Tim Beames (00:01.596)
Okay, welcome to another episode of the Pain Podcast and I am the host today, Tim Beames, and I've got the great pleasure of introducing Alison Simm, who is joining us from Melbourne. So we're at other ends of the day, aren't we, at the moment?

Alison Sim (00:21.006)
We are, we are.

Tim Beames (00:23.036)
A huge thanks for joining me and we're gonna, I'll introduce you in two secs, but we're gonna delve into your PhD and how that applies to clinical work as well. But just a little heads up, you originally qualified as an osteopath, I think you're the first.

You're the first osteopath that we've spoken to, I think so. So brilliant to have an osteopath, although I wonder whether that's how you identify now. And then you did a Masters in Pain and you've been an author. You wrote a lovely book. It's about stories of recovery and hope, isn't it? Pain heroes, pain heroes, stories of hope and recovery.

Alison Sim (00:55.054)
I'm sorry.

Alison Sim (01:08.782)
That's right, that's right. That's right.

Tim Beames (01:15.516)
Which is great, I love that. I mean, how many people who experience pain want to hear that things can be, there's hope for them. So, like brilliant, yeah. And now you, I mean, crazy person, but now you're doing a PhD and you're keeping up with your clinical work, family, life, et cetera, et cetera. So maybe we can ask how that's going as well.

Alison Sim (01:25.87)
Yeah, that's exactly right. Yeah.

Alison Sim (01:34.326)
you

Tim Beames (01:44.988)
So, yeah.

Alison Sim (01:45.518)
Yeah, brilliant. Thanks for having me, Tim. It's lovely to see your face and have a chat.

Tim Beames (01:52.06)
definitely. Yeah, it's been a long time. So, well, can you could you do your best? Maybe this is good practice, isn't it? How would you describe what you're looking at with your PhD at the moment?

Alison Sim (02:01.614)
Yeah.

Alison Sim (02:07.854)
It's a good question and in my final year I'm hoping to submit towards the end of the year and I think you should have your spiel down by this stage. I'm still probably not quite there. I am interested in looking at early interventions to prevent the development of chronic pain following injury and particularly interested in injury in the setting of compensable care. So under

workers' compensation or motor vehicle accident insurance schemes. So that's where I've focused my PhD. Yeah.

Tim Beames (02:46.332)
So I'm hearing or I'm thinking this has huge value for the type. So for me as a clinician, I have to say I don't work so much nowadays, but I certainly did a lot. I saw a lot of people who were in accidents and they had an ongoing claim at the same time. And I don't know if this is what you're finding, but the process of the claim was...

Alison Sim (03:14.862)
Thank you.

Tim Beames (03:15.068)
unbelievably stressful sometimes and in fact could impact a lot of both the care but also their life.

Alison Sim (03:19.022)
Yeah.

Alison Sim (03:25.486)
Yeah, yeah, absolutely. And that's, that's been the crux of both the drive to get into this space as a clinician, but also it's, it's been where the research has gone to. And exactly as you said there, Tim, that the distress of actually interacting with the processes that are required to, you know, engage with that claim are actually a really big predictor of poor outcomes. So, you know, people who have that stressful claim tend to have.

poorer outcomes and that's been well documented in the literature. But it's also what we found in our qualitative research is that as a source of distress it almost comes up as number one. And then when we look at the data that compares people who have a claim and an injury versus people who don't have a claim and an injury, without the presence of the claim people just tend to do better. So it's...

As you say, it's really clinically relevant stuff and most people who are working with patients who have a compensation claim will be nodding along because it's certainly something that's very familiar to them.

Tim Beames (04:34.044)
Yeah, yeah, yeah, yeah. I have someone in mind at the moment where they are having to do a lot of the footwork, you know, chasing, you know, am I able to have funding for this? I feel like I need it. And the, I'm sorry, this is, God, I don't want to overtake this, but I'm just, God, this has such relevance. Because...

they are having to be the advocate for themselves. And I've had this conversation where I'm like, it's almost like you've had to learn how to navigate healthcare and the claim culture as well in order for you to be able to get the best for yourself.

