16:39.037 So things like movement, sleep, stress, 00:16:39.256 --> 00:16:40.937 all have the ability to either turn that 00:16:40.956 --> 00:16:43.197 dimmer down or turn it up. 00:16:43.418 --> 00:16:45.097 And then I try to pick, you know, 00:16:45.177 --> 00:16:47.119 after the patients watch that five minute 00:16:47.139 --> 00:16:47.759 video, I say, 00:16:47.778 --> 00:16:49.779 did anything resonate with you there on 00:16:49.820 --> 00:16:50.980 your sleep and your diet? 00:16:52.495 --> 00:16:55.759 your exercise levels, your stress levels, 00:16:55.798 --> 00:16:56.320 things like that. 00:16:56.360 --> 00:16:59.142 Did anything resonate with you on that 00:16:59.182 --> 00:16:59.482 front? 00:16:59.562 --> 00:17:01.725 And they'll always come up with one. 00:17:01.764 --> 00:17:01.904 Yeah, 00:17:01.965 --> 00:17:03.966 I should get some more sleep or I 00:17:03.986 --> 00:17:06.409 should drink more water or things like 00:17:06.469 --> 00:17:06.709 that. 00:17:07.410 --> 00:17:09.951 And then I'll pick one small achievable 00:17:10.211 --> 00:17:11.532 change at a time. 00:17:11.574 --> 00:17:14.135 So maybe let's increase your activity. 00:17:14.155 --> 00:17:15.297 Let's try and have you go for a 00:17:16.678 --> 00:17:17.097 every day. 00:17:17.317 --> 00:17:19.098 Or let's come up with a consistent 00:17:19.138 --> 00:17:19.578 bedtime. 00:17:19.618 --> 00:17:20.778 Why don't you start going to bed at 00:17:20.818 --> 00:17:22.700 the same time every night so you get 00:17:22.740 --> 00:17:25.540 a consistent amount of sleep so your 00:17:25.580 --> 00:17:26.520 tissues can heal? 00:17:26.601 --> 00:17:29.102 So I try not to become a nutritionist 00:17:29.162 --> 00:17:30.061 or a psychologist. 00:17:30.142 --> 00:17:32.042 I just try to help them see how 00:17:32.083 --> 00:17:35.304 these habits can influence healing and 00:17:35.663 --> 00:17:37.564 collaborate with them on coming up with 00:17:37.624 --> 00:17:40.184 some strategies that may help them. 00:17:40.992 --> 00:17:41.452 Yeah. 00:17:41.472 --> 00:17:43.494 And I think based on my experience, 00:17:43.575 --> 00:17:45.695 even incremental change has changed. 00:17:45.776 --> 00:17:47.916 So even if we can help them implement 00:17:48.417 --> 00:17:49.958 a little bit of extra sleep or a 00:17:50.019 --> 00:17:50.919 fifteen minute walk, 00:17:50.939 --> 00:17:52.680 and I usually say to patients outside 00:17:52.799 --> 00:17:53.941 always, you know, 00:17:54.161 --> 00:17:57.042 unless it's it's not safe or the weather 00:17:57.083 --> 00:17:57.702 is not in favor, 00:17:57.722 --> 00:17:59.663 it's so good for you to do that. 00:17:59.723 --> 00:18:00.565 But, you know, 00:18:01.125 --> 00:18:02.246 there is a lot of power in it 00:18:02.286 --> 00:18:03.287 being incremental. 00:18:03.406 --> 00:18:04.727 And I don't think we're necessarily 00:18:04.846 --> 00:18:06.327 outside of our scope and making those 00:18:06.347 --> 00:18:07.128 recommendations. 00:18:08.375 --> 00:18:08.516 Yeah, 00:18:08.536 --> 00:18:10.115 and it can be overwhelming for patients if 00:18:10.135 --> 00:18:11.616 you throw it all at them at once. 00:18:11.656 --> 00:18:13.537 I need you to eat better, 00:18:13.557 --> 00:18:14.597 and I need you to sleep better, 00:18:14.678 --> 00:18:15.998 and I need you to drink more water, 00:18:16.038 --> 00:18:17.538 and I need you to decrease your stress 00:18:17.578 --> 00:18:17.959 levels, 00:18:18.019 --> 00:18:19.419 and I want you to do some mindfulness 00:18:19.439 --> 00:18:19.999 kind of things. 00:18:20.019 --> 00:18:22.059 The patients are like, whoa, whoa, whoa. 00:18:22.079 --> 00:18:23.420 This is physical therapy, isn't it? 00:18:23.440 --> 00:18:24.901 Yeah, yeah. 00:18:27.054 --> 00:18:30.115 You talked about the importance in the 00:18:30.174 --> 00:18:31.714 article of language, 00:18:31.954 --> 00:18:33.855 and we did talk about this already a 00:18:33.915 --> 00:18:34.135 bit, 00:18:34.175 --> 00:18:37.057 but what are some common phrases or 00:18:37.116 --> 00:18:40.577 metaphors that you have found helpful or 00:18:40.617 --> 00:18:42.959 maybe even harmful in communicating things 00:18:42.999 --> 00:18:44.798 to patients? 