November 22, 2025 • 53 mins
Without understanding social determinants of health, pain care becomes guesswork dressed as certainty. Monica Noy helps us separate influence from cause and shows why humility is a clinical skill.
• why private care creates privilege and access gaps
• how BPS gets narrowed and misused as causation
• influence versus cause across bio, psycho and social factors
• education gaps in neuroscience and pain mechanisms
• harms of structural narratives and “root cause” claims
• core social determinants: income, racism, education, work, sleep, access
• sex and gender biases in research and pain treatment
• racism and under treatment of pain
• practical ways to center context without blame
• building trust through transparency and uncertainty
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Eric (00:12):
Hello and welcome to the Massage Science Podcast.
My name is Eric Purves.
I'm a course creator, educator,researcher, RMT, and advocate
for evidence-based care.
Today is episode three of myseven-episode series of Monica
Noi.
In this episode, we continue adiscussion on social
determinants of health, herconcerns with some of the causal
explanations of thebiopsychosocial model, and some
(00:35):
reasoning errors withtraditional structural
approaches to manual therapy.
Monica's course, Pain EducationNo Script Provided, is now
available for purchase on mywebsite, the CEBE.com.
Here we are, episode three withMonica Noy.
(00:56):
We are going to talk about newcourse.
And last week we had a verylong and important discussion on
healthcare ethics, and we wentway off topic, but I think it
was good because we discussed alot of really important things
that don't get discussed enoughin our profession.
Today we're going to try totalk about some social
(01:16):
determinants of health, see howthat's important and what that
means, and why are we talkingabout it?
What is it and what isn't it?
I think that's an area ofdistinction.
And then hopefully we'll getinto some of the definitions and
try and understand why thesedefinitions are important and
what they actually mean.
So thanks again, Monica, forbeing here.
Monica (01:38):
Not a problem.
It's happy to be here.
But so yes, the socialdeterminants of health.
So that was one of the this isyeah, the second, is this the
second deck?
The second deck.
Eric (01:49):
The second, the second module, second deck.
Monica (01:51):
Yeah.
And part of the reasons I frontloaded the course with this was
basically that and the contextwas basically because I think
people jump into trying to learnabout pain without actually
understanding impacts of health,not just the context in which
(02:14):
people find themselves in pain,but all of the other impacts
that may be there related totheir health.
And a big part of this wasbecause of the push for
biosucosocial and the idea thatBPS was supposed to be.
(02:35):
I asked a question about thisin one of the many social
forums.
And the idea was that socialdeterminants of health are
supposed to be part of BPS.
And any of the descriptionsthat I've seen in relation to
the courses that get taught froma BPS perspective, especially,
(02:57):
well, actually not just inrelation to pain, but in
relation to health, is thesocial determinants are just
assumed to be there and notactually provided to any degree
of understanding.
And I remember that even fromeducation.
I don't know if you rememberfrom your education whether or
(03:19):
not you really went into anysort of detail about public
health matters and the socialdeterminants of health.
Eric (03:26):
Never, not in massage therapy education for sure.
It was never discussed.
During my master's, I know wedid similar, almost identical
degrees.
Actually, I think we did doidentical degrees at different
universities.
It was the public health, thesocial impacts was something
that was brought into prettymuch every course, or at least
(03:48):
it was discussed.
Monica (03:49):
Yeah, and I believe I was thinking about it at that
time because I'm just like, whatdoes this mean?
Right.
So there was uh the idea ofthis being a social impact or
whatever it might be.
I wasn't actually very wellversed on social determinants of
health and what that all meant.
Other than it's one of thosethings like critical thinking.
(04:12):
People tell you to go andcritical think about this, or
they go and tell you that thisit relates to social
determinants of health, and youcould I articulate that?
And I'm like, no, I could notarticulate what that means.
And when I can't articulatesomething like that, it it does
tell me that I don't know enoughabout it.
And what I saw in the, or whatI've seen in descriptions of BPS
(04:37):
courses that are provided isthat they also gloss over what
social determinants means.
So if you don't already havethat in your lexicon, if you
don't have that in youreducation, you're not likely to
get it through what would amountto a brief continuing
education, a BPS style course,or some sort of other add-on
(05:01):
type course that you might getin a particular setting.
Eric (05:10):
I would admit I'm guilty of that too, with when I've
taught.
Some of my older stuff that'sout there, I definitely needs to
be updated.
So sorry if someone has someaccess to some of my old course
notes or old course material.
It definitely needs to beupdated.
To me, it was always just amatter of yeah, this is a thing
we know is important, butdefinitely myself included, I
(05:32):
didn't know enough about it intohow to teach it or how to
incorporate it, other than thisis a thing.
And so I what you're sayingthere, how it being this kind of
side note really resonates withmy own understanding and then
how I have in the past been uhtaught this material or taught
similar material.
Monica (05:52):
Yeah, it becomes a heuristic, which is sometimes
how we do things, where wesimplify things enough to
understand them.
But often what happens is thatif you don't get an
understanding of it, you justget the simplification.
And so that was one of thereasons I wanted to dedicate
like a whole, and not just awhole teaching session time, but
(06:15):
to understand that will beintegrated into what you do and
so that you'd be able to, whenit comes to making a pain
assessment, you're making thatpain assessment on the
hypothesized biologicalmechanisms within a context that
you understand has thesedeterminants of health and
(06:37):
health impacts or healthinfluences.
So that's what we're talkingabout.
We're talking these about thesekey impacts and these processes
that influence health insociety.
And there's a lot of them.
Eric (06:50):
And we'll get those in a second.
Obviously, this is a hugecomponent of the course.
We could go into a lot ofdetail, but we'll just touch on,
I think, on some of the keyones here so we don't digress
too much.
So we don't want to give awaytoo much.
We don't want to teach thecourse over a podcast because
yeah, people so that people canget at least a taste of it, so
to speak.
Would you say though, that withthe social determinants of
(07:11):
health, that understanding theseand having an awareness of this
large body of literature orthis way uh of thinking or
understanding people and howsocial determinants impact
health, would you say thatbetter understanding those makes
(07:33):
you better able to assess andtreat and really appreciate the
person that's in front of you?
Is that the purpose of it?
Monica (07:42):
Ultimately, yes.
I think what it does is givesyou a different mindset within a
private profession.
We're in these professionswhere people pay for our
services, yet we talk aboutourselves existing within
medicine or existing withinhealthcare.
(08:04):
And I think that a lot of thetime we don't really necessarily
understand the context of whatthat means.
Like we operate outside of thatpublic health mindset.
And the public health mindset,I think, is maybe a better
(08:28):
understanding of context whenpeople come to see us.
Because then if we don't havethat mindset, if we don't
understand the context in whichsomeone's existing in life, we
have this idea of biosychosocialand this human being having all
these dimensions, but we don'tnecessarily understand those
dimensions.
And then when someone comes tous in a particular way, one of
(08:48):
the disadvantages that alreadyexists within that is that
there's a cost.
So there's a whole bunch ofpeople that already are not able
to access our services.
We exist in a place ofprivilege in relation to that.
And some of these socialdeterminants of health probably
(09:13):
relate to people who we don'tnecessarily see a lot of the
time.
But we're also not everprobably going to see unless we
do actually perhaps changesomething about how we operate
or the mindset of the professionor whatever the case may be.
And I think that's happeningmore and more, but it's not
(09:35):
going to happen withoutunderstanding those
determinants, but alsounderstanding how they intersect
with each other and how it'snot one thing or the other.
Nobody exists under onecategory, right?
Nobody is influenced by onlyone thing.
I think it's complicated.
I feel like I tend to have abit of a public health mindset,
(09:56):
and that might be what drove meto look in this direction.
Would I say I'm an expert onthis?
Absolutely not.
I have if I had a public healthdegree, maybe I would be able
to claim more expertise.
But I am more knowledgeablethan some within our uh private
profession because I've lookedinto this and because I look at
(10:17):
it from a research perspective.
So I'm trying to find thoseresources that people can then
look at to say, oh, this is whatit means here.
This is what the researchshows, this is what the policies
are, those kinds of things thatpeople can actually start to
get a better handle on it.
Eric (10:36):
You made a good point there, Monica.
You said we we exist in a placeof privilege.
And for people that arelistening, that's probably
massage therapists or osteopathsor anyone else in the manual
therapy world.
That's a really important thingthat we need to accept is that
it's not what our services arenot cheap.
Monica (10:58):
Right.
Eric (10:58):
They're very expensive.
And if you don't have athird-party insurance, very few
places have public healthinsurance.
In BC, some groups get a littlebit of money, but I think
that's rare.
That the people we're seeingthat are coming to see us
usually come from a place ofprivilege too.
Monica (12:02):
Yes, not always, but the majority, I would say.
That's what I'm saying.
Yeah.
Eric (12:08):
One thing I'd like to say is we don't want to say always
or never.
There's you're likely to bewrong then.
Monica (12:15):
But unless we're arguing with our partners, in which
case exaggeration is required.
Eric (12:20):
Yeah.
Lots of head nods right now onthat for sure.
So that's something that Ireally wanted to, I think is
important for us to understandis that we come from a place of
privilege.
So if we're looking at thesocial determinants of health,
we talk about these things,these are important things to
understand, but we also have toview we know we're viewing these
things from a place ofprivilege, and those people that
(12:41):
maybe fit within part of theseor maybe impacted or part of
these overall socialdeterminants of health, is may
not be as applicable to us as wewould think we are, because
we're not in that public healthspace.
We're in that privilegedprivate health space.
Monica (12:57):
Yeah.
And when we're talking aboutpain, uh when you look at
statistically how many peoplehave pain or chronic pain and
how many people see us for thatparticular issue.
