Transcrição completa de Evidence vs. Experience: Navigating the Complexities of Patient Care

level is just better. 00:04:59.322 --> 00:05:11.817 So the attempt to import something that maybe has more value in a higher risk scenario is kind of moot. 00:05:11.817 --> 00:05:17.992 It doesn't really make much of a difference, at least as the lofty goal would be the way that I would approach it. 00:05:17.992 --> 00:05:20.988 So, yeah, the evidence, the EBM. 00:05:20.988 --> 00:05:27.500 Another thing that I'd like to kind of bring in is the concept that the map is not the territory. 00:05:27.500 --> 00:05:29.184 Have you heard that before? 00:05:29.184 --> 00:05:45.449 I have, yeah, yeah, so we could, if we use the analogy, we could say that research papers are a map, right, but they are not the territory of the individual client, patient, whatever term is preferred. 00:05:45.449 --> 00:05:46.250 That you're working with. 00:05:47.100 --> 00:05:51.588 So, yeah, this, I think in the class that you looked at for me, we talk about it in regards to. 00:05:51.588 --> 00:05:59.168 You know, a research paper is asking a specific question and your client may be a data point in the research, but it doesn't. 00:05:59.168 --> 00:06:09.767 Actually, you're not the mean, you're the actual data point, whereas the research is concluding an average, a mean and not the actual data point, and the client's the data point. 00:06:09.767 --> 00:06:39.100 But does that mean, from what you were saying a second ago, that you feel that, with the risk factor and the fact that you know it doesn't have as significant of a consequence in manual therapy which I would agree with do you therefore theorize that it's less valuable or more, that it's less necessary to adhere to in manual therapy because our risk level is low, as opposed to if somebody's cutting you open or they're giving you a medication that's going to interact with your internal structure? 00:06:39.781 --> 00:06:50.699 So I think maybe it's more the term, so the broad concept of EBM or EBP whatever term is preferred because EBP would be more appropriate and hands on. 00:06:50.699 --> 00:07:05.855 I think it's a concept that is not useful, not because there's no risk or not because there's less risk, but because maybe, if it has value, it's more valuable in more dangerous circumstances. 00:07:05.855 --> 00:07:17.312 Because you're required to have more technical knowledge, right so a physician has no choice but to have more technical knowledge than any other healthcare practitioner, right so somebody with an unlimited medical license? 00:07:17.312 --> 00:07:25.471 Well, people are dying, and people are often dying because you did the right thing, yeah, right so iatrogenic harm, iatrogenic death. 00:07:25.471 --> 00:07:43.648 So I think the thing that I'm trying to suggest is that EBM, ebp as a concept, has challenges on its face and importing it, trying to import it into a different environment that it wasn't necessarily built for, right? 00:07:43.648 --> 00:07:50.774 Also, I don't know if anybody would take major issue. 00:07:50.774 --> 00:07:54.507 I doubt you get high loads of vitriolic feedback. 00:07:55.428 --> 00:07:57.112 No, I don't I have. 00:07:57.112 --> 00:07:59.660 In the past I've definitely had some, especially in my pain science classes. 00:07:59.660 --> 00:08:18.223 I've had very much some intense feedback about people who don't believe the pain science, the way I talk about it, and they're welcome to it, because the good thing about science is it doesn't actually matter what you believe, it's just present the way it is and that's reality so gordon guy at, as far as I can tell. 00:08:19.105 --> 00:08:34.889 and so the, the gentleman that put forth the concept of ebm, put forth the, the definition of conscientious, judicious application of best available evidence, and whatever words I'm missing in that, that was a pretty good off the top of your head definition. 00:08:34.928 --> 00:08:39.783 I'm pretty sure that was exact Well we just had some reps at it and you helped. 