Tim Beams: Okay, welcome to the Pain Podcast. I'm the host for today, my name is Tim Beams. I'm the founder of Le Pub Scientifque, and I'm super excited to have a chat with Mike Stewart. We've already been having a talk about food, so we'll see where the conversation goes. A little about Mike and then we'll kick off. Mike, you're a pain specialist physiotherapist—I mean, I'm giving you that title, but pain interested, or however you want to call it—and educator. Some of you will know Mike from his courses, the "Know Pain" courses. Mike, great to have you here today. Thanks for agreeing to come out for a chat.

Mike Stewart: Absolute pleasure. Thanks for having me, Tim. It's been lovely to catch up, chat about food, chat about life in general. I suppose that's me—I have three jobs. I'm a physio. I'm one of these weird people; I always knew I wanted to be a physio from about the age of 14. I occasionally meet other people who are very similar. I have a twin brother who, now we're getting towards 50, still doesn't know what he wants to do. But I was convinced that I wanted to be a physio from an early age. I'm not sure what that's about.

Tim: You happy with that decision?

Mike: Yes and no. I go through periods of disillusion, but yeah, generally speaking, it's a fantastic job. So yeah, working as a clinician, working as a researcher, working as a teacher, doing education.

Tim: Cool, cool. There's a tinge of sadness in this meeting. The last time we were able to meet, we could have a lovely dinner together and a glass of wine. We'll have to do that remotely here.

Mike: Remote Malbec, exactly.

Tim: So we've got so many things that we could talk about, but I really like a suggestion that you had for us to drop in was around the notion of uncertainty in pain. I think if we position ourselves with that, I'm just like, why is the notion of uncertainty even important to discuss here? Do you think?

Mike: I think it's crucial for us as clinicians, more importantly, I think, for people who live with pain. Not knowing is one of the scariest things. Not having some sort of degree of certainty or idea—for me as a clinician, that's really uncomfortable. You know, you have to get comfortable with being uncomfortable, and that's definitely something we can delve into.

My Master's Degree was in education, and it was really interesting. I sort of discovered through the theories of education some of the underlying ideas behind uncertainty and coping with uncertainty and starting to feel more uncomfortable with that sort of not knowing, not being sure about things. I think that's a huge part of being a healthcare professional. And it's how do we then transmit that understanding and that comfortableness to people who are living with distressing levels of pain and disease and depression and all the rest that comes with pain?

Tim: Yeah, yeah. I've literally just come away from an appointment with someone, and that was a big part of what they were saying. They were just worried about what was happening, what was going to happen, what the diagnosis was and things. So yeah, you're absolutely right.

Mike: Not knowing why, I think, is—I often think that living with pain is a bit like, I use the metaphor of, it's a bit like living in a traffic jam. If you're stuck in a traffic jam and you don't know why you're stuck in a traffic jam, think about how that feels. It's really frustrating. You don't have any certainty about what's going to happen with the rest of your day. Can I meet—can I make this meeting? Can I go to the pub and meet my friends? Do all the things I love in life and value?

If suddenly you were able to sort of get into a helicopter and see why you're stuck in a traffic jam—if you can see that there's been a crash six miles ahead on the M1, or there's a toll road ahead, then suddenly you've got some understanding. When we use this with patients, often they'll say, "Yeah, you know, and from that higher up position, with that bigger vantage point, the bigger picture view, I can start to see maybe a road that I can take that's moving freely." You know, another road that I didn't see previously.

So yeah, I really like these ideas, particularly with uncertainty, of maybe like a journey metaphor which provides an optimistic cognitive reconstruction, a light at the end of the tunnel, somewhere new to go. I think they can be really helpful.

Tim: Like being able to provide a little bit of hope makes sense, doesn't it? If someone has got that uncertainty and worry and been experiencing pain. So yeah, lovely to hear.

Mike: That's it. You know, they're often in the dark, and I think sometimes living with pain is a bit like falling down a dark hole. I think my mistake—I don't know about anyone else who's listening or yourself, Tim—but I've made mistakes over the years where my initial reaction, seeing somebody living in this dark hole of pain where it's not very pleasant for them, is to try and rescue them. We do the rescue fantasy thing of trying to pull them out. Of course, that then gets exhausting for you as a clinician, repeatedly trying to pull somebody out of the situation. And of course, from the patient's perspective, they're not learning; they're just passively coming along for the rehab ride.

So I always think that it's about making sure that they understand that they've got to work out how to get out of this situation, and we've got to guide them rather than pull them.