And sometimes they see usbecause of some sort of
desperation to try and getsomething dealt with because
they're going through it at thetime.
(13:17):
We are going to be dealing withpeople from all walks of life
who some of them won'tnecessarily be able to afford
what we're doing.
We're offering them something,or we're claiming to offer them
something that will provide themwith relief or provide them
with even something curative orwhatever their claim may be.
(13:38):
You're going to pay me forthat, and there's no guarantee.
And also, to some degree, I'mmaking you this promise when
you're in a state of need forthat.
And I find I find ethicallyit's very challenging to be in
(14:00):
this position and making anykind of claim about anything
curative or any kind ofguarantee or anything like that.
But it's it's without thesesocial determinants of health,
it becomes a little bit more ofa narrowed perspective as well.
Because we because if we don'tunderstand how, if we only
(14:21):
understand the people who comeand see us and that privileged
position that they might be inversus based on what meet we
might be in, it's a very limitedviewpoint.
Once we start to widen ourviewpoint to see all of the
social determinants of healthand all of the people who might
intersect in that, and then weadd that to something like pain,
(14:42):
starts to become a challengingthing to think about in how
we're operating.
Eric (14:47):
And this can become a bit of a problem too.
When you mentioned earlierabout the social determinants,
is often part of a BPS ideamodule or like or course.
Monica (14:58):
Yeah.
Supposed to be incorporated inthat.
Eric (15:04):
The view of looking at the framework of the of everything
that could impact the person.
I would say, and let tell me ifyou agree with this or not,
that we need to be careful whenlooking at these social
determinants of health as thesebeing causative of pain.
Because the very thing that wewant as therapists, we put
(15:27):
generalizing as you and I, yeah,as humans is we want to have
answers.
We want to say, I hurt becauseof this.
And that's so much that's thatbio that purely biomedical,
biomechanics view of oh, youhurt because or biopsychosocial,
if we're gonna go there.
Yes, and that's what I was justgonna say.
Or it goes to psychosocialwhere it that gets blamed or
(15:50):
that gets a causative thing.
And so I think if we're talkingabout this stuff too, the
social determinants, so going toa little more specifics about
that, just because these thingsare influencing doesn't mean
that they're causing it.
And that is that causativething, regardless of whether
it's biomedical, biological,psychological, social, can be
(16:12):
problematic because say theirhealth care is because of some
of the things we'll talk about,like poverty or their place in
society or other environmentalfactors.
Maybe those things are playinga role, but we can't say that
those things are causing it.
Monica (16:29):
No, and they might be part of a causal understanding
because there's a challenge tohealth or whatever the case may
be.
But to pin a cause of, say,pain or something like that on
any one particular factor ishugely problematic.
Because when you start to lookat how many social determinants
(16:51):
of health there are and how theyintersect with each other, you
can't have these definitiveconversations about cause just
because there are so manyfactors that might be involved
that have an impact on how aperson might have been more
likely to get a particulardisease, and then whether or not
(17:11):
they are actually properlytaken care of because they exist
in a particular socioeconomiccategory, or race, there's
racial bias within the medicalsystem and all of those kinds of
things.
So we just have these elements,these factors that come
(17:33):
together to become part ofsomebody's life, or that's how
some of the choices are made, orhow some of the things happen.
And for us to this and this iswhere the I think this is what
the BPS, what it has becomereally grinds my gears, is that
(17:58):
when it gets narrowed down tothese psychological components,
which it often does, as the mostinfluential of factors or
something that can then betreated as a core as causal and
then can remove it, it's sosimplified to the point of being
(18:19):
ridiculous.
And it means that you areeither ignorant of or choosing
to be ignorant of or choosing toignore all of the other factors
that are involved in thisperson's life as this person
exists as a human being, andyou've chosen instead, which is
where we go to what you weresaying before with the
(18:41):
causative, whether it'sbiomedical or whatever, where
that just gets translated toBPS, where it's we're just gonna
change the causal associationwith that.
And I think if it's biomedical,if it's like biomechanical,
some of the elements that wehave with whatever the
musculoskeletal or whether it'sBPS, we are basically
(19:06):
highlighting how little we know.
It's basically saying, if I'mgonna take this and say, well,
this is the cause of your painor whatever it might be, what
I'm doing is exposing myintellectual deficits.
And if I'm saying, oh, if youdo mindfulness or if you do this
(19:31):
or whatever, if you learn moreabout pain, you'll have less
pain.
I'm exposing my intellectualdeficit of knowledge about
mechanisms of management ofpain.
And I think we've been doingthis for a while.
This is not undocumented.
This is not, we know that wehave these deficits, which it
goes back to that first deckthat we talked about.
(19:53):
We 100% know we have thosedeficits.
We have been flagging thosedeficits for a long time.
And that's why this is calledno script provided, because this
is a it this is an intellectualprocess.
In order for us to really havean understanding of the
mechanisms of management ofpain, there's a lot of work that
(20:16):
has to be done.
Eric (20:17):
And that work is not common.
It's not being taught anywherein entry to practice, or it's
not even common knowledge in theor common education in the CE
world either.
Monica (20:31):
No, that's why I think Sheridan's the course I created
for Sheridan might be a first ofits kind in terms of it being
just the whole semester.
But again, we haven't, it'sbased on, I hope, a kind of
foundational basic sciences andbasic neurological mechanisms
(20:52):
and consensus science, butthere's no measurement tool to
figure out whether or not thismakes a person reasonable in
their understanding ofmechanisms and management of
pain.
Eric (21:02):
That is coming, isn't it not?
Monica (21:03):
Isn't that coming, yeah.
Eric (21:06):
We will discuss that in another episode.
There's a paper coming outlooking at that.
Monica (21:13):
There are, and there are quite a few papers that I've
seen that do measure when peoplehave BPS courses and they've
tried to measure the impact ofthose courses, but the design
and reporting biases are fairlyhigh because the plausibility of
(21:38):
the education itself, andwhether or not that education is
reasonable to address the gapsthat we know that are there, the
knowledge gaps that are there,is not a consideration.
The conclusion assumes thepremise, basically, or the
premise assumes the conclusion.
(22:00):
It's like it's like BPS istaken for granted.
So any outcome, any positiveoutcome that says, oh, these
people held on to thesecharacteristics of this
education for the future is justa circular kind of a an
argument because you've alreadyassumed that BPS is the thing
(22:21):
that will be a reasonableeducation in mechanisms of
management pain.
Eric (22:29):
We look to confirm.
Monica (22:31):
But it's just not questioned.
I think that's I think that'swhat we're doing with what I've
been trying to do with this, andwhat what the idea has been is
that if we have this knowledgegap, how do we bridge the
knowledge gap?
It's like, what are theknowledge gaps?
The knowledge gaps, clearly, wetalked about this before.
Did you know the understood?
(22:52):
Did you know the definition ofpain at the end of your
education?
Did you know where to find thatdefinition?
Did you know how that wasbrought about?
We didn't know these things.
We we have so many causes ofpain.
We were told that this is acause of pain, that's a cause of
pain, that's a cause of pain,with all these tiny little
things that can be causal ofeither health deficits or
(23:15):
biomechanical problems or painor whatever it might be.
That basically is just againfundamental misunderstanding.
The idea is to go back tofoundational work, to say,
here's the foundation about myknowledge.
It's not absolute T truth, butit is the foundation, the
(23:39):
scientific consensus, our basicunderstanding of how these
mechanisms work before we leapoff into any other blaming
anything else for somebodyhaving pain.
Eric (23:55):
The term that gets thrown around all the time, which makes
me cringe, is the root cause.
I see people all the timeposting stuff online,
advertising things, saying thatthis is the root cause of and
that's actually the the way tofind it and fix it.
And as you said a few minutesago, is that just really
highlights your own lack ofknowledge or understanding
(24:15):
because that's not a thing.
Monica (24:19):
Right.
Right, understanding of theroot cause.
Because when you ask thatquestion, what is the root
cause?
And then we let's go back tothe social determinants of
health on that one, because nowwe understand that for us to
have a root cause, not only dowe need to take these
determinants of health intoaccount for how a person may
(24:40):
present, but then there's thebiomedicine, the biology, the
physiology of what's happeningas well.
And if we're missing componentsof that, and I know in
certainly in osteopathy andperhaps in some of the other
manual therapies, I thinkneuroscience has been a big miss
in terms of education thatwe've had.
Not that it was deliberatelyleft out, but I think it's a
(25:03):
very complex subject.
And that integration into therest of the biology and the
physiology has not been there.
It's being addressed more, butit's a that's a big there's a
big gap.
Eric (25:19):
Oh, it's huge.
I would say that in the entryto practice massage therapy
education, it is at some of theschools I work with, so it
hasn't and have had a look atsome of their curriculums and
how they and their courseoutlines and whatnot.
And it's still being taught.
They're teaching neuroscienceor teaching neurophysiology, but
it's at such a level, a basiclevel, that it really doesn't
(25:42):
address uh giving students thebase knowledge, the foundational
knowledge they would need tounderstand or have a better
understanding of both thesemechanisms these sensory
mechanisms or how the biology ofpain.
Because there is a pain andstress course that's taught at
most schools, and it's usuallyonly a couple lectures, but it's
(26:05):
not combined well.
And I'm I'm saying I'mgeneralizing, so people are
like, at my school, this is whatwe do.
I'm not talking about yourschool, I'm talking about
general feeling I've had fromworking in schools.
And from yeah, well, we alreadyknow there's a deficit, so
yeah, we know it's there, butthere's the pain and then the
neuroscience and all these otherfactors aren't put together for
(26:26):
for students.
Uh I I don't feel.
I feel it's this piece and thenthat's left.