00:18:45.278 --> 00:18:47.420 Well, we've all heard these, 00:18:47.440 --> 00:18:49.080 but I see college-age students who are 00:18:49.121 --> 00:18:50.520 told by their healthcare provider, 00:18:50.560 --> 00:18:51.520 you have the spine of a 00:18:54.471 --> 00:18:56.612 It's out of alignment or you need to 00:18:56.632 --> 00:18:57.251 be careful. 00:18:57.511 --> 00:18:59.173 You could make this worse, you know, 00:18:59.232 --> 00:19:00.073 those kinds of things. 00:19:00.833 --> 00:19:01.093 You know, 00:19:01.153 --> 00:19:03.094 really educating the patients that really, 00:19:03.253 --> 00:19:04.354 if we're talking about back pain, 00:19:04.374 --> 00:19:06.914 your back is strong and it can tolerate 00:19:06.994 --> 00:19:07.635 a lot of load. 00:19:07.695 --> 00:19:09.615 It's not going to explode if you bend 00:19:09.655 --> 00:19:10.036 forward, 00:19:10.076 --> 00:19:12.257 which a lot of patients truly believe 00:19:12.297 --> 00:19:12.497 that, 00:19:12.557 --> 00:19:14.077 that if they bend forward and try and 00:19:14.097 --> 00:19:14.817 touch their toes, 00:19:14.857 --> 00:19:17.159 something terrible is going to happen. 00:19:18.118 --> 00:19:19.180 And then also, you know, 00:19:19.220 --> 00:19:20.420 the pain science stuff, 00:19:20.460 --> 00:19:21.820 pain does not equal harm. 00:19:22.080 --> 00:19:22.820 You know, if we can... 00:19:23.393 --> 00:19:25.453 get that into patient's head. 00:19:25.534 --> 00:19:26.953 Yeah. 00:19:26.993 --> 00:19:27.214 You, 00:19:27.634 --> 00:19:29.536 you helped somebody move last weekend and 00:19:29.556 --> 00:19:31.316 your back is really sore and it's probably 00:19:31.355 --> 00:19:33.017 going to be sore for, you know, 00:19:33.057 --> 00:19:34.237 a period of time overall, 00:19:34.257 --> 00:19:36.137 but pain does not mean you're causing any 00:19:37.138 --> 00:19:38.838 damage to the tissues overall. 00:19:39.038 --> 00:19:41.240 And then really getting the patients to 00:19:41.299 --> 00:19:43.980 think about their body is a complex system 00:19:44.000 --> 00:19:45.041 that requires, you know, 00:19:45.102 --> 00:19:47.042 not just strength and mobility, 00:19:47.083 --> 00:19:49.124 but all those other lifestyle factors, 00:19:49.163 --> 00:19:51.344 appropriate sleep and decreased stress 00:19:51.384 --> 00:19:52.545 levels and those kinds of things. 00:19:53.153 --> 00:19:54.273 Yeah. 00:19:54.354 --> 00:19:56.634 And I have another kind of separate 00:19:56.654 --> 00:19:56.974 question. 00:19:57.015 --> 00:19:58.315 I remember we talked about this with 00:19:58.355 --> 00:19:59.816 Jeremy when the three of us were just 00:19:59.836 --> 00:20:02.496 kind of having a conversation about some 00:20:02.536 --> 00:20:02.796 of this. 00:20:02.855 --> 00:20:06.076 But at least where I'm working in 00:20:06.176 --> 00:20:07.817 outpatient and hospital system, 00:20:08.798 --> 00:20:10.958 imaging is a huge barrier. 00:20:11.018 --> 00:20:13.459 And I spend a lot of time undoing 00:20:13.479 --> 00:20:13.638 it. 00:20:14.019 --> 00:20:14.318 You know, 00:20:14.378 --> 00:20:16.059 I have a patient that comes with imaging 00:20:16.200 --> 00:20:17.540 and then we have to talk about, 00:20:18.142 --> 00:20:18.442 you know, 00:20:18.561 --> 00:20:20.282 thinking about the imaging in a slightly 00:20:20.323 --> 00:20:20.943 different way. 00:20:20.983 --> 00:20:23.585 And it's not catastrophic and your body is 00:20:23.605 --> 00:20:23.986 strong. 00:20:24.006 --> 00:20:25.467 And to your point, you know, 00:20:25.926 --> 00:20:28.989 your lumbar spine is well supported 00:20:29.048 --> 00:20:30.910 ligamentously and by all these muscles. 00:20:30.990 --> 00:20:32.750 And maybe you're just reacting, 00:20:33.192 --> 00:20:34.873 the tissues are reacting to some load. 00:20:34.913 --> 00:20:37.434 But Jeremy was describing he didn't quite 00:20:37.454 --> 00:20:39.256 have the same problem because they don't 00:20:39.435 --> 00:20:42.518 utilize imaging as readily or as often as 00:20:42.577 --> 00:20:43.739 we do in the United States. 00:20:44.038 --> 00:20:45.820 what, where do you see the, 00:20:46.320 --> 00:20:47.603 how are we ever going to kind of 00:20:47.682 --> 00:20:49.605 get around this culture? 