Tim: Yeah, yeah. So I suppose from that sort of thread already, we've got multiple paths or roads to travel, haven't we? I'm wondering, with pain and as a diagnostician, how actually there are times when we can't necessarily offer certainty around a diagnosis. What are your thoughts around that?

Mike: I think that's a crucial thing. I think if you're thinking about things to avoid in terms of communication and education, it's to avoid the pressure of succumbing to a structural diagnosis, of thinking that you know. I've often said this when I'm teaching junior doctors: F1 doctors will often say, "Yeah, I know that I shouldn't say it's coming from this exact part of the tendon," or "It's coming from this Holy Grail magic off-switch patho-anatomically." But often, the consultants are sitting there saying, "No, no, no, you have to give it a label. You've got to give it a diagnostic name."

Which then, of course, can help the patient because now they're sort of saying, "Okay, I've got a specific diagnosis. The uncertainty has gone." But that then leads to more problems. I think one of the biggest issues is, if we think about when people are learning something, when you're going through a learning process, the educational literature suggests that there are sort of four distinct stages. You begin in that stage of dualism—right or wrong, black or white.

So in diagnostic terms, you go to see the doctor with back pain, and the doctor says you've got chronic degenerative disc disease. Now, in a sense, as a patient, you're happy to a degree because you've got some certainty. The doctor has told you what the problem is. And then the doctor will send you to go and see maybe a physio, for example. Without realizing it, the physio will quite often send the patient into a bit of a spin of uncertainty again because we might say, "Well, I've assessed you, and I don't think it's as simple as saying it's your disc. I think it's your muscle, it's your fascia, it's something else."

So we send them into stage two of learning, which is pluralism. Central to that is confusion, where patients are then sort of going, "Well, hang on, who's right? Is the doctor right with the disc? Is the physio right with the muscle?" We've got to understand that that confusing part of learning is part of the process. We have to break things down to build things back up again.

So you've got to go through that and then get to the third stage, relativism, where people sort of start to acknowledge that, well, okay, people think differently. As Louis Gifford always used to say, "Who you see is what you get." So of course, if I see a surgeon, they'll give me a surgical perspective. Or if I see a physio, they'll give me a physio perspective. Or if I see ten different physios, they'll give me ten different physio perspectives because no one has a perfect perspective.

And then gradually, hopefully, we want to reach that sort of fourth stage, commitment, where you're then comfortable to go it alone. This is where empowerment happens, where you're going, "Well, I've been through all of the process of listening to different opinions, and now I have a clear idea as to where my path forward is."

So there is this sort of process that I think being aware of is like being aware of what's sitting underneath the skin. You know, trying to use manual therapy without an understanding of anatomy would be quite tricky. Trying to understand pain education without an understanding of the educational concepts, I think, likewise can be quite challenging.

Tim: Yeah, yeah. So from that, I'm wondering how mindful are you in terms of uncertainty and where that fits in an educational model? Are you mindful of creating a little bit of doubt then? And what might that look like then when you're with your patients?

Mike: I think it's really important. We've got to set up some cognitive dissonance. We've got to set up some doubt. Robert Sapolsky always says, you know, the best question to ask people is, "What's that about?" So set up those sorts of scenarios where you'll say, "Well, okay, so you're telling me that you bent forwards and you pick the kettle up, and sometimes you pick the kettle up and it's empty, and you're dropping to the floor with immense pain in your back and your legs. But then sometimes you pick the kettle up and it's full, and you don't get anything. What's that about?"

I've got my understanding. I'll share with you my ideas, but I'll say to the patient, "Well, what do you think? I want to try and understand why you think it can be unpredictable sometimes, why it's not always the same." I think the answers to people's problems often lie in their experiences, in their words and their thoughts and their beliefs. A huge part of being a clinician is to understand that—to understand that they have the answers. We have to draw them out.

The word "education" comes from a Latin word, "educare," which means to draw out things from within others, rather than what I think we often do purely based on our training or lack of educational training, which is we pour in our knowledge. It's almost like a copy and paste method. We talk, they listen, they recall every bit of information we give them. And of course, that's not how we guide people. That's not how people change.

Tim: Yeah, yeah. I mean, as with often my conversations with people, you're massaging lots of my biases here. So thanks, Mike. It's really lovely to hear the process, the educational process here in your thinking. I'm sort of taking myself back a bit, and I'm thinking about how I was feeling uncertain about certain processes. The reason I want to do that is, as I'm listening to you, what I'm mindful of is how much knowledge and experience you have of working with people. Clearly, that comes out as I'm listening to you. Not everybody has that. We don't have that. We work towards that. You know, it's something that you grow over a period of process.