And so when they come and takea course, or I do a lecture or a
presentation and I talk aboutthese things, it's completely
new knowledge, even though thecomponents of it could be there
in I think in school, butthey're just not they're not put
together for them in a way thatis cohesive, that makes sense.
(26:48):
At least that's in myexperience.
That's what I find.
Monica (26:51):
And also I think to some degree overwhelmed by some of
our traditions, maybe.
And the traditions being if amassage therapy trigger points,
definitely a big one, andpostural assessment, and in
osteopathy, it's very much theidea of whether something is
rotated or upslipped or whateverthe case may be.
(27:13):
So there's these definite sortof structural or biomechanical
kind of components, and and howthings work, perhaps on a
neurological level, isn't quiteas detailed in that regard.
Like why would it be that ifyou can do these tests that
(27:33):
might show that something, sayone of the hips isn't moving as
well as the other one, and thatperson has pain in the SI area,
and they might be standing in aparticular postural association,
and the structure is taken asthe cause.
It's well, this the this is outof place.
So therefore, that's the cause.
(27:53):
And it might definitely lookout of place and it might
definitely feel like the tissueshave some reaction to that.
Um, but then again, that's thentaking this one thing as this
umbrella, as this umbrellasolution, right?
As this is the root causesbecause this is not in the right
place.
If we put this in the rightplace, then it will change
(28:15):
something about what ishappening.
And it doesn't then allow youto be wrong.
Because what happens, let'ssay, if you treat someone and
they feel better afterwards andthey then tell you they have
less pain in that area, andthat's fine.
They walk out there happy,you're happy, everyone's happy,
(28:39):
but half an hour later, they'reback to where they started in
terms of the pain in that area.
And it's like, what then?
Did you do something wrong?
Was your treatment bad?
Did they do something wrong?
Is it if we go tobiosychosocial, did they think
(29:00):
badly about it?
Did they do something physical?
So there's all these questionsthat come up that we can only
solve in very limited ways inour thinking, because now we
have to go, well, theirstructure's gone back out of
place.
So then we have to do somethingabout that.
And then we just get on thiswheel or this cycle, or our
patient gets on this cycle of Ihave to go and see my therapist
(29:23):
because I have this thing again,and they're the only person who
can deal with it.
And then that becomes a bitproblematic for them.
Eric (29:31):
And that's very common, particularly for people that
live with ongoing pain, chronicpain population.
The it's this constant cycle ofsearching and finding somebody
and then having them treat it,and then you're having to keep
come back, or if that doesn'twork, then you go see somebody
else, and every person gives youa different rationale,
different explanation, that'sactually structurally based of
(29:54):
some kind, and the persondoesn't get better.
Well, how well uh the questionI always like to ask, and when
I'm speaking with with studentsor with new or experienced
therapists, depending, I say,well, how does that make the
person feel?
Inevitably the answer is willmake them feel confused, it
makes them feel scared, it makesthem feel unsure, it makes them
(30:15):
feel untrusting, and exactlybecause we're putting a blame or
we're putting a causativefactor on something that is
trying to be fixed when maybewe're looking at the wrong
thing.
Monica (30:29):
Yeah, or looking at the it the wrong way.
Eric (30:33):
The wrong way is a better way of putting it.
Monica (30:34):
Yeah, and the wrong thought process along with it.
And that's one of the it's oneof the reasons for this is to
when we get to making a painassessment.
Is to understand where we canplace these neurophysiological
mechanisms, these neurologicalmechanisms within a larger
(30:56):
context.
The social determinants ofhealth is really about
understanding an even largercontext to that before that
person even gets into the clinicor where that clinic is
situated.
So that clinic is situated in abuilding that exists in a much
bigger world.
So yeah, it becomes complex.
(31:17):
I'm not sure if I'm makingsense here.
It's like I find once you starttalking, it's like the social
alternative health where there'sjust so many things that not
only relate to it, to that, butalso relate to each other.
And so then you start to go,it's like I'm not keeping myself
(31:38):
linear here.
I just start to go off onlittle tangents.
Oh, and then there's this, andthen there's this.
So it becomes a little morechallenging to keep yourself a
little bit more defined, whichI'm gonna try and do.
Eric (31:53):
Let's talk maybe a little more detail about the social
determinants of what is it, andwhat are some examples of what
would fit within a socialdeterminant of health?
You mentioned poverty.
Monica (32:04):
Yeah, so the so interestingly enough, there is
like Canada.ca has public healthinformation pages.
They provide a definition.
And uh, what are the socialdeterminants of health?
They describe it as this broadrange of personal, social,
economic, environmental factors.
(32:24):
And they have main ones.
Things will be like race andracism, income, social status,
employment, working conditions.
And I know in our healthhistories sometimes we'll have
blue flags where it's is theresomething about the working
condition that may be impactingthis person and what they're
coming to you for?
Literacy, health literacy,education in general, a physical
(32:48):
environment that a person mightexist in, any social supports
they might have, various copingskills that may or may not be
available to them or that theyhave, the kinds of we talk about
lifestyle and lifestylebehaviors, but some of those
might also be impacts.
We know that the they can becellular insults in relation to
(33:09):
how lack of consistent lack ofsleep, smoking, consistent poor
diet, like consistent lack ofexercise, all of these things
end up being cellular impactsover time.
So we know that's that can bephysical, but it's also part of
a social environment.
Access to healthcare services,uh, when we go to say poverty or
(33:31):
race and racism, we're talkingthen about even access within
those healthcare services.
So even if someone gets into ahealthcare service, then what
their access looks like aboutbeing treated reasonably.
But people's culture andgenetics is one of those things
to consider as well.
And then we might be talkingabout predispositions in
(33:53):
relation to that as well.
It's just what we can considerkey impacts and how they are
dealt with on a societal,economic, and then on a personal
level.
It can relate to anindividual's place in their
society and then that largersocietal impact on that
individual.
Eric (34:13):
One thing you mentioned in this, which is a topic that
does not get discussed enough,at least in what I have seen.
I've only seen maybe one or twoother presentations very brief
in my life on sex and gender andsex categories and how this
influences not just research,but also pain and treatment of
(34:33):
pain.
Can you elaborate a little biton that?
Monica (34:37):
Well, I think in terms of the research that's been
done, most research defaults tothe binary.
If ever there's participantresearch, usually the categories
that will be looked at will beboth the sex category of man,
woman, uh woman, and then thegender category of male, female.
It will basically be just orman and woman.
(34:59):
So we're just staying with thatbinary.
So questions will relate to thebinary.
There's not, there's often notan option.
You start to see more and morethere is options when people
sign up, but often when there'scomparisons with relation to
something like pain, it'll bemore of a default to the binary.
And again, some gooddefinitions that come up with
(35:22):
this in relation to sex andgender come from some Canadian
websites as well, so Canadiangovernment websites.
And they did some defining ofsex and gender in 2014, which is
actually quite interestingbecause I think that number one,
sometimes people confuse thecategories.
(35:43):
And number two, people think ofthese categories in terms of
defining characteristics.
And when we really explorethese categories, there isn't
necessarily a definingcharacteristic for any of them
that would we'd be able to sayyou have this characteristic,
therefore you fit into thiscategory of man, woman, male,
(36:08):
female, whatever it might be.
Because there'll be somethingelse that has that character or
characteristic that would thenalso put it into that category,
but we might not, like on a sortof an external level, you would
be like, oh, hold on, no, thatperson wouldn't fit there.
And I've heard other ways ofdescribing these characteristics
(36:30):
that, or these categories thatmean that we don't have to rely
on a defining characteristic tobe in the category.
But we still need to have a lotmore options in terms of not
only how people see thesecategories, what categories
there are, but also the kinds ofdiscrimination that occurs
(36:55):
because people are notimmediately aligned with one
category or the other on anobservational level, especially
in a healthcare setting.
Um so that's one of thosedeterminants that that exists
that has a real problem fordiversity for people who just
(37:18):
don't fit in that category ordon't see themselves in that
category.
Eric (37:23):
And you you shared too, and there's some research about
their uh not being uh goodenough, and we know, okay, this
is a million times, there's thisknowledge gaps about sex and
gender in pain education, andthere is some curriculum that's
been developed, but it hasn'treally been implemented yet.
Is that correct?
Uh what do you mean with regardto oh just with regard there
(37:44):
was this one one uh paper youshared that looks at the a paper
introduced to curriculumdevelopment to be implemented in
medical school and otherhealthcare programs to look
about inclusiveness and equalopportunities in health, about
sex and gender.
But the paper's from 2023, soit's right in pain education.
Yeah, so it's very new.
(38:04):
I guess I'm just kind ofbringing up saying that there's
this this conversation we had,but the actual application of
this into education is has nothappened yet, even though some
of the background information oncurriculum development and what
to do with this information isthere.
Monica (38:18):
The application well, a lot of the a lot of this goes
back to our knowledge gaps.
So when you see papers likethis, where this one was gender
and sex bias in prevention andclinical treatment of women's
chronic pain.
So it was a hypothesis of a ofcurriculum development, which I
think is basically what we'redoing with this pain course as
well, as a kind of a hypothesisof pain development to basically
(38:43):
try and address some of thegaps that exist in our not in
not just in our knowledge, butin our management of people who
have pain or have who might haveanother condition that relates
and is seeking healthcare.
I'm again definitely not anexpert on the management of
this.
My goal here was to give peoplean understanding, definitions,
(39:08):
a place to find thosedefinitions.
This is not an exhaustive listbecause I know there are places
in within Ontario as well thathave much more specific
healthcare related to people whoare transgender or genderqueer
or whatever it is.
So people are going to have amuch better understanding of
management with relation tothat.
My perspective comes more fromwhat are our definitions, what's
(39:33):
our research around it, all ofthose kinds of things.