00:08:39.783 --> 00:08:45.607 So Gordon Guyatt is credited as an author on over 1,200 papers. 00:08:45.607 --> 00:08:57.577 1,200 papers is a lot of papers Now I think he's been going since mid to early 80s as a published academic. 00:08:57.577 --> 00:09:08.749 Far as I can see, one of the reasons that's happened is because if you look at how authorship is negotiated in papers, you negotiate it first off. 00:09:08.749 --> 00:09:11.785 If you call somebody and ask them for advice, they might negotiate authorship. 00:09:12.769 --> 00:09:13.553 I actually just did. 00:09:13.553 --> 00:09:26.681 My last podcast that I published was on the 10,000 papers that were retracted in 2023, or 20,000 papers, and it was with a lady who that's her specialty she was specializing in in she. 00:09:26.681 --> 00:09:31.662 I met her in Jamaica at our medical conference there and she presented it and, um, we talked about that. 00:09:31.662 --> 00:09:45.109 We talked about how a lot of people actually pay an author just to have their name on the paper, because then the paper will get picked up by a bigger journal or more likely to get published, and a lot of the times the author actually hasn't even paid attention to the paper. 00:09:45.109 --> 00:09:46.770 Yeah, they're not even aware. 00:09:46.770 --> 00:09:51.225 So gordon guyad's name might be on many that he actually, because there's no way he was involved with 1200 papers. 00:09:51.225 --> 00:09:55.386 I mean, that's, that's a lot of time in the lab he put forward. 00:09:55.427 --> 00:09:57.914 Well, he's not a lab guy, he's a meta guy. 00:09:57.914 --> 00:10:00.662 He's a meta analysis, much more so. 00:10:00.662 --> 00:10:02.505 Also the if you. 00:10:02.505 --> 00:10:06.714 I don't remember how the acronym breaks down, but he put forth the GRADE protocol. 00:10:06.714 --> 00:10:10.309 So it's essentially a protocol for evaluating medical literature. 00:10:11.402 --> 00:10:12.847 Yeah, the one through five pyramid. 00:10:13.841 -->

00:10:17.772 Probably I don't remember it exceptionally well, but I know that he put forth the GRADE protocol. 00:10:17.772 --> 00:10:27.692 So if you've put forth a methodological protocol, oftentimes people will call you or email you and ask you one question and, you know, pop me on as an author because I contributed to the outcome of your paper. 00:10:27.692 --> 00:10:31.902 Yeah, yeah, he's a physician, but I don't think he's a lab guy. 00:10:31.902 --> 00:10:41.167 So if you see really, really high sight, like you know, authorship, then something's unique about a circumstance and 1200 papers. 00:10:41.167 --> 00:10:56.014 You know to get a paper published is not an easy thing to get your uh, depending on what it is you're looking at, if you're looking at actual experimentation or even observation, or say you're looking at retrospective chart analysis. 00:10:56.900 --> 00:11:08.511 Or any version of outcomes Well, not even any version of outcomes, but anything that's going to involve human or living tissues To be published in a journal, you need ethics board approval. 00:11:08.511 --> 00:11:10.643 You're not getting there. 00:11:10.643 --> 00:11:13.711 But meta analyses you can churn those out. 00:11:13.711 --> 00:11:15.744 Right, you can churn those out. 00:11:16.325 --> 00:11:44.144 So that said, so I think it's at least reasonable to hypothesize that Dr Guy might be a little bit less in touch with the actual practice and more in touch with the academic game, and it's one of those hard balances that people always find with research. 00:11:44.144 --> 00:11:47.448 When you're a clinician is OK, I have this piece of research in front of me that tells me X, y, z. 00:11:47.448 --> 00:11:50.214 But then I have this client in front of me that tells me ABC and the two aren't coming together. 00:11:50.214 --> 00:11:56.260 But when I do ABC, my client is happy, and when I apply XYZ my client's not happy. 00:11:56.260 --> 00:11:58.062 And yet long term we know that if we do XYZ the majority of clients are happy. 00:11:58.062 --> 00:12:01.648 And so it becomes this really weird thing, and I think a great example of that is for me is myofascial release. 