00:20:49.644 --> 00:20:51.185 And maybe it's too big of a question 00:20:51.246 --> 00:20:52.467 for, for, you know, 00:20:52.528 --> 00:20:53.347 us to even think about, 00:20:53.428 --> 00:20:56.010 but it's really a barrier in my opinion 00:20:56.070 --> 00:20:56.912 to recovery. 00:20:57.432 --> 00:20:58.933 What do you think the answer is at 00:20:58.973 --> 00:21:00.335 least in the United States and in our 00:21:00.375 --> 00:21:02.617 health system in terms of our utilization 00:21:02.657 --> 00:21:04.259 of imaging or over-utilization, 00:21:04.318 --> 00:21:04.779 I should say? 00:21:06.556 --> 00:21:06.796 Yeah, well, 00:21:06.816 --> 00:21:10.160 it's got to be a systemic change overall. 00:21:10.200 --> 00:21:11.961 And if we just followed the guidelines, 00:21:12.022 --> 00:21:13.423 I mean, the guidelines are very clear. 00:21:13.443 --> 00:21:14.726 If you have a new onset of back 00:21:14.766 --> 00:21:15.787 pain with no red flags, 00:21:15.886 --> 00:21:17.509 imaging is not indicated. 00:21:17.749 --> 00:21:19.030 Don't even go there. 00:21:19.090 --> 00:21:20.531 But unfortunately, like you said, 00:21:21.773 --> 00:21:23.455 when you were talking about Jason, 00:21:23.596 --> 00:21:23.855 you know, 00:21:24.457 --> 00:21:26.259 He feels like he has to order the 00:21:26.298 --> 00:21:27.079 imaging or whatever. 00:21:27.099 --> 00:21:29.862 It's kind of part of the script that 00:21:29.902 --> 00:21:30.583 you go through. 00:21:30.643 --> 00:21:32.345 But, you know, really changing that, 00:21:32.384 --> 00:21:33.405 if you read the guidelines, 00:21:33.445 --> 00:21:34.346 they are very clear. 00:21:34.365 --> 00:21:36.568 And if we just followed that, you know, 00:21:36.608 --> 00:21:38.170 on the radiology front, it's interesting, 00:21:38.931 --> 00:21:40.511 you know, where I practice up in Boulder, 00:21:40.531 --> 00:21:42.193 a lot of the radiologists are starting to 00:21:42.253 --> 00:21:43.275 put little blurbs at the 00:21:47.944 --> 00:21:50.526 Patients who are from thirty to forty, 00:21:50.566 --> 00:21:52.067 it's common to see this or that, 00:21:52.166 --> 00:21:53.847 just to put that in on the bottom 00:21:53.867 --> 00:21:55.548 so that the patients can see that some 00:21:55.568 --> 00:21:57.769 of these findings are normal in people who 00:21:57.829 --> 00:22:00.590 don't have symptoms overall. 00:22:00.791 --> 00:22:04.232 The setting I work in, 00:22:05.034 --> 00:22:06.734 about seventy percent of the patients we 00:22:06.755 --> 00:22:07.714 see are direct access, 00:22:07.734 --> 00:22:09.135 so they come in and see us first. 00:22:10.054 --> 00:22:10.294 Man, 00:22:10.334 --> 00:22:12.015 seeing somebody with two days of back pain 00:22:12.055 --> 00:22:14.036 who has not seen another provider is, 00:22:14.476 --> 00:22:14.817 you know, 00:22:15.336 --> 00:22:17.077 life-changing as a physical therapist 00:22:17.117 --> 00:22:18.838 compared to the patient who has seen ten 00:22:18.858 --> 00:22:21.000 providers and had pain for five years and 00:22:21.500 --> 00:22:23.280 had all the imaging and things like that. 00:22:23.340 --> 00:22:23.540 You know, 00:22:23.580 --> 00:22:27.363 those are so much harder patients to treat 00:22:27.462 --> 00:22:29.124 overall because they've got all of this 00:22:29.344 --> 00:22:31.425 information in their head that is just, 00:22:32.185 --> 00:22:32.586 you know, 00:22:32.705 --> 00:22:34.227 we've done a lot on expectations. 00:22:34.267 --> 00:22:36.708 Their expectation is rude, right? 00:22:36.748 --> 00:22:38.449 Their back is broken. 00:22:38.469 --> 00:22:39.289 Yeah. 00:22:39.309 --> 00:22:39.609 Yeah. 00:22:41.500 --> 00:22:42.480 I envy you, Paul. 00:22:43.881 --> 00:22:45.480 I haven't seen a patient with acute low 00:22:45.500 --> 00:22:47.642 back pain in over ten years. 00:22:49.061 --> 00:22:49.622 Unfortunately, 00:22:49.642 --> 00:22:51.481 we don't have direct access in our 00:22:51.501 --> 00:22:52.282 hospital system, 00:22:52.303 --> 00:22:53.883 which is unfortunate because we're in a 00:22:54.262 --> 00:22:55.722 state that allows direct access. 