Where can we gainunderstanding?
Where can we gain someknowledge?
On a management level, thiscourse doesn't have that within
it, because that's not thiscourse.
Certainly, those courses willprobably exist to some degree,
(39:54):
but that's not this one.
This is more on a knowledgebase.
Eric (39:58):
Yeah.
Which makes sense because itthere's only so much you can
teach on the subject and inkeeping it within something
that's digestible for people.
Monica (40:10):
Yeah, and I wish I had more knowledge and I'm gaining
more knowledge as I go.
So usually I try and updatethese every time I review them.
And it's like, well, what elsedo we know?
But the knowledge has beenaround for a little while.
It's just, yeah, you're right.
It's not as well uptaken.
I think part of it is becausewe see that if someone's got a
hypothesis of curriculumdevelopment that will address
(40:32):
these gaps, some of these gaps,we're not necessarily seeing
that curriculum to a large scaledegree in healthcare.
Eric (40:41):
No, not yet.
But hopefully soon.
Sometime sooner than later.
Monica (40:45):
Hopefully soon.
Yeah.
Eric (40:48):
Yeah.
I mean, because the kind ofthree main categories that you
have here for in the socialdeterminants, and these are not
an exhaustive, are racism, sex,gender, and poverty.
I'm assuming that those are thethree big areas of the social
determinants.
I'm sure there's others.
Monica (41:08):
Well, I thought I I looked at these ones
specifically because they have arelationship to pain as well.
So we do know in some of theresearch that there's also a
correlation there.
So one of these studies, whichis from again 2023, which is
related to transgender andgender-diverse people, what they
found was that the literaturepoints to this increase in pain
(41:30):
experiences.
And again, there's a knowledgegap here.
What does that mean for theincrease in pain experiences and
how are they getting treated?
And what are there anyeffective treatments?
What are the uniqueconsiderations?
Some of that is anunderstanding of what's
happening within within researchin relation to that.
So that's good.
(41:51):
There's other transgenderresearch or research related to
transgender and gender codecategories that's being
conducted.
The same thing with race andracism, because it's already a
structural system thatprivileges some groups of people
over others and ends upcreating barriers to care
(42:13):
because automatically the wayit's set up is that someone will
be disadvantaged within thisstructure.
And also in terms of theresearch that we can see with uh
racism and pain is that blackpeople are not taken care of
properly when with relation tohaving pain.
(42:35):
They're not treated in the sameway, and pain is often seen as
not as bad or not taken asseriously.
And we can see examples of thatin news, we've had recent
examples of that in Canada, andthose are really big important
things to consider.
(42:56):
And I don't think that like wethink of ourselves as good
people, you know, we're comingfrom a white perspective here,
but we're not if we don'tunderstand our own privilege,
not just our own privilege, butour own place in a privileged
society, in a society thatautomatically privileges us, and
(43:16):
that we're the education we'regetting is structured to support
that society.
One of the things that happenswith research and racism is that
there's marginalization thatoccurs also within a research
setting.
So we're not getting as much ofthat career progression in
academia.
We're also seeing perhapsinequity in funding and also
(43:40):
inequity in subject that mightbe studied.
So then we're not getting theinformation that we need to
address the knowledge gaps aswell, and for people to be able
to consider their own privilegeand perspective when they treat
someone who is gender diverse orwhen they treat someone who is
(44:01):
a person of color with withinour society.
So social determinants ofhealth is not necessarily just
about understanding what theyare, it's understanding where we
fit within that societalstructure that means that those
determinants have an impacteither on us or on the people
(44:21):
that we see.
And this is one of the probablythe big intersections that we
might see is that we come from aplace where, oh, I was
supported with my education or Iam supported with structural
elements within society, and Isee these people who are not.
But I don't necessarily takethat into consideration.
(44:43):
And also a level ofuntrustworthiness that exists if
you're in a privileged positionwhere you're asking for money
for a particular service thatyou say will help somebody, but
you're saying, well, you have topay me first before I will help
you on a healthcare level.
So there's a lot of, yeah, alot of these different things
(45:05):
that are occurring in a lot ofdifferent ways, where it's these
systemic issues very much arepublic health related.
And we can be insulated fromthat in some way because we
divorce ourselves from thatpublic health mindset.
Eric (45:24):
Which is where we started the conversation today, too,
about our place of privilege andthe place that we exist in
healthcare as as professions.
And I think this theseconversations are so great.
I'm really happy we're havingthese because I don't hear other
people having theseconversations in our world, in
our profession.
I it's these other professionsand in public health stuff and
(45:47):
in medicine, but I don't thinkwe're having enough of these in
ours.
So hopefully people areappreciating this and
understanding the importance ofthis.
But what I loved what you saidis is it's not so much about
just understanding, but it'smore about acknowledging where
we fit within these structureswithin the system.
I think is something that weshould all stop and reflect on
(46:11):
because I I can pretty surethat's I know I haven't done
much of this enough, and I'lladmit that not done enough of
that to really think how do Ifit in this and where do I fit.
Monica (46:23):
And one of the reasons for me delving into this was
this understanding because wewent into this sort of BPS
mindset where we went throughthese understanding of, well, oh
no, someone's told us thatthey're stressed about
something.
So we have to take that intoconsideration, and it very
easily becomes this biggerfactor than it should be in the
(46:45):
presentation that they're there,and we're focused on their
stress and maybe trying to dealwith how they can limit that,
and perhaps that will be helpfulin their pain and all of those
sorts of things.
But it was so, it just seems solimited to me because when we
look at the amount of socialdeterminants of health and the
(47:05):
impacts that they can have andthe ways in which they
intersect, every time a personsteps into our clinic, despite
the fact that we might be in aprivileged position because
we're asking for money andthey're in a position that
they're willing to or have theability to pay for that.
Anytime someone steps into ourclinic, any one or combination
(47:28):
of those determinants will havesome impact on how a person
presents, on how a personrecovers, on their ability to
access our care, but also otherforms of healthcare.
If we're just talking about sexdiscrimination, the research
shows us that just sexism on alevel of a binary level between
(47:50):
men and women, like women arehighly discriminated against
with relation to pain as well,in a healthcare setting,
structured in that way.
So their access to care isgoing to change in different
ways as well.
Our own biases, we don't evenknow that we have these biases,
but we are educated in thatsocietal structure.
(48:12):
We're educated in thathealthcare structure that exists
in a society that is created tobe discriminatory against a
bunch of people and is was notjust created to be
discriminatory, but is sustainedin such a way.
And we are part of that.
We actually are educated in uhmaintaining that, not that it's
(48:34):
not that overt, but because ofthe way we think, because of the
knowledge gaps that are there,because of the kinds of things
that we might say, because ofthe way we think of ourselves as
experts within a particularfield, and that we maybe have
intellectual arrogance becausewe think we know everything
within this small healthcaresetting, that we are not taking
(48:58):
into account our own implicitand perhaps explicit biases
towards people from culturesthat we're not familiar with, or
who have genetic conditionsthat we don't have an
understanding of, or who haveexist within a place where they
maybe don't have the supportsthat they need, or just being
(49:20):
discriminated against in otherways.
We're not looking in our owncontext.
We're not necessarily lookingat the patient context, except
in really narrow ways.
And I think that becomes veryproblematic when we want to when
we want to claim that we arepatient or person-centered
(49:40):
healthcare therapists, becausewe are talking the talk, but we
have no idea how to walk thewalk.
Eric (49:52):
That was brilliant, Monica.
And I think we'll wrap it upthere because that was a really
powerful and important way toend that.
Next episode, we'll discusssome of the mechanisms, some of
the definitions.
I knew we weren't gonna get tothat topic.
Monica (50:09):
No, there's no way I was I ram I rambled a bit today, so
you can edit in post.
Eric (50:15):
I honestly think that the ramblings, the more
unstructured, the more freethoughts that come out of these
podcast episodes are the stuffthat people like the most
anyway.
Monica (50:27):
Well, I think it's also characteristic of our inability
to grasp sometimes.
Like even though I've set thisup as a course and I've looked
into all of these things and Ihave some knowledge about this,
I still understand that myknowledge has limitations to it.
So the more we know And thoseare the things when you're
trying to articulate it, it'slike it can take some time to
(50:49):
really fully articulate that,and perhaps some education that
I don't have as well.
Eric (50:54):
Well, the more we know, the more we know that we don't
know.
Exactly.
And it is hard.
I know from my own personalexperiences when you're learning
something, one of the best waysto learn it is to try to
articulate it, to try to speakit, to try to teach it, to try
to have a conversation about it.
Because if you that's how youwork through things and you
(51:17):
understand it gives you anopportunity to try to explain
things in different ways or tryto get some feedback from
somebody to say, does this makesense?
Is this right?
Is this wrong?
What do you think of this?
And and that's the way I'mviewing these conversations that
we've had is just to listen towhat you have to say, but also
when appropriate, to try toreflect back some of my own
(51:38):
understandings, just see wheream I on this?
Because either talking to acomputer screen by yourself or
to a brick wall is not nearly asuseful as having these
conversations.
So I think it's great, it'sreal, and that's what we wanted
with these.
Yeah, I'm really happy withthat.
And yeah, I think it'll I thinkit comes out comes across
really well for listeners.
So next time, we're only gonnatalk definitions, mechanisms,
(52:01):
and our clinical plane paindescriptors next time, and we
won't plan anything else, sothat way we can get through
that.
Monica (52:07):
Yeah, and we'll see if we can follow our plan.
Eric (52:10):
Yeah, okay.
Well, thanks, Monica.
Monica (52:13):
No worries, thank you again, and I will talk again
next week.
Eric (52:18):
Thank you for listening.