00:12:01.648 --> 00:12:08.543 I think it's probably for me one of the best examples of evidence-based medicine. 00:12:08.543 --> 00:12:09.985 That's hard to apply in the clinic. 00:12:09.985 --> 00:12:22.312 Evidence-based medicine shows us from a lot of the research with Robert Schleip that the mechanical forces it takes to break apart adhesions to create permanent deformation of collagen is more than 64 kilograms of force. 00:12:22.312 --> 00:12:25.811 No one's really doing that in the clinic because that's really painful. 00:12:25.811 --> 00:12:26.955 You know it would be. 00:12:26.955 --> 00:12:27.778 It would be quite unpleasant. 00:12:27.778 --> 00:12:29.586 You could potentially break bone in that scenario. 00:12:29.586 --> 00:12:33.985 So now you're malfeasance, so now you're actually hurting people, right, and so we don't do that. 00:12:34.264 --> 00:12:46.794 And yet he also goes on to state in the similar paper and this was a 2014 myofascial converse that oscillation and tangent tangential oscillation and vibration have the best effect on changing fascia. 00:12:47.436 --> 00:13:02.128 Okay, and yet when you go get treatment and most therapists who are going to do myofascial release are still trying to rip you apart, they're still trying to rip you in half, they're still doing their broad base, they're still doing a pin and stretch and the client still goes I feel good and I enjoyed it, yeah. 00:13:02.128 --> 00:13:07.051 And yet the evidence is suggesting what's happening is almost an impossibility. 00:13:07.051 --> 00:13:09.823 Yep, based on fascia. 00:13:09.823 --> 00:13:26.743 So when we look deeper like I teach in my classes for students who have taken it we know that it goes into the sensory system, we know as it goes into the brain, it goes into other components, which is why they're feeling better, yeah, but it comes into this thing of if the evidence suggests, stop wailing on your client, stop going deep, stop trying to do those things. 00:13:26.743 --> 00:13:33.947 And yet people are doing it because the client trusts the process, feels good with the process, has had that experience in the past with positive outcomes. 00:13:33.947 --> 00:13:39.427 Now your evidence and your client are conflicting with each other yep, yeah, I. 00:13:39.908 --> 00:13:48.808 I would say that the the challenge in a lot of things where your environment of observation is external to the thing you're targeting, like I don't know how you hit a target when you can't see it. 00:13:48.808 --> 00:13:58.640 So, as a simple analogy, the, the use of the term myofascial release and the assumptions that are built into it, is probably the issue. 00:13:58.640 --> 00:14:18.817 Right, so the the real deal is I can get consistent results in a general range of positive directions, whether it's alteration of movement, characteristic alteration of tone, like observable alteration of movement, characteristic tone, and possibly, but more variably, positive patient report. 00:14:18.817 --> 00:14:20.077 Exactly. 00:14:20.077 --> 00:14:26.212 Then I may be talking about the wrong mechanism, but doing the right behavior. 00:14:27.120 --> 00:14:49.570 And I think that's actually where most people like, when you look at a lot of critics of manual therapy which there are some and you look at a lot of people who are pro-manual therapy and there are some there as well you know, we're both manual therapists, we're both actively practicing clinicians and we're both educators I think it becomes one of those things where people try to I don't know if it's because it's the social media thing and getting followers and the. 00:14:49.570 --> 00:15:04.732 You know there's that component to the sensationalization of it, but I think there's also a big component of they don't understand