Alison Sim (05:05.07)
Yeah.

Alison Sim (05:17.07)
Yeah.

Yeah, exactly. And often what we found in that qualitative research is people would do really well in a system where they don't have to jump through a lot of hoops, they'd be recovering really well. And then they get to a point where they're having to apply for sessions or ongoing care. And if there's a delay that occurs with that, and those delays often come about because of a lack of awareness that those processes were required. And therefore,

You know, you're often looking at, you know, we were talking to people who'd had up to six week delays when things have been going really well for three months, they're on a great trajectory. And then they're in that period where treatment is interrupted. And that again is a massive source of distress. And you can imagine as well from a claimant point of view or a patient point of view, that's where the injustice starts. And we know, again, that that's a massive predictor of poor outcomes. So,

You know, in our research to underpin the intervention that we went on to deliver, we really heard very strongly that these sources of distress were often avoidable, but very common.

Tim Beames (06:37.692)
Yeah, yeah. So, given that that is the case, who should we be sort of getting this knowledge to then, do you think?

Alison Sim (06:50.242)
So at its heart, it's a systems problem and I think everyone is aware that this is about the systems that deliver these things and the people who deliver these systems are very well intentioned that they're there to try and provide really good care and to look after the people that their insurance systems cover. But as we know, we've been institutions and system problems that some things do go a bit awry.

I guess, so we're looking at where can we have an influence. So if you can't change the entire system, we looked at the things that we could try and change. So perhaps I'll talk a little bit about the intervention that we did end up delivering. So we first of all did this qualitative work with clinicians and claimants. And so we spoke to people who were either receiving care or delivering care, and we spoke to about 30 clinicians who were delivering care within that.

compensable space. And from that, what we heard was essentially that the experiences of both the claimants and the clinicians about their frustrations with the system overlapped. So describing things like delays to care and a lack of that social connection, so feeling like no one cared, those kind of things. Both the clinicians and the claimants were reporting the same sorts of things.

And that informed us, like even learning about that idea of the delays to treatment and how they came about was really important for us as we then went on to the next phase. So I was then lucky enough to get a grant as part of the TAC, is our Transport Accident Commission, that's Victoria's no fault motor vehicle insurance scheme. And so our team got a grant to then run a pilot trial for an intervention. So we,

We drew on that research that we'd done in the qualitative work and then we then went on to do a co -design phase. So we worked with former and current claimants to try and understand what would have helped in the time. What would have made things better to see if they could help us to generate those answers as to, you know, if we can't fix the whole system, how can we help you? And that was a wonderful process. It gave us the clue that there were three main things that people felt would be helpful.

Alison Sim (09:19.566)
One was they really described that they didn't understand the claims process. And as you sort of say that they then had to upskill in that area. But the big barrier to that when you'd sort of say, when you point out that, were you aware this information is on the website and the website for the TAC is very comprehensive and quite easy to navigate. The message that we got back was very strongly that people are overwhelmed and they didn't feel it was their job.

And to the point that they almost felt like, particularly if they weren't at fault, that this information should be coming to them. There should be an element of passivity to this. It's not their job to be seeking that out, which, you know, without doing that foundational research, that stuff we wouldn't have been aware of. So we heard that about the claims process, that they didn't feel that there was enough information about that. We also interestingly heard about

a desire for pain self -management strategies. So this idea that, you know, people were saying things like, you should be warned about opioids before you start taking them or they should give you other tips and tricks to avoid getting stuck on the medication. That was really interesting. And again, that then drove us to, you know, as we develop that intervention to put in there some pain self -management strategies.

And then the third thing that we really heard strongly was this desire for social support. So again, just that feeling of when someone cares, it really feels nice. And that in that system, it can be quite lonely and it can be quite isolating and it can leave you with a sense that people don't really care. So people would say things like the phone check -ins were really helpful or you just wanted that sense that someone was showing that they cared about you.