Mike: Exactly.

Tim: But if I look at, you know, me as a young clinician, there were times when I had a lot of pressure, self-imposed pressure on myself, thinking that I needed to know something where actually, perhaps getting a bit more comfortable with that uncertainty would have helped at that time. Have you got any—sorry, you want to jump in then?

Mike: Yeah, I'm just wondering how we might help people who are new to a profession, who are newly qualified or fairly new, recently qualified healthcare professionals, and how they might...

Tim: Yeah, yeah.

Mike: I think it's a really important point that you've made because I know for me—I think some people make the mistake that they think that, you know, people like us who will go around, we'll teach, we've got lots of experience behind us, that we're really sure about what we're doing, we're really confident about what we're doing. I don't know about you, Tim, but for me, I constantly live with that feeling that somebody's going to tap me on the shoulder and go, "This is rubbish. You're rubbish. You should go and do another job instead." So I'm always living with that sort of slight uncertainty and trying to get comfortable with it. It's an ongoing process for me.

I remember back in the day when I was a young, baby, junior physio, I remember going to the pub with mates, and there'd be some sort of bravado. My other physio mates would be saying, "Oh, I had a great experience today. I saw Mrs. Jones, and I cured her 20-year history of back pain with a single manip." And I remember thinking to myself, I must be really rubbish because inside I was thinking, I've never done that. I've never had that experience where somebody is, you know, the magic wand, the "baguette magique" as the French call it. I'd never had it.

So I thought maybe that's me. Maybe I don't have the skills to do that. And so I've had to develop, and I've had to try and find ways of discovering solace and comfort in not feeling sure about what I do. One of the things that really helps me, and hopefully it will help everyone who's listening here—I listened to a podcast interview with the late, great Stephen Hawking, you know, the professor of astrophysics from Cambridge. It was with Sue Lawley, Desert Island Discs in the BBC archives, and it's well worth a listen.

I was listening to that, and the interviewer asked him, she said, "I'm interested to know why you didn't go into healthcare. Your father was a doctor. Why did you not choose to follow your father's footsteps?" And he said something that's always helped me ever since. He said, "I realized from watching my dad that healthcare is far too chaotic, far too uncertain, far too unpredictable. So I decided to do something easier. I decided to study black holes."

So whenever I'm feeling really crap at my job and not very confident, I remember that. It's little things like that that sort of make me go, "Yeah, yeah, yeah, it's... you know, we're doing a job that Stephen Hawking knew was too tricky."

I think it's got harder because nowadays there's so much information coming at us through our phone screens. If we think about social media, you're constantly being bombarded. If you're a young physio, an inexperienced physio, there's all these different theories and ideas and people saying this is right or that's wrong. So you're constantly in that sort of muddy swamp of confusion, trying to figure out what's right, what's wrong. And of course, the answer often is that there isn't one right or one wrong. There's just lots of things that you have to find for yourself, that you pick out, that becomes your practice, that becomes what you do. And as long as it's based in evidence, as long as it's got some empathy behind it and some care, then great. You're doing a good job.

Tim: Yeah, yeah. And I'm thinking about your visit to the pub with your peers from your first job or a job as a junior, and you do hear this black and white, don't you? And people do gravitate towards that. And it's also fairly understandable then that people in pain might want to gravitate towards that sort of compelling story of black and white, you know, this clear diagnosis: "I know what's wrong with you."

Mike: Very much so, and again, I think to make sense of that in educational terms, Donald Schön did some work with this. It's an oldie but a goodie in educational research, but he thinks that we all sit on a thinking continuum. So at one end of that continuum, he terms it the muddy swamp of professional artistry. So it's sort of your uncertain of things. If you're that physio or you're a patient, because everyone's on this spectrum somewhere, you're that person who's not sure why your shoulder hurts. You don't know what's going on. Do you need surgery?

At the other end of that spectrum, you're somebody who's really certain. You're on the high, hard ground of technical rational thinking. So rather than being in the swamp of confusion where you're not sure why your shoulder hurts, you're convinced you know exactly what's going on. And equally, if you're a clinician, you can either be in the swamp where you're going, "I don't know what's going on here. This is all really muddy and confusing." Or you're a clinician who's at the other end on the mountain of certainty saying, "Well, if we just do this, this, and this, you'll be 87.9% better within 6 weeks, 3 days, and 2 hours." You know, you can be precise with your clinical reasoning and your decision-making.