that that's what we're trying to bridge and that it's almost it's almost impossible to bridge in current terminology. 00:15:04.732 --> 00:15:11.816 The word, the phrases have to change, like myofascial release, trigger point therapy, you know, functional movement. 00:15:11.816 --> 00:15:17.394 These phrases have to change to accommodate for what the evidence is telling us. 00:15:17.917 --> 00:15:36.567 And then not only do they have to change, they have to change to a point where culture knows them as colloquial so that even they believe you when you say, oh, how you move is fine, it's not whether your knees line up with your toes, it's that you're moving, that's important, kind of thing like that, yeah, yeah, I think and I think that's really a hard thing with evidence-based medicine is that it's not catching up. 00:15:36.626 --> 00:15:53.260 The terminology is not catching up to the people who love it and the people who hate it yeah, the my general approach to a lot of things is I try to the best of my ability, get to a construct that no longer dissolves into smaller parts, right? 00:15:53.260 --> 00:16:03.990 So if we, if we look at the topic, we start with whether it's evidence-based medicine or patient-centered care, they dissolve into smaller things, right? 00:16:03.990 --> 00:16:15.333 So evidence-based medicine realistically, what I would do if we use medical ethics, I would say that evidence-based medicine takes care primarily of non-maleficence and beneficence. 00:16:15.333 --> 00:16:20.888 So, first, do no harm and then, after you've crossed the threshold of whatever I choose should do no harm. 00:16:20.888 --> 00:16:28.706 I want it to be good, right, but in being good, I also have to make sure that I'm telling that person and that they have the ability to choose. 00:16:28.706 --> 00:16:32.105 And then autonomy is where patient-centered care comes in. 00:16:32.105 --> 00:16:35.177 So, as constructs, it dissolves down into these things. 00:16:35.177 --> 00:16:37.422 So we're building things on top of it. 00:16:37.422 --> 00:16:52.207 With respect to the actual terms of systems or techniques or methods, I think the terms are subdivided systems that are not properly what I would term bedrock or the ground constructs. 00:16:52.688 --> 00:17:15.028 So in osteopathy, one of the things I talk about is, if you want to talk about things like muscle injury, things like strain-counter strain, things like facilitated positional release, things like HVLA Like HVLA stands out because it's fast, right, and it's not something that anybody in Canada should be doing as far as an osteo, but in other countries, sure, why not? 00:17:15.028 --> 00:17:16.614 Their laws are different. 00:17:16.614 --> 00:17:30.083 But these different systems, myofascial release, whatever it happens to be, if you look at the behavior, you can't absolutely tell what somebody's doing based on how they're moving. 00:17:30.083 --> 00:17:37.066 So as a practitioner, so let's just

say I hold something still right, I put a little tissue drag into something. 00:17:37.066 --> 00:17:39.352 It hits what we could call a barrier and I wait. 00:17:39.352 --> 00:17:45.230 You could call that myofascial release, right, you could call it inhibition. 00:17:45.230 --> 00:17:46.010 How do you? 00:17:46.030 --> 00:17:54.130 tell the difference Exactly and I think most people that's exactly what happens is based on your training, based on the vocabulary that was given to you. 00:17:54.130 --> 00:17:58.892 You call it one thing and you're replicating what other people are doing. 00:17:58.892 --> 00:18:14.352 Something you had mentioned to me was that, or in the, in the feedback you gave me, was the um, the fact that they're the fractioning system that is manual therapy. 00:18:14.352 --> 00:18:22.067 Like you know, we all have these different titles and early on in our education, you go to school, you graduate and you really stay in your lane. 00:18:22.067 --> 00:18:24.682 You're really like, okay, now this is, this is what I'm doing. 00:18:24.682 --> 00:18:25.503 Now I'm not. 00:18:25.784 --> 00:18:56.587 I'm not supporting the idea that you should be out of scope of practice, but any therapist who has been in profession for an extended period of time and that extended period of time is a variable because it depends on how much you learn and who's taken continuing education classes from anybody who's not their education they're learning stuff that completely relates to them, yep, and yet is out of their scope of practice, and yet they can somehow modify it slightly to make it within their zone of gray and put it within their scope of practice. 