So really that desire for social support was the third thing that we heard. So we then took that and again, under that workshop process with the claimants, we proposed a five session telehealth intervention that was delivered by allied health professionals. So we used OTs and physios and a couple of osteopaths to deliver that over telehealth so that we could reach everyone in Victoria. And,

Alison Sim (11:46.702)
Yeah, so essentially it was delivered over five sessions. The first two sessions contained standardized videos about the claims process. And to put that together, we used the stuff off the website, but we also used some of the things that we'd learned in that qualitative research to prioritize what to put in those videos and why it was important. And then the pain self -management strategies were sort of evidence -informed strategies that our team had previously used in other approaches.

And so we had these two sort of seven or eight minute videos that were delivered in the first and second session. And then our clinicians, we trained them to use their existing skills, but to really use that motivational interviewing approach to identify where there were things that were finding difficult and what in the videos had provided answers to that. And then how they might go about, you know,

sorting out those issues themselves. So a real emphasis on self -efficacy rather than the clinicians stepping in and saying, well, let me sort that out for you. So yeah, we delivered that intervention to a small cohort. It was an acceptability and feasibility study. So we delivered it to 11 people and found that participants were overwhelmingly really pleased with the outcomes of that.

So they found that it did meet those needs for helping with the claims information. In some cases, people were describing that it really stopped them from or they could see that without having that prior knowledge of what to do, that they definitely would have had gaps in their treatment and that that would have been upsetting for them. And we were able to deliver it over telehealth as well. So that was that was one of the aims. Was this feasible to deliver?

Tim Beames (13:37.052)
Yeah, yeah. So if I was had something to do with the funding, then I would be thinking this sounds like a really, really positive thing to do. So, yeah. Wow. Cool. Did you say and then you said about the social support. Was that within the?

Alison Sim (13:56.718)
Hmm.

Tim Beames (14:04.764)
within what you delivered. Did you?

Alison Sim (14:07.022)
Yeah, so I think any, you've had plenty of people on to describe this before, but the contact with the healthcare provider is really powerful. And I think as clinicians, we need to keep that in mind that by providing validation and support and reassurance, we are getting most of the job done and that really counts. So yeah, just the high contact, the one -on -one, they will.

sessions so that provided the social support.

Tim Beames (14:43.036)
Yeah, I mean you're beating me to it, but it sounds like you're being a human being aren't you you're just being?

Alison Sim (14:48.238)
Exactly, exactly. Yeah, a consistent, consistent friendly listening ear. And I think the the participants did they did really like the fact that they were health professionals that were delivering it. So so they could bounce ideas off about their rehab or when when a clinician was reassuring them about their recovery that they would that was trustworthy advice. So I think that was really valuable as well as was using experienced clinicians for that.

Tim Beames (15:18.652)
Yeah, yeah. So if that if by delivering this that felt valuable for people, do you feel that this will have an impact if it was delivered more widely in terms of the possibility of people recover, you know, having better recovery or.

Alison Sim (15:35.886)
Hmm.

Yeah, obviously in a feasibility study, we didn't take any health outcomes. So we can't predict what that would have done, but that is our next step. That's what we'd like to do next is run an RCT. And I think, you know, we're talking about changing systems to get systems to change money talks. And so I think we really need to get in there and actually evaluate total claims costs, because that's what's going to make people sit up and pay attention.

The other thing that I have always thought is, and this is what sort of again, as a clinician made me sitting there with patients and thinking things didn't have to be this bad. And particularly when you have patients who are angry and they're really looking for justice and the only avenue open to them is to seek financial compensation in the form of a lump sum. I really feel like if we can...

take the sting out of the process, less people are likely to, you know, to go looking for that lump sum payment. And I think that's where the money will talk if we can evaluate that down the track. So that's what interests me. But as you say as well, from a patient point of view, I think hopefully what you'd see is less people developing chronic pain because they're less distressed, better disability outcomes, better engagement with rehabilitation, all of those kinds of things that you would hope to see.

Tim Beames (17:07.868)
Yeah, yeah. I've got this. I don't know where this fits in entirely, but I just got like, I don't know, a television advert or something, but this this phrase, where there's blame, there's a claim sort of running through my head. And I'm thinking.

Alison Sim (17:25.965)
Mmm!