Mike: (continued) I think it's important to understand where you sit as an individual on that spectrum. I'm definitely more towards the swamp, and I have to get comfortable with being down there. But I have to recognize that when I work with other clinicians, other colleagues, when I'm teaching students, when I'm working particularly with patients, I have to try and make a judgment call based on my understanding of that concept as to where my patient is.

For example, I had a patient who was an engineer and very linear thinking, very "2 plus 2 equals 4" type of character, on the mountain of certainty in his world. I have to recognize that there's a mismatch between me and my fluffy swamp of biopsychosocial world and him on his mountain of certainty with his biomechanical thinking as an engineer. So I have to understand that difference, and then I have to find a way of meeting in the middle. I have to climb out of my swamp and go and meet him towards his mountain and gain some trust, gain some therapeutic alliance and rapport. And then when he's ready, then drag him into the swamp a bit, say, "Look at all of this stuff. This is... it's not quite as clear-cut as we would think on the mountain. It's a bit more complex." So that's one example of how I think some of these theories help in terms of helping you to adapt to each patient that comes to see you.

Tim: Lovely, lovely to hear. Love this muddy swamp of professional artistry. You're inviting people to get a little bit dirty, which sounds great, doesn't it?

Mike: It really does, and I think I talk in those terms with patients. Let's get down into this swamp. Let's try and figure out what it is. Let's try and—most importantly—not leave them in that confused state where they're going, "Well, this is all muddy and confusing," but to try and find something that they can grab onto, something where they can... And I think that's where it's really important to then... I'm a huge believer in solution-focused care. I'm always saying to patients, "The problem isn't the problem. The solution is the problem." So let's keep our focus based around what do you want, what are the things that you want to be back doing again, rather than constantly going through "Why is this happening? What... let's explore the problem." Let's make sense of the problem and then let's shift towards what we do about it. I think that's crucial.

Tim: Lovely. So you sort of started to touch on this actually, but maybe if I position it in a sort of problem that you might see, like in an acute pain situation. Someone's hurt themselves, they've injured themselves. Perhaps we assign more certainty to our attribute cause and effect. When might we sort of, on that continuum between mountain of certainty and the muddy swamp of professional artistry, when do we start sort of embracing the need to be comfortable with uncertainty, would you say? Or are there certain things that you're listening out for, looking out for?

Mike: I think it exists across the board. I think if I'm working with somebody with an acute ankle sprain that's just happened this morning, I have to be aware that whatever I say, whatever I do, the advice I give, the poster they see on the wall in the clinic waiting area—all these little things, these non-verbal cues, anything really can have an impact that will very quickly either have a really helpful impact or a detrimental impact that's going to lead to chronicity or lead to barriers going up towards them getting better.

So I think that uncertainty—you're right, Tim—I think in those acute situations, it's far more... in a sense, it's far more simple than a 40-year history of pain all over the place and lots of uncertainty. But at the same time, we've got to be aware of how those variables can impact someone's perception of pain.

So I think I would be looking out for, in that situation, what they tell me. The answers lie in them again. If somebody's really concerned that they've caused a huge amount of damage, then I'll be turning my focus into trying to reassure them about what has happened and what hasn't happened. That sort of firefighter idea of checking all the rooms in the building when I'm doing an assessment and saying, "Well, that's good. This is good. No sign of anything wrong here." So those sort of reassuring messages would be key in that situation.

I think it's that being aware of adapting the language that we use and the way that we communicate with people according to what it is they're saying, rather than coming in with our formulas or recipes, which we often think about. That formulaic, recipe-based approach because it makes us more comfortable, it makes us more certain in a very uncertain world.

Tim: Yeah, yeah. And you do often hear this as an educator, don't you? "But Mike, tell us exactly what do you say?" Oh, I love it. It's my favorite one. You often have that conversation, and then it ends in that question, "So what should I do?"

Mike: You know, I had somebody once, a student once, who said to me—because I always ask people, "What's your wish? What do you want to get from this learning experience?"—and somebody once said, it was a physio and a very physio thing to say, "I want to know what percentage of my patient problem is bio, what percentage is psycho, what percentage is so..." Like it's a textbook, you know, really sort of orderly and sensible.

I think it's really quite challenging, and one thing again, if you're looking for a way to try to deal with uncertainty, one thought experiment that I use is to shift us away from categorical thinking. Because the world looks very comfortable and easy when we put things in small boxes, but that's not how the world works.