00:18:57.190 --> 00:19:09.086 And when you do it long enough, if you interchange one therapist who's a physio to a therapist who's a Cairo to a therapist's a chiro to a therapist who's a very talented osteo or massage or acupuncture. 00:19:09.086 --> 00:19:30.722 At one point, sessions begin to look very similar, and that, to me, is something that is so interesting, because in evidence based medicine, in theory we're doing manual therapy if you're touching, and yet we're all supposed to have a scope of practice that separates us from others and that somehow makes our treatment different from what somebody else is doing. 00:19:30.722 --> 00:19:32.711 And yet, like you just said, is it myofascial release? 00:19:32.711 --> 00:19:33.736 Are you hitting r1? 00:19:33.736 --> 00:19:34.844 Is it in? 00:19:34.844 --> 00:19:35.828 Is it inhibition? 00:19:35.828 --> 00:19:36.190 Is it? 00:19:36.190 --> 00:19:40.525 Are you facilitating a different movement and inhibiting one, depending on what I'm trying to do? 00:19:40.645 --> 00:20:01.179 right, like it's such a, it's such a gray area at that point yeah, well, if your fundamental intervention is interacting with another human being physically right, so I'm going to touch them and we are both humans then the base construct is that we're all doing the same thing. 00:20:01.179 --> 00:20:16.313 We're using different words, we may be thinking in different, but the net result is the interaction is going to shake out exceptionally similar, unless you are governed by the idea and you force the idea into the situation. 00:20:16.313 --> 00:20:24.813 If you force the idea into the situation, then you're actually violating a lot of ethical practices because you're not paying attention, right. 00:20:24.833 --> 00:20:35.932 So, say, you take something like patient-centered care, that's actually a great bridge into patient-centered care, because now you're forcing a thought yeah, but as a broad term, right it's like no. 00:20:36.011 --> 00:20:43.731 I need to consider how this person is or might respond right in hands-on therapy in the moment. 00:20:43.731 --> 00:20:47.482 You need to consider how they are responding and adjust iteratively. 00:20:47.482 --> 00:20:54.903 So from point of new information to change behavior as a prediction for how to get more of the outcome we're looking for. 00:20:54.903 --> 00:20:57.990 So the if I bring osteopathy in. 00:20:58.270 --> 00:20:58.491 Can you? 00:20:58.491 --> 00:21:00.883 Can you say that sentence one more time only? 00:21:00.883 --> 00:21:09.330 Because this is why I love talking to you, because what you just said to me was a fluid conversation, it was a clear sentence and it made a hundred percent sense to me. 00:21:09.330 --> 00:21:22.863 But I have spent a lot of time talking about prediction, talking about iterating behaviors, talking like that's, that's what I like doing, but I know not everybody does that, and so for them, they're going to take a second and they're going to pause and they go wait a minute. 00:21:22.863 --> 00:21:24.505 What did Sam just say? 00:21:24.505 --> 00:21:33.476 Because it was a lot of big words that they're not used to hearing, necessarily, but not that they're not smart enough to understand it, just that they don't tend to think those sentences one after another. 00:21:33.476 --> 00:21:39.906 So you may say it a little differently, but if you could just repeat roughly what you just said, because I think it's such a valuable point. 00:21:40.446 --> 00:21:54.590 Or maybe what I'll do is I'll try to give it the essence with different words so you interact with another human being physically, you apply some manual interaction with them. 00:21:54.590 --> 00:21:57.328 They are going to respond in some direction. 00:21:57.328 --> 00:21:59.968 You need to know what the goal of that is. 00:21:59.968 --> 00:22:11.332 If I want to add tension and have no protective response, they don't jump, then I can monitor for tension and if they do not jump or do anything abrupt, I'm okay. 00:22:11.332 --> 00:22:17.993 If they jump, I've missed my target because I have a behavioral target the tissue behavior and the person behavior. 00:22:17.993 --> 00:22:22.932 So if I add tension and they do jump, I need to alter it. 00:22:23.099 --> 00:22:26.962 I