Tim Beames (17:28.476)
Like given the messages that people will have been bombarded by over the years, I mean in the UK for instance, I think there's this thing where people go and like, I think it's called brake check, like they go and they drive and they suddenly brake in front of you as a way to simulate a crash. I don't know whether this is true or not, but.

People are out there trying to force this on. But you're bombarded by all these messages. I'm wondering how helpful that is in terms of the self -efficacy process.

Alison Sim (18:09.622)
Yeah, yeah, I would agree. I think, I think the fact that there is a compensation overlay does, it does change the way people view their recovery. There's, there's no doubt about that. And, you know, you're talking about lawyers getting involved. The interesting thing about Australia is we do have state -based systems and they're all very different.

And when researchers go and look at that and try and compare the systems, what they find is where there are more lawyers, there are worse outcomes in terms of function and pain and things like that. So, you know, getting those systems to look after people better so they don't have to seek that is obviously in the best interest of everyone.

Tim Beames (18:59.932)
Yeah, but I mean, they're not going to want to suddenly leave, are they? So, I'm interested in you and you and the process and what you've learned and things like that as well. So obviously you at heart are a clinician. This is what you've done over years and then you've

Alison Sim (19:05.774)
Hehehehe

Alison Sim (19:20.782)
Hmm.

Tim Beames (19:24.06)
taken your interest of pain into your PhD, which is obviously one way of doing it, isn't it? Is that you've gone there with an interest. Have you sort of been surprised in any way from what you have found or the process that you've gone through of doing this research?

Alison Sim (19:31.958)
Yes, yeah.

Alison Sim (19:47.342)
I think the process for me in doing a PhD has actually been a lot more pleasant than I was expecting. It's been incredibly family friendly. So it's meant that through the back end of the COVID years, I was able to work from home and we still managed to get this project up and running. I think...

you go into it with these big bright ideas and things get chipped down and chipped down. So I think I've definitely learnt a lot about the barriers to all sorts of things, including research and implementation, those kind of things. I think one of the really interesting things that I have loved in the research has been some of the implications that came out of the qualitative research that we did with clinicians.

I found that really exciting and fascinating and I really think that clinicians will find it interesting as well. So we interviewed, as I said, about 30 clinicians who deliver care in compensable settings and we started to see a bit of a theme emerge, which is why we kept recruiting when we sort of initially thought we would stop after between 10 and 15 and we were seeing these really interesting things.

And I think it was because we were recruiting, we were snowball recruiting, so one person would refer the next. And once we started getting into the really experienced chronic pain clinicians, we started to see this interesting pattern emerge about this idea of working in complexity. And I know it's a bit of a topic at the moment. I noticed you've been talking about that with Mike Stewart recently. And there's a lot of research that's talking about.

complexity and how clinicians engage with that. And when we think about compensable care, or if you're talking about compensable care with clinicians, there is that tendency to have that kind of groan and the thought about it being the heart sync patient and all those kinds of things. And that comes with the complexity, right? That's the thing that...

Alison Sim (22:01.646)
that clinicians think about is if I have to do a full day of that, that is going to be quite full on. There's going to be a lot of talking. There's going to be a lot of emotion. These patients do tend to present a lot more distress and that's going to affect me as a clinician, how I deal with that. And I guess the assumption that comes with that is that it's draining, it's exhausting and that people don't like it.

And there certainly is an attrition we wouldn't get, we wouldn't catch in our data the people that find that really hard and then leave the profession and go and do something that suits them a bit more. But what we found in this cohort of really experienced clinicians was this idea that there's a bit of a pattern to it. So people would realize that they felt out of their debt, that they didn't have the skills to perhaps be able to address the needs of this complex population.

It prompted them to go and do usually further research. So a lot of people, it was the impetus for them to go and do a Masters in Pain or further training in another area. We heard a lot about experienced clinicians doing lots of mentoring, lots of further training, particularly around communication and communication skills. And I think essentially what they're learning to do is to

deal with in that further training and mentoring is sitting with discomfort and sitting with uncertainty as well, learning to be okay with that. And from there, what these clinicians were describing was this sense of mastery. So getting to a space where they, you know, were essentially feeling like they were a ninja, that they could take on these really complex cases and know that their skills, that they had the skills to meet that complexity and to do a really good job.