00:22:55.762 --> 00:22:58.923 But I'm not going to stir up that 00:22:58.963 --> 00:23:00.163 hornet's nest at the moment. 00:23:00.203 --> 00:23:03.605 But it's unfortunate because I believe, 00:23:03.664 --> 00:23:04.505 and you know this too, 00:23:04.545 --> 00:23:06.365 the trajectory can be so different 00:23:07.185 --> 00:23:07.266 um, 00:23:07.425 --> 00:23:08.708 when you see someone just a couple of 00:23:08.728 --> 00:23:11.549 days out of an injury or a new 00:23:11.609 --> 00:23:13.330 onset of pain versus someone that I 00:23:13.412 --> 00:23:15.133 usually can't see for eight to ten weeks. 00:23:15.553 --> 00:23:17.095 And by then they've already had imaging 00:23:17.234 --> 00:23:19.096 and a whole plethora of other things have 00:23:19.115 --> 00:23:21.317 happened, um, you know, in that, 00:23:21.417 --> 00:23:23.480 in that time, which is just, um, again, 00:23:23.519 --> 00:23:24.240 it's just unfortunate. 00:23:24.260 --> 00:23:24.340 Yeah. 00:23:24.361 --> 00:23:27.363 You know, I had to, uh, 00:23:27.804 --> 00:23:30.246 taught a course this weekend and had a 00:23:30.286 --> 00:23:32.326 great discussion with some of the people 00:23:32.366 --> 00:23:35.109 there and, um, the, uh, 00:23:37.201 --> 00:23:38.981 uh, we, we kind of talked about, 00:23:39.001 --> 00:23:39.241 you know, 00:23:39.482 --> 00:23:41.884 primary care physicians role in treating 00:23:41.923 --> 00:23:43.164 conditions like back pain. 00:23:43.204 --> 00:23:44.547 And, you know, in my opinion, 00:23:44.586 --> 00:23:46.008 and you've taught the medical students at 00:23:46.048 --> 00:23:47.388 the university of Colorado as well, 00:23:47.788 --> 00:23:49.530 they get very limited training in 00:23:49.570 --> 00:23:51.432 musculoskeletal conditions. 00:23:51.491 --> 00:23:53.513 So for a primary care physician to see 00:23:53.574 --> 00:23:56.135 a patient with back pain to me is 00:23:56.476 --> 00:23:58.217 out of their scope of practice overall. 00:23:58.237 --> 00:23:59.999 I mean, they can handle the, the, the, 00:24:01.038 --> 00:24:01.198 you know, 00:24:01.278 --> 00:24:03.441 major conditions and things like that. 00:24:03.500 --> 00:24:04.883 But that would be like us trying to 00:24:04.923 --> 00:24:06.704 treat somebody with a complex, you know, 00:24:06.806 --> 00:24:09.028 endocrine problem or something like that. 00:24:09.067 --> 00:24:11.070 You know, the physical therapist, 00:24:11.090 --> 00:24:13.673 the providers who should be the front door 00:24:13.755 --> 00:24:15.477 to the management of musculoskeletal 00:24:15.517 --> 00:24:17.700 conditions and not that we can diagnose 00:24:17.720 --> 00:24:19.000 cancer or some of these other 00:24:20.682 --> 00:24:22.262 But we know the patients that belong in 00:24:22.303 --> 00:24:23.863 our clinic today and those that don't, 00:24:23.883 --> 00:24:25.463 and we refer appropriately. 00:24:25.523 --> 00:24:25.723 I mean, 00:24:25.784 --> 00:24:29.404 we've published a report on over sixteen 00:24:29.484 --> 00:24:31.486 thousand patients seen direct access. 00:24:31.506 --> 00:24:33.686 We didn't miss a single fracture or tumor 00:24:33.906 --> 00:24:34.767 or that type of thing. 00:24:34.807 --> 00:24:36.528 So, again, 00:24:36.587 --> 00:24:37.928 we should be the ones seeing them. 00:24:38.448 --> 00:24:39.028 And if we do, 00:24:39.067 --> 00:24:41.088 the trajectory is completely different. 00:24:41.743 --> 00:24:42.023 Yeah. 00:24:42.325 --> 00:24:43.164 Yeah, I agree with that. 00:24:43.224 --> 00:24:44.747 I was just yesterday I was talking to 00:24:44.787 --> 00:24:45.988 Stephen Spoonmore, 00:24:46.347 --> 00:24:48.809 who we both did research with many moons 00:24:48.849 --> 00:24:49.089 ago, 00:24:49.130 --> 00:24:50.632 and he has worked for a number of 00:24:50.672 --> 00:24:53.453 years up in Alaska with some of the 00:24:53.473 --> 00:24:54.555 indigenous populations. 