could remove a little bit of tension, kind of soften things up. 00:22:26.962 --> 00:22:29.670 I can change the pressure with my monitoring hand. 00:22:29.670 --> 00:22:31.181 I can change something. 00:22:31.181 --> 00:22:37.468 There are multiple variables but I have to kind of pay attention to them, to change it on purpose, because I know that I have a goal. 00:22:37.468 --> 00:22:48.943 The net goal in most cases for me is to alter motion characteristic and hopefully the reason that they're presenting whatever internal sensation. 00:22:48.943 --> 00:22:52.432 They're presenting changes because it was properly related. 00:22:52.432 --> 00:22:54.969 If not, then they move better and they feel the same. 00:22:54.969 --> 00:22:55.893 And that's not for me. 00:22:56.395 --> 00:23:09.215 it's out, it's outside of what my skills can do so it's still a positive outcome because they're getting more active daily lifestyle, less disability but knowing no changes in pain symptoms yeah, so the and that's that's not an abnormal thing, right? 00:23:09.738 --> 00:23:14.709 but maybe another way to say it is you have a goal, you shoot at it. 00:23:14.709 --> 00:23:20.516 If you get the feedback that you missed the goal, you know what you did, you know what you were aiming for. 00:23:20.516 --> 00:23:21.480 You know you missed. 00:23:21.480 --> 00:23:26.784 Now that you have a new point of information, the iteration is learning from the miss. 00:23:27.746 --> 00:23:28.728 So what do you do? 00:23:28.807 --> 00:23:29.430 how do you change? 00:23:29.430 --> 00:23:30.692 Yeah, how do you change? 00:23:30.692 --> 00:23:34.207 But you have to know why you did what you did, what you were aiming at, and you know. 00:23:34.207 --> 00:23:34.988 Okay, I missed. 00:23:34.988 --> 00:23:38.603 Now I can change based on what I did. 00:23:38.603 --> 00:23:42.893 So I know what I did and I can change it some way up down, left right now see. 00:23:43.059 --> 00:23:49.673 This is where I think evidence-based medicine helps manual therapy, because a lot of therapists will offer treatment. 00:23:49.673 --> 00:23:55.402 They may not get the results they're looking for and the next session they come in they do the same thing. 00:23:55.402 --> 00:23:59.632 I remember I had a client many years ago and I was still living in Colorado. 00:23:59.632 --> 00:24:01.423 He came in with severe low back pain. 00:24:01.423 --> 00:24:07.755 Now, when he was four, he had had a liver transplant at the age of four, which is very, very, very rare. 00:24:07.755 --> 00:24:12.824 He had a type of metastasizing cancer I can't remember what it was called at the time. 00:24:12.824 --> 00:24:13.846 It's been too long. 00:24:13.846 --> 00:24:18.086 He had a lung removal and when I saw him he was 48 years old. 00:24:18.086 --> 00:24:26.400 So he'd had this for 44 years already and his scar was incredibly long already. 00:24:26.400 --> 00:24:27.201 And his scar was incredibly long. 00:24:27.201 --> 00:24:32.515 He had this like 12 to 13 inch scar that went from essentially his xiphoid all the way on his ribs to straightest anterior attachments on the back. 00:24:32.515 --> 00:24:34.471 It was a very large and it was deep and it was large. 00:24:34.952 --> 00:24:39.412 But he was coming in with a primary complaint of low back pain and he had a medical file. 00:24:39.412 --> 00:24:45.931 Like he came prepared, he had a medical file that was a foot tall, quite literally, and he was wealthy. 00:24:45.931 --> 00:24:48.445 He had spent money seeing faith healers over the globe. 00:24:48.445 --> 00:24:50.029 He had done the best surgeries. 