And with that then came this really strong sense of fulfillment. So this idea that they really get a lot out of their work and instead of feeling drained and exhausted, that it actually charged them up and felt fantastic. Now that wasn't across the board, it was a bit of an interesting pattern and you'd often have clinicians in that cohort describing both in the same sentence, feeling exhausted.

Alison Sim (24:16.302)
that the work is exhausting and it's draining, but at the same time it's exhilarating and it's fun and you're kind of dancing in those upper realms of being a ninja clinician.

Tim Beames (24:27.932)
That sounds awesome, doesn't it? Brilliant. Yeah. I love hearing that. Yeah. And it's on a very selfish level. It feels like it validates what we do as educators as well, doesn't it? So, yeah, wonderful to hear that. So, I mean, it sort of fits this idea of...

Alison Sim (24:29.614)
Yeah, really, really interesting. Not what we were expecting.

Alison Sim (24:45.198)
Mmm. Mmm.

Tim Beames (24:58.14)
Yeah, the relationship between the two, both of you coming to that space in the right place. So reducing the distress for the claimant or the person that's injured and in pain, but also creating the condition and the environment so that the person treating them is also, I love this, the ninja.

Alison Sim (25:09.934)
Mm -hmm.

Alison Sim (25:26.766)
Yeah, yeah, yeah.

Tim Beames (25:28.06)
They're like a ninja, yeah. Having a sense of mastery and how we might go about that as well. Yeah, and the flipping it from, I think back to early career, but I can remember people saying things like, this is a heart -sync patient. And God, if you've said it, imagine what you're going to be like with that person as well.

Alison Sim (25:34.862)
Yeah. Yeah.

Alison Sim (25:52.702)
Yeah, yeah, exactly, exactly. And so I think having those structures in a clinic and some of the clinicians that we spoke to, the mentoring sounded amazing. I was ready to pack up and move over and join their clinics. You know, they had sessions where they're all observing each other across the board. They're recording some of their...

sessions and going through them with mentors to say, you know, perhaps you could have done this a bit better. Being quite scrupulous, which is a really vulnerable place to be, yes. It sounds a little bit terrifying, but obviously the outcomes for those clinicians were really positive. So I think taking away from that the idea of further education in communication skills is obviously of benefit, but also the mentoring structure seems to be really important.

Tim Beames (26:49.532)
Yeah, yeah, yeah, yeah. And in some professions, obviously, that is a bit more catered for and others less so. So yeah, that's what I'm thinking about if you are in a profession where it is not a part of your ongoing work. Yeah. And then, God, we're running out of time, which is ridiculous, isn't it? I'm just scratching the surface here, but.

Alison Sim (26:54.99)
Hmm.

Alison Sim (27:00.238)
Mm, yep.

Tim Beames (27:18.236)
I'm wondering about you as a clinician as well. You've obviously come from being already an extremely competent and knowledgeable clinician. Have you noticed changes in yourself as you work in your clinic as well?

Alison Sim (27:36.846)
I think so. Doing that project prompted me to seek mentoring. I think it made me realize just how important it was to be scrupulous with ourselves and how we're delivering care, to really reflect on what it is that you're doing and put it under the microscope a little bit more. So that's been wonderful for me. I've been doing some coaching with Laura Rathbone, who I know you've had on here before.

That's really helped my practice enormously. I think the whole experience has just made me a lot more empathetic as well to people's experiences in compensable care. The idea that sometimes it's really dehumanizing and upsetting. And I think that's a good thing. I think just talking about it with other people as well that people in compensable care do miss out.

and that they can do without help.

Tim Beames (28:42.812)
And this might, I'm going to stick it out there, but imagine if we had the ability to completely change the system of claimant and commensable care and you just...

you wanted to design it for the best of clinician and best of the person who's there suffering and how, what might that look like in a thousand years time?