Pain Education, no scriptprovided, is now available for
purchase on my website,thece.com.
To listen to more of theseepisodes, please subscribe on
your favorite podcast network.
If you enjoyed this episode,please like and share to your
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(52:41):
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over to buymeacoffee.com slashhello.
Hello and welcome to the Massage Science Podcast.
My name is Eric Purves.
I'm a course creator, educator,researcher, RMT, and advocate
for evidence-based care.
Today is episode three of myseven-episode series of Monica
Noi.
In this episode, we continue adiscussion on social
determinants of health, herconcerns with some of the causal
explanations of thebiopsychosocial model, and some
(00:35):
reasoning errors withtraditional structural
approaches to manual therapy.
Monica's course, Pain EducationNo Script Provided, is now
available for purchase on mywebsite, the CEBE.com.
Here we are, episode three withMonica Noy.
(00:56):
We are going to talk about newcourse.
And last week we had a verylong and important discussion on
healthcare ethics, and we wentway off topic, but I think it
was good because we discussed alot of really important things
that don't get discussed enoughin our profession.
Today we're going to try totalk about some social
(01:16):
determinants of health, see howthat's important and what that
means, and why are we talkingabout it?
What is it and what isn't it?
I think that's an area ofdistinction.
And then hopefully we'll getinto some of the definitions and
try and understand why thesedefinitions are important and
what they actually mean.
So thanks again, Monica, forbeing here.
Monica (01:38):
Not a problem.
It's happy to be here.
But so yes, the socialdeterminants of health.
So that was one of the this isyeah, the second, is this the
second deck?
The second deck.
Eric (01:49):
The second, the second module, second deck.
Monica (01:51):
Yeah.
And part of the reasons I frontloaded the course with this was
basically that and the contextwas basically because I think
people jump into trying to learnabout pain without actually
understanding impacts of health,not just the context in which
(02:14):
people find themselves in pain,but all of the other impacts
that may be there related totheir health.
And a big part of this wasbecause of the push for
biosucosocial and the idea thatBPS was supposed to be.
(02:35):
I asked a question about thisin one of the many social
forums.
And the idea was that socialdeterminants of health are
supposed to be part of BPS.
And any of the descriptionsthat I've seen in relation to
the courses that get taught froma BPS perspective, especially,
(02:57):
well, actually not just inrelation to pain, but in
relation to health, is thesocial determinants are just
assumed to be there and notactually provided to any degree
of understanding.
And I remember that even fromeducation.
I don't know if you rememberfrom your education whether or
(03:19):
not you really went into anysort of detail about public
health matters and the socialdeterminants of health.
Eric (03:26):
Never, not in massage therapy education for sure.
It was never discussed.
During my master's, I know wedid similar, almost identical
degrees.
Actually, I think we did doidentical degrees at different
universities.
It was the public health, thesocial impacts was something
that was brought into prettymuch every course, or at least
(03:48):
it was discussed.
Monica (03:49):
Yeah, and I believe I was thinking about it at that
time because I'm just like, whatdoes this mean?
Right.
So there was uh the idea ofthis being a social impact or
whatever it might be.
I wasn't actually very wellversed on social determinants of
health and what that all meant.
Other than it's one of thosethings like critical thinking.
(04:12):
People tell you to go andcritical think about this, or
they go and tell you that thisit relates to social
determinants of health, and youcould I articulate that?
And I'm like, no, I could notarticulate what that means.
And when I can't articulatesomething like that, it it does
tell me that I don't know enoughabout it.
And what I saw in the, or whatI've seen in descriptions of BPS
(04:37):
courses that are provided isthat they also gloss over what
social determinants means.
So if you don't already havethat in your lexicon, if you
don't have that in youreducation, you're not likely to
get it through what would amountto a brief continuing
education, a BPS style course,or some sort of other add-on
(05:01):
type course that you might getin a particular setting.
Eric (05:10):
I would admit I'm guilty of that too, with when I've
taught.
Some of my older stuff that'sout there, I definitely needs to
be updated.
So sorry if someone has someaccess to some of my old course
notes or old course material.
It definitely needs to beupdated.
To me, it was always just amatter of yeah, this is a thing
we know is important, butdefinitely myself included, I
(05:32):
didn't know enough about it intohow to teach it or how to
incorporate it, other than thisis a thing.
And so I what you're sayingthere, how it being this kind of
side note really resonates withmy own understanding and then
how I have in the past been uhtaught this material or taught
similar material.
Monica (05:52):
Yeah, it becomes a heuristic, which is sometimes
how we do things, where wesimplify things enough to
understand them.
But often what happens is thatif you don't get an
understanding of it, you justget the simplification.
And so that was one of thereasons I wanted to dedicate
like a whole, and not just awhole teaching session time, but
(06:15):
to understand that will beintegrated into what you do and
so that you'd be able to, whenit comes to making a pain
assessment, you're making thatpain assessment on the
hypothesized biologicalmechanisms within a context that
you understand has thesedeterminants of health and
(06:37):
health impacts or healthinfluences.
So that's what we're talkingabout.
We're talking these about thesekey impacts and these processes
that influence health insociety.
And there's a lot of them.
Eric (06:50):
And we'll get those in a second.
Obviously, this is a hugecomponent of the course.
We could go into a lot ofdetail, but we'll just touch on,
I think, on some of the keyones here so we don't digress
too much.
So we don't want to give awaytoo much.
We don't want to teach thecourse over a podcast because
yeah, people so that people canget at least a taste of it, so
to speak.
Would you say though, that withthe social determinants of
(07:11):
health, that understanding theseand having an awareness of this
large body of literature orthis way uh of thinking or
understanding people and howsocial determinants impact
health, would you say thatbetter understanding those makes
(07:33):
you better able to assess andtreat and really appreciate the
person that's in front of you?
Is that the purpose of it?
Monica (07:42):
Ultimately, yes.
I think what it does is givesyou a different mindset within a
private profession.
We're in these professionswhere people pay for our
services, yet we talk aboutourselves existing within
medicine or existing withinhealthcare.
(08:04):
And I think that a lot of thetime we don't really necessarily
understand the context of whatthat means.
Like we operate outside of thatpublic health mindset.
And the public health mindset,I think, is maybe a better
(08:28):
understanding of context whenpeople come to see us.
Because then if we don't havethat mindset, if we don't
understand the context in whichsomeone's existing in life, we
have this idea of biosychosocialand this human being having all
these dimensions, but we don'tnecessarily understand those
dimensions.
And then when someone comes tous in a particular way, one of
(08:48):
the disadvantages that alreadyexists within that is that
there's a cost.
So there's a whole bunch ofpeople that already are not able
to access our services.
We exist in a place ofprivilege in relation to that.
And some of these socialdeterminants of health probably
(09:13):
relate to people who we don'tnecessarily see a lot of the
time.
But we're also not everprobably going to see unless we
do actually perhaps changesomething about how we operate
or the mindset of the professionor whatever the case may be.
And I think that's happeningmore and more, but it's not
(09:35):
going to happen withoutunderstanding those
determinants, but alsounderstanding how they intersect
with each other and how it'snot one thing or the other.
Nobody exists under onecategory, right?
Nobody is influenced by onlyone thing.
I think it's complicated.
I feel like I tend to have abit of a public health mindset,
(09:56):
and that might be what drove meto look in this direction.
Would I say I'm an expert onthis?
Absolutely not.
I have if I had a public healthdegree, maybe I would be able
to claim more expertise.
But I am more knowledgeablethan some within our uh private
profession because I've lookedinto this and because I look at
(10:17):
it from a research perspective.
So I'm trying to find thoseresources that people can then
look at to say, oh, this is whatit means here.
This is what the researchshows, this is what the policies
are, those kinds of things thatpeople can actually start to
get a better handle on it.
Eric (10:36):
You made a good point there, Monica.
You said we we exist in a placeof privilege.
And for people that arelistening, that's probably
massage therapists or osteopathsor anyone else in the manual
therapy world.
That's a really important thingthat we need to accept is that
it's not what our services arenot cheap.
Monica (10:58):
Right.
Eric (10:58):
They're very expensive.
And if you don't have athird-party insurance, very few
places have public healthinsurance.
In BC, some groups get a littlebit of money, but I think
that's rare.
That the people we're seeingthat are coming to see us
usually come from a place ofprivilege too.
Monica (12:02):
Yes, not always, but the majority, I would say.
That's what I'm saying.
Yeah.
Eric (12:08):
One thing I'd like to say is we don't want to say always
or never.
There's you're likely to bewrong then.
Monica (12:15):
But unless we're arguing with our partners, in which
case exaggeration is required.
Eric (12:20):
Yeah.
Lots of head nods right now onthat for sure.
So that's something that Ireally wanted to, I think is
important for us to understandis that we come from a place of
privilege.
So if we're looking at thesocial determinants of health,
we talk about these things,these are important things to
understand, but we also have toview we know we're viewing these
things from a place ofprivilege, and those people that
(12:41):
maybe fit within part of theseor maybe impacted or part of
these overall socialdeterminants of health, is may
not be as applicable to us as wewould think we are, because
we're not in that public healthspace.
We're in that privilegedprivate health space.
Monica (12:57):
Yeah.
And when we're talking aboutpain, uh when you look at
statistically how many peoplehave pain or chronic pain and
how many people see us for thatparticular issue.
And sometimes they see usbecause of some sort of
desperation to try and getsomething dealt with because
they're going through it at thetime.
(13:17):
We are going to be dealing withpeople from all walks of life
who some of them won'tnecessarily be able to afford
what we're doing.
We're offering them something,or we're claiming to offer them
something that will provide themwith relief or provide them
with even something curative orwhatever their claim may be.
(13:38):
You're going to pay me forthat, and there's no guarantee.