00:24:54.595 --> 00:24:56.296 And we were talking about this really cool 00:24:56.316 --> 00:24:56.436 idea. 00:24:56.936 --> 00:24:57.136 you know, 00:24:57.176 --> 00:24:59.138 primary care model that they were trying 00:24:59.179 --> 00:25:00.819 to get off the ground where, you know, 00:25:00.859 --> 00:25:03.080 patients are being triaged by this team, 00:25:03.121 --> 00:25:05.502 including primary care and sometimes 00:25:05.563 --> 00:25:08.224 behavioral health and PT as a part of 00:25:08.265 --> 00:25:10.926 that in order to kind of have this 00:25:10.967 --> 00:25:12.667 team-based approach to determining, 00:25:12.708 --> 00:25:14.249 you know, the best path for the patients. 00:25:14.269 --> 00:25:14.869 And I think that's, 00:25:15.369 --> 00:25:16.411 I think it's really cool. 00:25:16.490 --> 00:25:18.192 And I think it's kind of the ideal. 00:25:18.311 --> 00:25:18.952 So, you know, 00:25:18.972 --> 00:25:20.574 hopefully we can continue to work towards 00:25:20.614 --> 00:25:21.795 those, those models. 00:25:21.894 --> 00:25:22.214 Yeah. 00:25:23.654 --> 00:25:24.055 Yeah. 00:25:24.075 --> 00:25:26.096 Rebecca Griffith in the emergency room 00:25:26.135 --> 00:25:28.016 getting physical therapy in the emergency 00:25:28.036 --> 00:25:28.476 department. 00:25:28.756 --> 00:25:31.176 That is life-changing overall for 00:25:31.656 --> 00:25:32.457 everybody involved, 00:25:32.537 --> 00:25:33.656 even the healthcare providers. 00:25:33.757 --> 00:25:36.478 Yeah, absolutely. 00:25:36.557 --> 00:25:38.438 And she's done some great work, I believe, 00:25:38.518 --> 00:25:41.739 in really messaging that and how important 00:25:41.759 --> 00:25:43.118 that is at both a national and 00:25:43.159 --> 00:25:44.058 international level, 00:25:44.118 --> 00:25:47.380 which hopefully is another kind of agent 00:25:47.400 --> 00:25:48.019 for change. 00:25:48.604 --> 00:25:50.465 So in terms of education, I mean, 00:25:50.625 --> 00:25:52.607 we're both entry-level educators, 00:25:52.647 --> 00:25:53.388 but on top of it, 00:25:53.568 --> 00:25:55.570 you educate in some residency and 00:25:55.671 --> 00:25:56.311 fellowship. 00:25:57.613 --> 00:25:58.534 From that lens, 00:25:58.554 --> 00:26:00.234 what do you think needs to change in 00:26:00.275 --> 00:26:04.019 terms of how we educate students or 00:26:04.078 --> 00:26:05.259 learners, I should say, 00:26:05.319 --> 00:26:05.861 to better 00:26:06.606 --> 00:26:08.667 be prepared to kind of have this 00:26:08.748 --> 00:26:09.528 person-centered, 00:26:09.607 --> 00:26:11.749 non-pathoanatomical approach? 00:26:11.788 --> 00:26:14.410 And how do you still talk about 00:26:14.470 --> 00:26:18.392 pathoanatomy without it translating to the 00:26:18.451 --> 00:26:20.232 speak that we use with the patients? 00:26:20.272 --> 00:26:22.854 Because we're advocating in this article, 00:26:22.894 --> 00:26:23.534 in this viewpoint, 00:26:23.554 --> 00:26:25.535 to really talk about more of a functional 00:26:25.575 --> 00:26:26.234 diagnosis. 00:26:26.255 --> 00:26:29.037 Yeah, I mean... 00:26:30.638 --> 00:26:32.019 It's kind of the nature of the beast 00:26:32.039 --> 00:26:33.480 that we need to teach our students how 00:26:33.500 --> 00:26:35.461 to do all these exam things. 00:26:35.481 --> 00:26:36.981 And we have all these special tests that 00:26:37.002 --> 00:26:40.163 purportedly identify structural pathology 00:26:40.223 --> 00:26:41.065 and things like that. 00:26:41.105 --> 00:26:43.506 But I'm really trying to move my students 00:26:43.546 --> 00:26:44.105 away from that. 00:26:44.125 --> 00:26:45.467 I'll teach them those tests, 00:26:45.507 --> 00:26:48.407 but I also teach them how to interpret 00:26:48.448 --> 00:26:49.108 the findings, 00:26:49.169 --> 00:26:51.890 meaning that you can't rule in most 00:26:52.089 --> 00:26:54.451 conditions that we're seeing and really 00:26:54.531 --> 00:26:55.912 emphasizing that 00:26:57.692 --> 00:26:59.674 teaching them how to connect with people 00:26:59.734 --> 00:27:01.857 and how to improve the therapeutic 00:27:01.877 --> 00:27:04.201 alliance and treat the human being that's 00:27:04.221 --> 00:27:04.981 sitting in front of you. 00:27:05.021 --> 00:27:06.123 This is not a knee. 00:27:06.703 --> 00:27:07.944 This is not a shoulder. 00:27:08.045 --> 00:27:09.166 This is not a back. 00:27:09.567 --> 00:27:12.150 This is a human being that has complex 00:27:13.011 --> 00:27:13.893 things going on. 00:27:13.992 --> 00:27:16.174 So part of it is just 00:27:17.297 --> 00:27:17.798 It's habit. 