00:24:50.029 --> 00:24:51.422 He had fusions, injections. 00:24:51.422 --> 00:24:55.036 He'd seen the best therapists, you know the gurus of the trades. 00:24:55.036 --> 00:24:58.204 He'd seen everybody in the sun and he wasn't getting better. 00:24:58.525 --> 00:25:06.111 And I remember thinking my elbow is not somehow magical, my elbow is not more powerful than someone else's elbow. 00:25:06.111 --> 00:25:09.246 It's not like I know anatomy better than these other people. 00:25:09.246 --> 00:25:18.228 His anatomy is his anatomy and I said but if all they've ever done was focused on your back and you're not getting results, why would I continue to do the same thing? 00:25:18.228 --> 00:25:22.080 And we moved somewhere else and he actually got really good results. 00:25:22.642 --> 00:25:28.693 But this would be an example where the evidence suggests what we would normally do, which is traditionally people who have low back pain. 00:25:28.693 --> 00:25:36.688 They target regionally that area of the body because that's where their nociceptive or neuropathic signals are coming from and that's what they pay attention to. 00:25:36.688 --> 00:25:41.025 And yet if the miss is not getting better, well, what hasn't happened? 00:25:41.025 --> 00:25:42.048 Medical files. 00:25:42.048 --> 00:25:43.530 And then what do we change? 00:25:43.530 --> 00:25:48.551 And I think most therapists I don't know about that, most therapists is changing. 00:25:48.551 --> 00:26:03.647 I think a lot of therapists historically haven't adapted their cookie cutter techniques, be it through education, be it through stubbornness or be it laziness, be it through knowledge, to look at it and reevaluate that miss like you're talking about. 00:26:04.429 --> 00:26:10.256 So maybe I can add, you know an alternate angle or an appropriate analogy. 00:26:10.256 --> 00:26:21.910 What it sounds like is the person you're describing went to people for their specialty, so you could give it the analogy to a hammer Everything is a nail right. 00:26:21.910 --> 00:26:23.781 You said low back pain. 00:26:23.781 --> 00:26:25.230 I will look at your low back. 00:26:25.230 --> 00:26:27.903 My assumption doesn't line up with that at all. 00:26:27.903 --> 00:26:33.446 I'm going to look at as much as I can to find out where things are not moving, because I can find

things that aren't moving. 00:26:33.446 --> 00:26:34.981 I can interact with things that are not moving. 00:26:34.981 --> 00:26:43.103 I can alter them in a reliably positive way, and if that's why you're feeling what you're feeling, they'll change together. 00:26:43.624 --> 00:26:48.971 The problem being, it doesn't matter what you tell me you feel, I cannot find it. 00:26:48.971 --> 00:26:58.593 I can find proxy information, but if I can't shoot at it or I can't aim at it maybe a better term then I can't hit it. 00:26:58.593 --> 00:27:00.444 If I do hit it, it's by accident. 00:27:00.444 --> 00:27:13.105 What I would synthesize as a fundamental concept of osteopathy is there is a mechanical relationship between health and disease state, which would then possibly carry over to. 00:27:13.105 --> 00:27:25.944 There is a mechanical relationship between sensory state, but not always, because we know enough about sensory state to know that there could be neuropathic or nociplastic pain. 00:27:26.425 --> 00:27:33.884 Yeah, neurogenic, or things that are sensory based but not nociceptive based, not structural based, yeah, and cognitive, and they're not brain based either. 00:27:33.884 --> 00:27:36.130 It's you know Paul Lorimer Mosley. 00:27:36.130 --> 00:27:44.912 I had the chance to spend three days with him in New York last year studying with his fit for purpose model, and I think one of the things he really kind of like it was a light bulb moment for me. 00:27:44.912 --> 00:27:56.771 He's like you know, you have an endocrine system, you have a cardiovascular system, you have a muscular system, you also have a pain system, and your pain system is your peripheral nervous system, your central nervous system, your autonomic nervous system, as well as your brain. 