And also, to some degree, I'mmaking you this promise when
you're in a state of need forthat.
And I find I find ethicallyit's very challenging to be in
(14:00):
this position and making anykind of claim about anything
curative or any kind ofguarantee or anything like that.
But it's it's without thesesocial determinants of health,
it becomes a little bit more ofa narrowed perspective as well.
Because we because if we don'tunderstand how, if we only
(14:21):
understand the people who comeand see us and that privileged
position that they might be inversus based on what meet we
might be in, it's a very limitedviewpoint.
Once we start to widen ourviewpoint to see all of the
social determinants of healthand all of the people who might
intersect in that, and then weadd that to something like pain,
(14:42):
starts to become a challengingthing to think about in how
we're operating.
Eric (14:47):
And this can become a bit of a problem too.
When you mentioned earlierabout the social determinants,
is often part of a BPS ideamodule or like or course.
Monica (14:58):
Yeah.
Supposed to be incorporated inthat.
Eric (15:04):
The view of looking at the framework of the of everything
that could impact the person.
I would say, and let tell me ifyou agree with this or not,
that we need to be careful whenlooking at these social
determinants of health as thesebeing causative of pain.
Because the very thing that wewant as therapists, we put
(15:27):
generalizing as you and I, yeah,as humans is we want to have
answers.
We want to say, I hurt becauseof this.
And that's so much that's thatbio that purely biomedical,
biomechanics view of oh, youhurt because or biopsychosocial,
if we're gonna go there.
Yes, and that's what I was justgonna say.
Or it goes to psychosocialwhere it that gets blamed or
(15:50):
that gets a causative thing.
And so I think if we're talkingabout this stuff too, the
social determinants, so going toa little more specifics about
that, just because these thingsare influencing doesn't mean
that they're causing it.
And that is that causativething, regardless of whether
it's biomedical, biological,psychological, social, can be
(16:12):
problematic because say theirhealth care is because of some
of the things we'll talk about,like poverty or their place in
society or other environmentalfactors.
Maybe those things are playinga role, but we can't say that
those things are causing it.
Monica (16:29):
No, and they might be part of a causal understanding
because there's a challenge tohealth or whatever the case may
be.
But to pin a cause of, say,pain or something like that on
any one particular factor ishugely problematic.
Because when you start to lookat how many social determinants
(16:51):
of health there are and how theyintersect with each other, you
can't have these definitiveconversations about cause just
because there are so manyfactors that might be involved
that have an impact on how aperson might have been more
likely to get a particulardisease, and then whether or not
(17:11):
they are actually properlytaken care of because they exist
in a particular socioeconomiccategory, or race, there's
racial bias within the medicalsystem and all of those kinds of
things.
So we just have these elements,these factors that come
(17:33):
together to become part ofsomebody's life, or that's how
some of the choices are made, orhow some of the things happen.
And for us to this and this iswhere the I think this is what
the BPS, what it has becomereally grinds my gears, is that
(17:58):
when it gets narrowed down tothese psychological components,
which it often does, as the mostinfluential of factors or
something that can then betreated as a core as causal and
then can remove it, it's sosimplified to the point of being
(18:19):
ridiculous.
And it means that you areeither ignorant of or choosing
to be ignorant of or choosing toignore all of the other factors
that are involved in thisperson's life as this person
exists as a human being, andyou've chosen instead, which is
where we go to what you weresaying before with the
(18:41):
causative, whether it'sbiomedical or whatever, where
that just gets translated toBPS, where it's we're just gonna
change the causal associationwith that.
And I think if it's biomedical,if it's like biomechanical,
some of the elements that wehave with whatever the
musculoskeletal or whether it'sBPS, we are basically
(19:06):
highlighting how little we know.
It's basically saying, if I'mgonna take this and say, well,
this is the cause of your painor whatever it might be, what
I'm doing is exposing myintellectual deficits.
And if I'm saying, oh, if youdo mindfulness or if you do this
(19:31):
or whatever, if you learn moreabout pain, you'll have less
pain.
I'm exposing my intellectualdeficit of knowledge about
mechanisms of management ofpain.
And I think we've been doingthis for a while.
This is not undocumented.
This is not, we know that wehave these deficits, which it
goes back to that first deckthat we talked about.
(19:53):
We 100% know we have thosedeficits.
We have been flagging thosedeficits for a long time.
And that's why this is calledno script provided, because this
is a it this is an intellectualprocess.
In order for us to really havean understanding of the
mechanisms of management ofpain, there's a lot of work that
(20:16):
has to be done.
Eric (20:17):
And that work is not common.
It's not being taught anywherein entry to practice, or it's
not even common knowledge in theor common education in the CE
world either.
Monica (20:31):
No, that's why I think Sheridan's the course I created
for Sheridan might be a first ofits kind in terms of it being
just the whole semester.
But again, we haven't, it'sbased on, I hope, a kind of
foundational basic sciences andbasic neurological mechanisms
(20:52):
and consensus science, butthere's no measurement tool to
figure out whether or not thismakes a person reasonable in
their understanding ofmechanisms and management of
pain.
Eric (21:02):
That is coming, isn't it not?
Monica (21:03):
Isn't that coming, yeah.
Eric (21:06):
We will discuss that in another episode.
There's a paper coming outlooking at that.
Monica (21:13):
There are, and there are quite a few papers that I've
seen that do measure when peoplehave BPS courses and they've
tried to measure the impact ofthose courses, but the design
and reporting biases are fairlyhigh because the plausibility of
(21:38):
the education itself, andwhether or not that education is
reasonable to address the gapsthat we know that are there, the
knowledge gaps that are there,is not a consideration.
The conclusion assumes thepremise, basically, or the
premise assumes the conclusion.
(22:00):
It's like it's like BPS istaken for granted.
So any outcome, any positiveoutcome that says, oh, these
people held on to thesecharacteristics of this
education for the future is justa circular kind of a an
argument because you've alreadyassumed that BPS is the thing
(22:21):
that will be a reasonableeducation in mechanisms of
management pain.
Eric (22:29):
We look to confirm.
Monica (22:31):
But it's just not questioned.
I think that's I think that'swhat we're doing with what I've
been trying to do with this, andwhat what the idea has been is
that if we have this knowledgegap, how do we bridge the
knowledge gap?
It's like, what are theknowledge gaps?
The knowledge gaps, clearly, wetalked about this before.
Did you know the understood?
(22:52):
Did you know the definition ofpain at the end of your
education?
Did you know where to find thatdefinition?
Did you know how that wasbrought about?
We didn't know these things.
We we have so many causes ofpain.
We were told that this is acause of pain, that's a cause of
pain, that's a cause of pain,with all these tiny little
things that can be causal ofeither health deficits or
(23:15):
biomechanical problems or painor whatever it might be.
That basically is just againfundamental misunderstanding.
The idea is to go back tofoundational work, to say,
here's the foundation about myknowledge.
It's not absolute T truth, butit is the foundation, the
(23:39):
scientific consensus, our basicunderstanding of how these
mechanisms work before we leapoff into any other blaming
anything else for somebodyhaving pain.
Eric (23:55):
The term that gets thrown around all the time, which makes
me cringe, is the root cause.
I see people all the timeposting stuff online,
advertising things, saying thatthis is the root cause of and
that's actually the the way tofind it and fix it.
And as you said a few minutesago, is that just really
highlights your own lack ofknowledge or understanding
(24:15):
because that's not a thing.
Monica (24:19):
Right.
Right, understanding of theroot cause.
Because when you ask thatquestion, what is the root
cause?
And then we let's go back tothe social determinants of
health on that one, because nowwe understand that for us to
have a root cause, not only dowe need to take these
determinants of health intoaccount for how a person may
(24:40):
present, but then there's thebiomedicine, the biology, the
physiology of what's happeningas well.
And if we're missing componentsof that, and I know in
certainly in osteopathy andperhaps in some of the other
manual therapies, I thinkneuroscience has been a big miss
in terms of education thatwe've had.
Not that it was deliberatelyleft out, but I think it's a
(25:03):
very complex subject.
And that integration into therest of the biology and the
physiology has not been there.
It's being addressed more, butit's a that's a big there's a
big gap.
Eric (25:19):
Oh, it's huge.
I would say that in the entryto practice massage therapy
education, it is at some of theschools I work with, so it
hasn't and have had a look atsome of their curriculums and
how they and their courseoutlines and whatnot.
And it's still being taught.
They're teaching neuroscienceor teaching neurophysiology, but
it's at such a level, a basiclevel, that it really doesn't
(25:42):
address uh giving students thebase knowledge, the foundational
knowledge they would need tounderstand or have a better
understanding of both thesemechanisms these sensory
mechanisms or how the biology ofpain.
Because there is a pain andstress course that's taught at
most schools, and it's usuallyonly a couple lectures, but it's
(26:05):
not combined well.
And I'm I'm saying I'mgeneralizing, so people are
like, at my school, this is whatwe do.
I'm not talking about yourschool, I'm talking about
general feeling I've had fromworking in schools.
And from yeah, well, we alreadyknow there's a deficit, so
yeah, we know it's there, butthere's the pain and then the
neuroscience and all these otherfactors aren't put together for
(26:26):
for students.
Uh I I don't feel.
I feel it's this piece and thenthat's left.
And so when they come and takea course, or I do a lecture or a
presentation and I talk aboutthese things, it's completely
new knowledge, even though thecomponents of it could be there
in I think in school, butthey're just not they're not put
together for them in a way thatis cohesive, that makes sense.
(26:48):
At least that's in myexperience.
That's what I find.
Monica (26:51):
And also I think to some degree overwhelmed by some of
our traditions, maybe.