Alison Sim (29:18.222)
Yeah.

man, that's the magic wand question, isn't it Tim? I think it would be really early access to high quality care. And I think that's, it's not always easy. You know, there's some emerging evidence that clinicians refusing to treat is a really big problem. And I think services tend to fill the economic structures that are put in place. So, you know, if you're not,

paying very much for these types of services, then you tend to get lower quality services. So I think if we could pay people better to be in that space, we'd pay clinicians, experienced clinicians to be in that space and to be rewarded properly, to be able to access that care nice and early and continuously so there's not administrative cause delays to care.

And to make the process as smooth as possible for claimants, just if we did those really simple things so that they're not having to fight, so that they're not having to sell the fact that they've got pain when they pick up the phone, so that we just automatically believe them, I think those things would be a good start.

Tim Beames (30:41.148)
Yeah, I mean, that sounds great. So can I do my best to summarize a little bit? So first of all, we talked about your PhD looking at early interventions to prevent persistence from injury and...

Alison Sim (30:49.998)
I'm sorry.

Tim Beames (31:05.404)
looking at the stress of engaging with claims and how it's an incredibly stressful distressing process and interestingly that clinicians are also quite distressed and frustrated by it as well.

That's one particular area that you really found interesting was the frustration overlap between the two and the feeling that no one really cared. I mean, surely we can do better immediately there, can't we?

Alison Sim (31:39.118)
Mmm. Mmm.

Tim Beames (31:41.5)
doesn't need to be a magic wand for that one, I don't think. And that there was asking people who'd gone through the process what they thought could be done. They'd like to be able to understand the claims process. They felt quite overwhelmed by it. Had a desire, which I found quite interesting for self -management of pain.

So yeah, I mean, that would be wonderful, wouldn't it, that someone's coming and saying, okay, what can I do to help myself? And also the need for some support, some social support as well. And you designed an intervention that included...

Alison Sim (32:12.782)
and

Tim Beames (32:28.988)
elements of that that at least we're being a little bit careful aren't we about what you took from it but it looks like people really benefited from getting knowledge about the process and also some individually tailored knowledge about what they can do and what was going on for them.

And then, wow, so much actually, wasn't there? And then you talked about the interesting sort of findings of some of the clinicians working in that space and how some people really thrived. I thought that's what I got from it of realising that actually they didn't have the skills and they needed to go away and learn and explore and build and starting to find that they were quite comfortable in complexity.

Alison Sim (33:07.15)
and

Alison Sim (33:20.878)
Mmm.

Tim Beames (33:21.02)
uncertainty, complexity and felt like I've the ninja. I love this idea of being the feeling ninja of having mastery of or a sense of mastery and a sense of fulfillment doing that work as well. Is that a fair summary of what we've talked about?

Alison Sim (33:41.166)
Mm -hmm.

Alison Sim (33:45.55)
I think you've done a wonderful job, Tim.

Tim Beames (33:49.884)
I'm trying. It's been such a great chat. Thank you so much. I feel like there's so much relevance actually from and I'm a bit careful to share specifics but I can hear two people very specifically going through quite distressful times that I'm involved in with their care and.

if we could just make that easier. if we could just lower some of the distress you called it, didn't you? And I think that feeds in the suffering that goes with, you know, experiencing ongoing pain that can be incredibly disabling. So if we could just just take some what sound like relatively simple steps or we can just tweak the system slightly, then then we could minimise the risk of that happening. That sounds brilliant.

Alison Sim (34:13.934)
Mmm.

Alison Sim (34:18.766)
Yeah.

Alison Sim (34:41.197)
Yes.

Tim Beames (34:43.132)
Alison, thank you so much for that and look out for your work in the future. Soon as we see it coming out, then we'll make sure that we give you a big shout out. If you're listening to this podcast and you've enjoyed it, well, first of all, thanks very much for listening in and like it and share it and tell everybody about it. And if you want to do what some of the clinicians have obviously done where they're building their knowledge of pain, you can do that through

Le Pub. We have a premium membership where for £15 a month you can listen to people like Alison teach us about being better clinicians and learn from the researchers and I'm totally biased but I think it's amazing so come on board. Alison awesome thank you very much.

Alison Sim (35:30.382)
you

Alison Sim (35:35.63)
Tim, thanks so much for having me.