00:27:17.837 --> 00:27:19.920 It's what's been done before and that kind 00:27:19.940 --> 00:27:20.180 of thing. 00:27:20.201 --> 00:27:22.163 So we really need to shift the educational 00:27:22.703 --> 00:27:26.588 model from teaching our patients to look 00:27:26.628 --> 00:27:28.490 for something that's broken or something 00:27:28.691 --> 00:27:32.095 to fix and steering more towards that ICF 00:27:32.115 --> 00:27:33.696 model to think in terms of 00:27:34.218 --> 00:27:36.779 function and how impairments affect a 00:27:36.819 --> 00:27:38.260 human being's daily life, 00:27:38.340 --> 00:27:41.564 not just what structures are involved. 00:27:41.644 --> 00:27:42.763 So, you know, 00:27:42.805 --> 00:27:44.986 I try to present a balanced approach with 00:27:45.026 --> 00:27:45.165 it. 00:27:45.205 --> 00:27:45.987 But unfortunately, 00:27:46.007 --> 00:27:48.048 they need to learn some of these special 00:27:48.088 --> 00:27:49.930 tests for the board exams and things like 00:27:49.970 --> 00:27:50.250 that. 00:27:50.269 --> 00:27:51.070 Right. 00:27:51.111 --> 00:27:51.290 But 00:27:52.147 --> 00:27:52.468 You know, 00:27:52.728 --> 00:27:56.211 I really do look at individuals now from 00:27:56.250 --> 00:27:57.310 that ICF model. 00:27:57.330 --> 00:27:58.751 They have low back pain width. 00:27:58.832 --> 00:28:00.772 What's the underlying impairment that's 00:28:00.854 --> 00:28:02.615 most likely to give us the biggest bang 00:28:02.634 --> 00:28:04.615 for our buck from the intervention 00:28:05.517 --> 00:28:06.136 standpoint? 00:28:06.257 --> 00:28:08.699 And then really teaching them about the 00:28:08.719 --> 00:28:11.059 therapeutic alliance and taking time to 00:28:11.119 --> 00:28:12.540 get to know the individual. 00:28:12.580 --> 00:28:12.780 You know, 00:28:12.820 --> 00:28:15.643 I've said over and over again to my 00:28:15.682 --> 00:28:16.262 students, you know, 00:28:16.303 --> 00:28:17.844 your interaction may outweigh your 00:28:17.864 --> 00:28:18.384 intervention. 00:28:19.105 --> 00:28:20.165 Yeah, yeah. 00:28:20.665 --> 00:28:23.249 It is tricky because we have to kind 00:28:23.288 --> 00:28:24.990 of teach both things and then at the 00:28:25.030 --> 00:28:27.913 same time somehow cohesively deliver a 00:28:27.953 --> 00:28:29.375 message that we don't want to be 00:28:30.436 --> 00:28:33.019 over-emphasizing pathoanatomic terms with 00:28:33.059 --> 00:28:33.619 patients. 00:28:34.080 --> 00:28:35.942 I was just teaching in our hybrid 00:28:36.743 --> 00:28:38.665 immersion at University of Colorado 00:28:38.685 --> 00:28:39.165 yesterday, 00:28:39.205 --> 00:28:39.346 and I 00:28:39.886 --> 00:28:42.710 we were working on teaching shoulder 00:28:42.750 --> 00:28:43.210 content. 00:28:43.891 --> 00:28:45.291 And one of the ways I felt like 00:28:45.352 --> 00:28:47.814 I could kind of try to couch this 00:28:47.854 --> 00:28:51.478 together is we were talking about shoulder 00:28:51.498 --> 00:28:53.318 pain with movement coordination deficits. 00:28:53.358 --> 00:28:54.820 But then we were talking about what 00:28:54.961 --> 00:28:57.462 pathologies might kind of nest underneath 00:28:57.502 --> 00:28:57.804 that. 00:28:58.263 --> 00:28:58.964 But still, 00:28:59.065 --> 00:29:00.465 because we don't have confidence, 00:29:00.625 --> 00:29:02.347 we know for sure that someone has 00:29:03.028 --> 00:29:04.769 multi-directional instability or that they 00:29:04.809 --> 00:29:06.451 have a laboral issue. 00:29:07.172 --> 00:29:09.815 It's still just a hypothesis under this 00:29:09.875 --> 00:29:12.298 broader category of movement coordination. 00:29:12.357 --> 00:29:14.078 And so I was trying to figure out 00:29:14.118 --> 00:29:16.442 a way to kind of house pathoanatomy under 00:29:16.561 --> 00:29:17.323 each of these, 00:29:17.403 --> 00:29:19.565 but being very explicit with the students 00:29:19.585 --> 00:29:22.488 that we don't have confirmation all the 00:29:22.528 --> 00:29:25.130 time that this is exactly what we're 00:29:25.150 --> 00:29:26.551 dealing with and it can be harmful. 