And the traditions being if amassage therapy trigger points,
definitely a big one, andpostural assessment, and in
osteopathy, it's very much theidea of whether something is
rotated or upslipped or whateverthe case may be.
(27:13):
So there's these definite sortof structural or biomechanical
kind of components, and and howthings work, perhaps on a
neurological level, isn't quiteas detailed in that regard.
Like why would it be that ifyou can do these tests that
(27:33):
might show that something, sayone of the hips isn't moving as
well as the other one, and thatperson has pain in the SI area,
and they might be standing in aparticular postural association,
and the structure is taken asthe cause.
It's well, this the this is outof place.
So therefore, that's the cause.
(27:53):
And it might definitely lookout of place and it might
definitely feel like the tissueshave some reaction to that.
Um, but then again, that's thentaking this one thing as this
umbrella, as this umbrellasolution, right?
As this is the root causesbecause this is not in the right
place.
If we put this in the rightplace, then it will change
(28:15):
something about what ishappening.
And it doesn't then allow youto be wrong.
Because what happens, let'ssay, if you treat someone and
they feel better afterwards andthey then tell you they have
less pain in that area, andthat's fine.
They walk out there happy,you're happy, everyone's happy,
(28:39):
but half an hour later, they'reback to where they started in
terms of the pain in that area.
And it's like, what then?
Did you do something wrong?
Was your treatment bad?
Did they do something wrong?
Is it if we go tobiosychosocial, did they think
(29:00):
badly about it?
Did they do something physical?
So there's all these questionsthat come up that we can only
solve in very limited ways inour thinking, because now we
have to go, well, theirstructure's gone back out of
place.
So then we have to do somethingabout that.
And then we just get on thiswheel or this cycle, or our
patient gets on this cycle of Ihave to go and see my therapist
(29:23):
because I have this thing again,and they're the only person who
can deal with it.
And then that becomes a bitproblematic for them.
Eric (29:31):
And that's very common, particularly for people that
live with ongoing pain, chronicpain population.
The it's this constant cycle ofsearching and finding somebody
and then having them treat it,and then you're having to keep
come back, or if that doesn'twork, then you go see somebody
else, and every person gives youa different rationale,
different explanation, that'sactually structurally based of
(29:54):
some kind, and the persondoesn't get better.
Well, how well uh the questionI always like to ask, and when
I'm speaking with with studentsor with new or experienced
therapists, depending, I say,well, how does that make the
person feel?
Inevitably the answer is willmake them feel confused, it
makes them feel scared, it makesthem feel unsure, it makes them
(30:15):
feel untrusting, and exactlybecause we're putting a blame or
we're putting a causativefactor on something that is
trying to be fixed when maybewe're looking at the wrong
thing.
Monica (30:29):
Yeah, or looking at the it the wrong way.
Eric (30:33):
The wrong way is a better way of putting it.
Monica (30:34):
Yeah, and the wrong thought process along with it.
And that's one of the it's oneof the reasons for this is to
when we get to making a painassessment.
Is to understand where we canplace these neurophysiological
mechanisms, these neurologicalmechanisms within a larger
(30:56):
context.
The social determinants ofhealth is really about
understanding an even largercontext to that before that
person even gets into the clinicor where that clinic is
situated.
So that clinic is situated in abuilding that exists in a much
bigger world.
So yeah, it becomes complex.
(31:17):
I'm not sure if I'm makingsense here.
It's like I find once you starttalking, it's like the social
alternative health where there'sjust so many things that not
only relate to it, to that, butalso relate to each other.
And so then you start to go,it's like I'm not keeping myself
(31:38):
linear here.
I just start to go off onlittle tangents.
Oh, and then there's this, andthen there's this.
So it becomes a little morechallenging to keep yourself a
little bit more defined, whichI'm gonna try and do.
Eric (31:53):
Let's talk maybe a little more detail about the social
determinants of what is it, andwhat are some examples of what
would fit within a socialdeterminant of health?
You mentioned poverty.
Monica (32:04):
Yeah, so the so interestingly enough, there is
like Canada.ca has public healthinformation pages.
They provide a definition.
And uh, what are the socialdeterminants of health?
They describe it as this broadrange of personal, social,
economic, environmental factors.
(32:24):
And they have main ones.
Things will be like race andracism, income, social status,
employment, working conditions.
And I know in our healthhistories sometimes we'll have
blue flags where it's is theresomething about the working
condition that may be impactingthis person and what they're
coming to you for?
Literacy, health literacy,education in general, a physical
(32:48):
environment that a person mightexist in, any social supports
they might have, various copingskills that may or may not be
available to them or that theyhave, the kinds of we talk about
lifestyle and lifestylebehaviors, but some of those
might also be impacts.
We know that the they can becellular insults in relation to
(33:09):
how lack of consistent lack ofsleep, smoking, consistent poor
diet, like consistent lack ofexercise, all of these things
end up being cellular impactsover time.
So we know that's that can bephysical, but it's also part of
a social environment.
Access to healthcare services,uh, when we go to say poverty or
(33:31):
race and racism, we're talkingthen about even access within
those healthcare services.
So even if someone gets into ahealthcare service, then what
their access looks like aboutbeing treated reasonably.
But people's culture andgenetics is one of those things
to consider as well.
And then we might be talkingabout predispositions in
(33:53):
relation to that as well.
It's just what we can considerkey impacts and how they are
dealt with on a societal,economic, and then on a personal
level.
It can relate to anindividual's place in their
society and then that largersocietal impact on that
individual.
Eric (34:13):
One thing you mentioned in this, which is a topic that
does not get discussed enough,at least in what I have seen.
I've only seen maybe one or twoother presentations very brief
in my life on sex and gender andsex categories and how this
influences not just research,but also pain and treatment of
(34:33):
pain.
Can you elaborate a little biton that?
Monica (34:37):
Well, I think in terms of the research that's been
done, most research defaults tothe binary.
If ever there's participantresearch, usually the categories
that will be looked at will beboth the sex category of man,
woman, uh woman, and then thegender category of male, female.
It will basically be just orman and woman.
(34:59):
So we're just staying with thatbinary.
So questions will relate to thebinary.
There's not, there's often notan option.
You start to see more and morethere is options when people
sign up, but often when there'scomparisons with relation to
something like pain, it'll bemore of a default to the binary.
And again, some gooddefinitions that come up with
(35:22):
this in relation to sex andgender come from some Canadian
websites as well, so Canadiangovernment websites.
And they did some defining ofsex and gender in 2014, which is
actually quite interestingbecause I think that number one,
sometimes people confuse thecategories.
(35:43):
And number two, people think ofthese categories in terms of
defining characteristics.
And when we really explorethese categories, there isn't
necessarily a definingcharacteristic for any of them
that would we'd be able to sayyou have this characteristic,
therefore you fit into thiscategory of man, woman, male,
(36:08):
female, whatever it might be.
Because there'll be somethingelse that has that character or
characteristic that would thenalso put it into that category,
but we might not, like on a sortof an external level, you would
be like, oh, hold on, no, thatperson wouldn't fit there.
And I've heard other ways ofdescribing these characteristics
(36:30):
that, or these categories thatmean that we don't have to rely
on a defining characteristic tobe in the category.
But we still need to have a lotmore options in terms of not
only how people see thesecategories, what categories
there are, but also the kinds ofdiscrimination that occurs
(36:55):
because people are notimmediately aligned with one
category or the other on anobservational level, especially
in a healthcare setting.
Um so that's one of thosedeterminants that that exists
that has a real problem fordiversity for people who just
(37:18):
don't fit in that category ordon't see themselves in that
category.
Eric (37:23):
And you you shared too, and there's some research about
their uh not being uh goodenough, and we know, okay, this
is a million times, there's thisknowledge gaps about sex and
gender in pain education, andthere is some curriculum that's
been developed, but it hasn'treally been implemented yet.
Is that correct?
Uh what do you mean with regardto oh just with regard there
(37:44):
was this one one uh paper youshared that looks at the a paper
introduced to curriculumdevelopment to be implemented in
medical school and otherhealthcare programs to look
about inclusiveness and equalopportunities in health, about
sex and gender.
But the paper's from 2023, soit's right in pain education.
Yeah, so it's very new.
(38:04):
I guess I'm just kind ofbringing up saying that there's
this this conversation we had,but the actual application of
this into education is has nothappened yet, even though some
of the background information oncurriculum development and what
to do with this information isthere.
Monica (38:18):
The application well, a lot of the a lot of this goes
back to our knowledge gaps.
So when you see papers likethis, where this one was gender
and sex bias in prevention andclinical treatment of women's
chronic pain.
So it was a hypothesis of a ofcurriculum development, which I
think is basically what we'redoing with this pain course as
well, as a kind of a hypothesisof pain development to basically
(38:43):
try and address some of thegaps that exist in our not in
not just in our knowledge, butin our management of people who
have pain or have who might haveanother condition that relates
and is seeking healthcare.
I'm again definitely not anexpert on the management of
this.
My goal here was to give peoplean understanding, definitions,
(39:08):
a place to find thosedefinitions.
This is not an exhaustive listbecause I know there are places
in within Ontario as well thathave much more specific
healthcare related to people whoare transgender or genderqueer
or whatever it is.
So people are going to have amuch better understanding of
management with relation tothat.
My perspective comes more fromwhat are our definitions, what's
(39:33):
our research around it, all ofthose kinds of things.
Where can we gainunderstanding?
Where can we gain someknowledge?
On a management level, thiscourse doesn't have that within
it, because that's not thiscourse.
Certainly, those courses willprobably exist to some degree,
(39:54):
but that's not this one.
This is more on a knowledgebase.
Eric (39:58):
Yeah.
Which makes sense because itthere's only so much you can
teach on the subject and inkeeping it within something
that's digestible for people.