So I try something with patients. If I've got a patient in front of me, for example, who's saying, "It's all coming from the L4/5 disc on the left-hand side," I'll say, "Well, let me try something with you." We can try it now, Tim, to try and shift you into a different way of viewing this.

If I give you three letters, how would you pronounce these three letters as a word? C-H-O.

Tim: Cho.

Mike: Cho, yeah. Okay. If I try another word with you, P-H-O, how would that sound?

Tim: Fo, pho. That works. Depends if I'm getting some food, yes. Vietnamese food.

Mike: The third word, bit easier. U-S-E.

Tim: Use.

Mike: Use, yeah. Okay, fine. So now, Tim, if you put those three words together in your head and you think about how they'd sound if they were one word—the first one was cho, the second one was fo, the third one was use—how would that sound as one word?

Tim: Cho-fo-use.

Mike: Cho-fo-use. Now I would say to you, or I'd say to my patient, does "cho-fo-use" have any meaning? Does that mean anything to you?

Tim: Cho-fo-use... does it make sense? Of course not.

Mike: Cho-fo-use means nothing in any language, any culture. So now what we do is—in front of the patient, I'd get them to write it out. I'd say, "Write out those nine letters." So anyone who's listening to this or watching this, you could try it now, and you'll discover that when you write out C-H-O-P-H-O-U-S-E, you don't get cho-fo-use. You get chop house.

So chop house—you only can make sense of information when you provide it within a bigger picture, within a context. So contextual thinking is far better. But of course, human beings are designed to think categorically. When you go into Homebase to choose a paint color, you pick yellows or browns or blues or pinks. But that's not how color works. Look at a puddle, and you see how color works. It's a little bit more enmeshed and more complex.

So I use that with patients to try to get them to think about, you know, what does this mean for you? Is it just about coming from that one place? If you're thinking about the disc as a clinician or as a patient, then you're just stuck in "cho," and you're not able to make sense of cho-fo-use, chop house. And it starts to sort of separate out too much. It's too reductionistic.

Tim: Lovely. Oh, it's a really lovely little thought experiment, as you say, and brings us towards the notion of contextual thinking. I've got one last question, and then I'm afraid we're going to have to just bring it to a close. Getting comfortable being uncomfortable—I believe it was the sort of first thing that you said, or certainly the first thing that resonated, that you were saying. So what we have, as I'm seeing, hearing from you, is we have a number of different educational strategies of understanding the process, seeing where someone is within their learning framework, in order for us to know whether or not we need to give someone a little more certainty or create some fundamental doubt in certainty to move them forward. Would you say that's sort of at the heart of what you're saying—getting comfortable with being uncomfortable?

Mike: Very much so. I think it begins with understanding yourself first. So I think if you understand, like for example, come back to that idea of the professional thinking continuum. For me, it took me years. I remember doing my Master's Degree down at Brighton University and thinking to myself, "Why wasn't I shown this earlier? Why wasn't I told about this?" If I understood this concept when I was a student physio, it would have made me feel much more comfortable.

For example, I remember being a student physio and thinking, "Well, this is confusing because I've learned all about Maitland, and then I started to learn about McKenzie, and then I started to learn about Cyriax." So I was confident as long as I understood Maitland. I had my Maitland box here, and I was going, "I know what to do with that bit there." But now there's all these other conflicting schools of thought. And that's no different from a patient who's going, "It's just my disc. Oh, somebody else says it's the muscle. Somebody else says it's the tendon." We've got all these conflicting, differing viewpoints.

So I think begin with where you are, understand how you think, and then you can start to understand—as Buytendijk once said, I love this quote—"To encounter a new person is to encounter a new world." So every time your 8:00 patient is entirely different, it's like Mars and Venus. And those worlds are constantly in flux, which means that you have to constantly be in flux. We've got to constantly be able to adapt to the person in front of us. But that begins with understanding who you are.

Tim: Lovely. Mike, I'm afraid that's all the time we have for today. So look, huge, huge thanks. I think what you've done beautifully there is give people a little flavor of not just what to think about but also how to apply it as well with their patients. So thanks for those examples that you've come up with. I particularly love the muddy swamp of professional artistry, which has to be my favorite phrase for the week, month, year. I mean, there's still a few more months to go, but thank you so much for that.

Mike: Yeah, get the snorkel in there and get into the swamp. It's a great place to be.

Tim: And for those people listening, if you enjoyed what you heard—I hope you did—I love chats, and I love having chats with Mike as well. So huge thanks to Mike. But yeah, tell other people about it and share it and like it, etc. So huge thanks.

Mike: Pleasure. Thanks.