00:29:27.212 --> 00:29:29.294 to describe pathoanatomy to the patient in 00:29:29.314 --> 00:29:30.814 the absence of clarity. 00:29:30.854 --> 00:29:32.694 Because to your point earlier, 00:29:32.795 --> 00:29:33.674 even with imaging, 00:29:34.134 --> 00:29:35.914 we don't have a hundred percent clarity 00:29:35.934 --> 00:29:38.455 that that's the pathoanatomy that's kind 00:29:38.476 --> 00:29:40.856 of driving the symptoms. 00:29:41.217 --> 00:29:41.457 So. 00:29:43.017 --> 00:29:43.137 Yeah. 00:29:43.198 --> 00:29:44.417 And I, you know, 00:29:44.438 --> 00:29:46.618 I've used that engineering that, that, uh, 00:29:46.778 --> 00:29:46.959 uh, 00:29:49.528 --> 00:29:51.491 meme or whatever the engineering flow 00:29:51.531 --> 00:29:54.297 chart where does it move yes should it 00:29:54.317 --> 00:29:56.582 no then you know then what are we 00:29:56.602 --> 00:29:57.804 going to do we're going to stabilize it 00:29:57.824 --> 00:29:59.026 we're going to put some duct tape on 00:29:59.086 --> 00:29:59.988 it or that kind of thing right try 00:30:00.849 --> 00:30:01.330 and uh 00:30:01.846 --> 00:30:02.105 You know, 00:30:02.145 --> 00:30:03.405 hold it down a little bit or keep 00:30:03.425 --> 00:30:04.426 it from moving too much. 00:30:04.487 --> 00:30:05.366 Or does it move? 00:30:06.406 --> 00:30:06.727 No. 00:30:06.906 --> 00:30:07.267 Should it? 00:30:07.406 --> 00:30:07.807 Yes. 00:30:07.867 --> 00:30:09.827 Then that's WD-Forty. 00:30:09.867 --> 00:30:11.709 Squirt some WD-Forty on it so it moves 00:30:11.729 --> 00:30:12.368 a little bit better. 00:30:12.409 --> 00:30:13.868 So applying some manual therapy. 00:30:13.909 --> 00:30:16.089 So when I use those same kind of 00:30:16.130 --> 00:30:17.190 descriptions to patients, 00:30:17.210 --> 00:30:18.309 you're a little stiff through here. 00:30:18.329 --> 00:30:20.151 You're not moving like you should be. 00:30:20.851 --> 00:30:22.592 And if we can improve the mobility here, 00:30:22.632 --> 00:30:25.173 then it's likely that it will decrease the 00:30:25.193 --> 00:30:27.395 amount of compensation you need to do at 00:30:27.435 --> 00:30:28.215 the level above. 00:30:28.415 --> 00:30:29.977 Or if you're moving too much, 00:30:30.017 --> 00:30:32.878 we need to just improve your body's 00:30:32.898 --> 00:30:36.801 ability to stabilize that level and keep 00:30:36.842 --> 00:30:39.683 it from getting irritated by moving beyond 00:30:39.723 --> 00:30:41.105 its normal physiologic motion. 00:30:41.755 --> 00:30:41.994 Yeah. 00:30:42.115 --> 00:30:42.836 And I agree. 00:30:42.875 --> 00:30:44.436 And I think that actually makes sense to 00:30:44.477 --> 00:30:44.837 people. 00:30:44.897 --> 00:30:46.659 Somehow we just get tempted to kind of 00:30:46.699 --> 00:30:48.420 fall in the trap of pathoanatomy, 00:30:48.460 --> 00:30:51.343 but that's not always the most productive 00:30:51.522 --> 00:30:52.243 place to go. 00:30:52.423 --> 00:30:53.144 But I agree. 00:30:53.223 --> 00:30:55.046 I think that language makes a ton of 00:30:55.086 --> 00:30:55.786 sense to people. 00:30:56.946 --> 00:30:58.647 Um, so as we kind of close up, 00:30:58.708 --> 00:31:00.209 what are some things that you're currently 00:31:00.249 --> 00:31:01.829 working on or what, what, 00:31:01.849 --> 00:31:03.690 what other passion projects do you have? 00:31:03.730 --> 00:31:05.530 Are you working on any research right now? 00:31:05.590 --> 00:31:06.652 What, what's, uh, 00:31:06.692 --> 00:31:07.811 what's blowing your hair back at the 00:31:07.832 --> 00:31:08.353 moment, Paul? 00:31:08.373 --> 00:31:09.553 Well, I guess you don't have that much, 00:31:09.593 --> 00:31:09.732 so. 00:31:14.531 --> 00:31:19.976 I'm really moving into looking at burnout 00:31:20.016 --> 00:31:22.377 and mindfulness and things like that. 00:31:22.518 --> 00:31:24.160 We're working on a project where we're 00:31:24.180 --> 00:31:25.480 looking at dry needling. 00:31:25.500 --> 00:31:27.122 We just published a case report on a 00:31:27.182 --> 00:31:29.023 patient that I caused pneumothorax on, 00:31:29.064 --> 00:31:30.766 which I think as a profession, 00:31:30.806 --> 00:31:32.547 we need to be honest and say these 00:31:32.606 --> 00:31:35.009 things do happen and the prevalence is 00:31:35.068 --> 00:31:36.691 probably much higher than we think it is 00:31:36.871 --> 00:31:37.230 overall. 