Monica (40:10):
Yeah, and I wish I had more knowledge and I'm gaining
more knowledge as I go.
So usually I try and updatethese every time I review them.
And it's like, well, what elsedo we know?
But the knowledge has beenaround for a little while.
It's just, yeah, you're right.
It's not as well uptaken.
I think part of it is becausewe see that if someone's got a
hypothesis of curriculumdevelopment that will address
(40:32):
these gaps, some of these gaps,we're not necessarily seeing
that curriculum to a large scaledegree in healthcare.
Eric (40:41):
No, not yet.
But hopefully soon.
Sometime sooner than later.
Monica (40:45):
Hopefully soon.
Yeah.
Eric (40:48):
Yeah.
I mean, because the kind ofthree main categories that you
have here for in the socialdeterminants, and these are not
an exhaustive, are racism, sex,gender, and poverty.
I'm assuming that those are thethree big areas of the social
determinants.
I'm sure there's others.
Monica (41:08):
Well, I thought I I looked at these ones
specifically because they have arelationship to pain as well.
So we do know in some of theresearch that there's also a
correlation there.
So one of these studies, whichis from again 2023, which is
related to transgender andgender-diverse people, what they
found was that the literaturepoints to this increase in pain
(41:30):
experiences.
And again, there's a knowledgegap here.
What does that mean for theincrease in pain experiences and
how are they getting treated?
And what are there anyeffective treatments?
What are the uniqueconsiderations?
Some of that is anunderstanding of what's
happening within within researchin relation to that.
So that's good.
(41:51):
There's other transgenderresearch or research related to
transgender and gender codecategories that's being
conducted.
The same thing with race andracism, because it's already a
structural system thatprivileges some groups of people
over others and ends upcreating barriers to care
(42:13):
because automatically the wayit's set up is that someone will
be disadvantaged within thisstructure.
And also in terms of theresearch that we can see with uh
racism and pain is that blackpeople are not taken care of
properly when with relation tohaving pain.
(42:35):
They're not treated in the sameway, and pain is often seen as
not as bad or not taken asseriously.
And we can see examples of thatin news, we've had recent
examples of that in Canada, andthose are really big important
things to consider.
(42:56):
And I don't think that like wethink of ourselves as good
people, you know, we're comingfrom a white perspective here,
but we're not if we don'tunderstand our own privilege,
not just our own privilege, butour own place in a privileged
society, in a society thatautomatically privileges us, and
(43:16):
that we're the education we'regetting is structured to support
that society.
One of the things that happenswith research and racism is that
there's marginalization thatoccurs also within a research
setting.
So we're not getting as much ofthat career progression in
academia.
We're also seeing perhapsinequity in funding and also
(43:40):
inequity in subject that mightbe studied.
So then we're not getting theinformation that we need to
address the knowledge gaps aswell, and for people to be able
to consider their own privilegeand perspective when they treat
someone who is gender diverse orwhen they treat someone who is
(44:01):
a person of color with withinour society.
So social determinants ofhealth is not necessarily just
about understanding what theyare, it's understanding where we
fit within that societalstructure that means that those
determinants have an impacteither on us or on the people
(44:21):
that we see.
And this is one of the probablythe big intersections that we
might see is that we come from aplace where, oh, I was
supported with my education or Iam supported with structural
elements within society, and Isee these people who are not.
But I don't necessarily takethat into consideration.
(44:43):
And also a level ofuntrustworthiness that exists if
you're in a privileged positionwhere you're asking for money
for a particular service thatyou say will help somebody, but
you're saying, well, you have topay me first before I will help
you on a healthcare level.
So there's a lot of, yeah, alot of these different things
(45:05):
that are occurring in a lot ofdifferent ways, where it's these
systemic issues very much arepublic health related.
And we can be insulated fromthat in some way because we
divorce ourselves from thatpublic health mindset.
Eric (45:24):
Which is where we started the conversation today, too,
about our place of privilege andthe place that we exist in
healthcare as as professions.
And I think this theseconversations are so great.
I'm really happy we're havingthese because I don't hear other
people having theseconversations in our world, in
our profession.
I it's these other professionsand in public health stuff and
(45:47):
in medicine, but I don't thinkwe're having enough of these in
ours.
So hopefully people areappreciating this and
understanding the importance ofthis.
But what I loved what you saidis is it's not so much about
just understanding, but it'smore about acknowledging where
we fit within these structureswithin the system.
I think is something that weshould all stop and reflect on
(46:11):
because I I can pretty surethat's I know I haven't done
much of this enough, and I'lladmit that not done enough of
that to really think how do Ifit in this and where do I fit.
Monica (46:23):
And one of the reasons for me delving into this was
this understanding because wewent into this sort of BPS
mindset where we went throughthese understanding of, well, oh
no, someone's told us thatthey're stressed about
something.
So we have to take that intoconsideration, and it very
easily becomes this biggerfactor than it should be in the
(46:45):
presentation that they're there,and we're focused on their
stress and maybe trying to dealwith how they can limit that,
and perhaps that will be helpfulin their pain and all of those
sorts of things.
But it was so, it just seems solimited to me because when we
look at the amount of socialdeterminants of health and the
(47:05):
impacts that they can have andthe ways in which they
intersect, every time a personsteps into our clinic, despite
the fact that we might be in aprivileged position because
we're asking for money andthey're in a position that
they're willing to or have theability to pay for that.
Anytime someone steps into ourclinic, any one or combination
(47:28):
of those determinants will havesome impact on how a person
presents, on how a personrecovers, on their ability to
access our care, but also otherforms of healthcare.
If we're just talking about sexdiscrimination, the research
shows us that just sexism on alevel of a binary level between
(47:50):
men and women, like women arehighly discriminated against
with relation to pain as well,in a healthcare setting,
structured in that way.
So their access to care isgoing to change in different
ways as well.
Our own biases, we don't evenknow that we have these biases,
but we are educated in thatsocietal structure.
(48:12):
We're educated in thathealthcare structure that exists
in a society that is created tobe discriminatory against a
bunch of people and is was notjust created to be
discriminatory, but is sustainedin such a way.
And we are part of that.
We actually are educated in uhmaintaining that, not that it's
(48:34):
not that overt, but because ofthe way we think, because of the
knowledge gaps that are there,because of the kinds of things
that we might say, because ofthe way we think of ourselves as
experts within a particularfield, and that we maybe have
intellectual arrogance becausewe think we know everything
within this small healthcaresetting, that we are not taking
(48:58):
into account our own implicitand perhaps explicit biases
towards people from culturesthat we're not familiar with, or
who have genetic conditionsthat we don't have an
understanding of, or who haveexist within a place where they
maybe don't have the supportsthat they need, or just being
(49:20):
discriminated against in otherways.
We're not looking in our owncontext.
We're not necessarily lookingat the patient context, except
in really narrow ways.
And I think that becomes veryproblematic when we want to when
we want to claim that we arepatient or person-centered
(49:40):
healthcare therapists, becausewe are talking the talk, but we
have no idea how to walk thewalk.
Eric (49:52):
That was brilliant, Monica.
And I think we'll wrap it upthere because that was a really
powerful and important way toend that.
Next episode, we'll discusssome of the mechanisms, some of
the definitions.
I knew we weren't gonna get tothat topic.
Monica (50:09):
No, there's no way I was I ram I rambled a bit today, so
you can edit in post.
Eric (50:15):
I honestly think that the ramblings, the more
unstructured, the more freethoughts that come out of these
podcast episodes are the stuffthat people like the most
anyway.
Monica (50:27):
Well, I think it's also characteristic of our inability
to grasp sometimes.
Like even though I've set thisup as a course and I've looked
into all of these things and Ihave some knowledge about this,
I still understand that myknowledge has limitations to it.
So the more we know And thoseare the things when you're
trying to articulate it, it'slike it can take some time to
(50:49):
really fully articulate that,and perhaps some education that
I don't have as well.
Eric (50:54):
Well, the more we know, the more we know that we don't
know.
Exactly.
And it is hard.
I know from my own personalexperiences when you're learning
something, one of the best waysto learn it is to try to
articulate it, to try to speakit, to try to teach it, to try
to have a conversation about it.
Because if you that's how youwork through things and you
(51:17):
understand it gives you anopportunity to try to explain
things in different ways or tryto get some feedback from
somebody to say, does this makesense?
Is this right?
Is this wrong?
What do you think of this?
And and that's the way I'mviewing these conversations that
we've had is just to listen towhat you have to say, but also
when appropriate, to try toreflect back some of my own
(51:38):
understandings, just see wheream I on this?
Because either talking to acomputer screen by yourself or
to a brick wall is not nearly asuseful as having these
conversations.
So I think it's great, it'sreal, and that's what we wanted
with these.
Yeah, I'm really happy withthat.
And yeah, I think it'll I thinkit comes out comes across
really well for listeners.
So next time, we're only gonnatalk definitions, mechanisms,
(52:01):
and our clinical plane paindescriptors next time, and we
won't plan anything else, sothat way we can get through
that.
Monica (52:07):
Yeah, and we'll see if we can follow our plan.
Eric (52:10):
Yeah, okay.
Well, thanks, Monica.
Monica (52:13):
No worries, thank you again, and I will talk again
next week.
Eric (52:18):
Thank you for listening.
Pain Education, no scriptprovided, is now available for
purchase on my website,thece.com.
To listen to more of theseepisodes, please subscribe on
your favorite podcast network.
If you enjoyed this episode,please like and share to your
favorite social media platforms.
If you'd like to connect withme, I can be reached to my
website, thece.com, or send me aDM through Instagram at Eric
(52:41):
underscore pervis underscore C EB E.
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This can be done by clicking onthe support button or heading
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