00:31:38.051 --> 00:31:38.211 You know, 00:31:38.231 --> 00:31:39.853 we're going to explore that and kind of 00:31:40.034 --> 00:31:42.375 survey emergency room physicians and kind 00:31:42.434 --> 00:31:44.957 of see how often do they see patients 00:31:44.997 --> 00:31:48.500 who have developed a pneumothorax due to 00:31:48.680 --> 00:31:50.902 potentially needling or those kind of 00:31:50.922 --> 00:31:51.301 things. 00:31:52.363 --> 00:31:53.903 But we're also, you know, 00:31:53.943 --> 00:31:55.805 Josh Cleland and Megan Donaldson and I are 00:31:55.825 --> 00:31:57.926 working on looking at burnout in academic 00:31:57.946 --> 00:31:58.386 faculty. 00:31:59.647 --> 00:32:02.210 There's a lot of evidence in medical 00:32:02.450 --> 00:32:04.612 literature, but as far as allied health, 00:32:04.912 --> 00:32:06.113 physical therapy, speech, 00:32:06.153 --> 00:32:07.193 occupational therapy, 00:32:07.753 --> 00:32:09.194 we don't really have a good handle on 00:32:09.255 --> 00:32:12.178 the level of burnout in academia overall 00:32:12.218 --> 00:32:13.378 because I've been through it. 00:32:14.378 --> 00:32:16.800 Josh, my best friend, has been through it. 00:32:17.981 --> 00:32:19.863 And it's definitely challenging. 00:32:19.903 --> 00:32:21.564 So number one, 00:32:21.765 --> 00:32:23.905 what's the prevalence of burnout in 00:32:23.965 --> 00:32:24.846 academic faculty? 00:32:24.885 --> 00:32:26.086 And then ultimately, 00:32:26.166 --> 00:32:28.868 how can we improve that or decrease the 00:32:28.909 --> 00:32:30.049 likelihood of that happening? 00:32:30.109 --> 00:32:31.750 So those are a couple of the big 00:32:31.790 --> 00:32:32.711 things that I'm working on. 00:32:32.750 --> 00:32:34.192 But I have my finger in a lot 00:32:34.211 --> 00:32:34.913 of different things, 00:32:35.353 --> 00:32:37.273 educational competencies and things like 00:32:37.294 --> 00:32:37.534 that. 00:32:37.574 --> 00:32:40.016 But plenty to keep me busy. 00:32:40.665 --> 00:32:41.906 Yeah, great. 00:32:41.926 --> 00:32:44.028 Well, I look forward to, you know, 00:32:44.067 --> 00:32:45.148 catching up at the conference, 00:32:45.169 --> 00:32:46.509 which is coming up in a couple weeks, 00:32:46.549 --> 00:32:48.730 and then also seeing the fruits of your 00:32:48.790 --> 00:32:50.471 labor in terms of some of this burnout 00:32:50.511 --> 00:32:51.752 work, which, you know, 00:32:51.853 --> 00:32:54.173 is very different from, I think, medicine. 00:32:54.294 --> 00:32:56.035 And so I love that you're calling that 00:32:56.174 --> 00:32:57.635 out and doing a little bit more work 00:32:57.655 --> 00:32:58.856 to explore maybe what some of the 00:32:58.876 --> 00:33:00.978 differences are and how we can mitigate 00:33:01.018 --> 00:33:01.117 it. 00:33:01.597 --> 00:33:03.859 Because it's hard work being in academia, 00:33:04.380 --> 00:33:06.181 lots of high expectations. 00:33:06.221 --> 00:33:08.321 And so I look forward to hearing a 00:33:08.342 --> 00:33:09.163 little bit more about that. 00:33:10.013 --> 00:33:11.755 Yeah, one more quote from Julie Whitman. 00:33:11.775 --> 00:33:12.976 I remember she told me, you know, 00:33:13.016 --> 00:33:13.655 in academia, 00:33:13.736 --> 00:33:14.876 once you get on the treadmill, 00:33:15.037 --> 00:33:16.116 you can never stop running. 00:33:16.136 --> 00:33:20.240 So that's how it works sometimes. 00:33:20.279 --> 00:33:21.059 That resonates. 00:33:22.740 --> 00:33:23.461 All right, Paul. 00:33:23.520 --> 00:33:25.021 Well, it was a great conversation. 00:33:25.182 --> 00:33:27.864 And thanks so much for the conversation 00:33:27.903 --> 00:33:29.365 about some of the work that you're putting 00:33:29.424 --> 00:33:29.904 out there. 00:33:30.065 --> 00:33:33.527 And we shall see you again when another 00:33:33.547 --> 00:33:34.708 brilliant paper comes out. 00:33:34.928 --> 00:33:37.169 We'll bring you on and unpack it together. 00:33:38.140 --> 00:33:39.125 All right, thanks so much, Amy. 00:33:39.145 --> 00:33:39.990 All right, thanks.