00:27:56.771 --> 00:28:09.695 And I was like, oh my God, it's a system, it's not, you know, one versus the other, and people often say it's a pain in the brain or an issue in the tissue, and it's like, no, but the system exists as a whole, similar to all the other systems. 00:28:09.695 --> 00:28:18.282 I like that. 00:28:18.303 --> 00:28:19.365 You said the specialty thing. 00:28:19.365 --> 00:28:22.223 To me that's a really good thing, because people do get specialized. 00:28:22.223 --> 00:28:25.566 You know, they get really good results with knees and so then they become the knee person. 00:28:25.566 --> 00:28:27.038 Or they get really good results with athletes. 00:28:27.038 --> 00:28:28.162 They become the athlete person. 00:28:28.162 --> 00:28:33.903 Um, and I I mean, I've been in the profession 20 years, so I've definitely had those moments and stuff like that. 00:28:34.304 --> 00:28:42.031 And I think the tricky part is people want to specialize in something and then they don't get a result with something and they don't know what to do. 00:28:42.031 --> 00:28:51.167 Or they end end up like if you live in a small community and you're really good with low back pain, you're really good with

knee pain, and then somebody comes in with neurogenic pain. 00:28:51.167 --> 00:28:58.428 You're kind of effed, and so then the problem becomes is how do you become a specialist for everyone? 00:28:58.428 --> 00:28:58.990 And you can't. 00:28:58.990 --> 00:29:05.204 We know that you can't, but people really want to be and I think aiming for that bedrock. 00:29:05.204 --> 00:29:16.769 You may not be a specialist for everybody, but you will definitely be better for a lot more people by aiming for the bedrock and not for the lofty goals and not the imaginary goals. 00:29:17.619 --> 00:29:28.121 So my, my argument and the thing that I bring when I teach students to become osteopathic practitioners is the search is more important than the move, right. 00:29:28.121 --> 00:29:30.345 So I just approach it from a different way. 00:29:30.345 --> 00:29:36.575 To attempt to teach technical intervention for a targeted purpose. 00:29:36.575 --> 00:29:48.031 Whatever you're teaching somebody, as the underlying assumption of what that target is has to be right, and if it's not right, then they're going to build on top of that faulty assumption. 00:29:48.031 --> 00:29:53.701 Faulty assumption. 00:29:53.721 --> 00:30:01.561 The general assumption that I attempt to inject into somebody's approach to another human being is you need to figure out where you have to zoom in, based on a fundamental goal. 00:30:01.561 --> 00:30:13.684 The fundamental goal is identify what's not moving, zoom into it, see if you can find the peak of the area that it's not moving and interface with it in a way that doesn't make them need to protect themselves, right. 00:30:13.684 --> 00:30:19.904 But the assumption that I'm trying to inject as the primary is if you can find what's not moving, you can be meaningful. 00:30:19.904 --> 00:30:33.740 If I attempt to inject the assumption that I have to have you learn this move, repeat this move, remember this move, apply it in the future at the appropriate time to the appropriate person for the appropriate reason. 00:30:33.740 --> 00:30:40.753 The cognitive load's too high, the likelihood of that being a real thing is low. 00:30:41.500 --> 00:30:43.544 I mean one in a very small number. 00:30:44.707 --> 00:31:02.867 Whereas if I teach you how to appropriately assess in a relatively fast, effective manner not to find everything, but to find where to look more to find the important stuff Then what I'm teaching you to do is generate solutions to the unique problems presented. 00:31:02.867 --> 00:31:04.612 That's the primary skill set. 00:31:04.612 --> 00:31:16.115 As a result of that, you have to build on technical details like how do you move somebody, how do you know if you're moving somebody in a way that they're not responding properly to, and how do you change that. 00:31:16.115 --> 00:31:23.359 So, if that's the skill set that I build, all the details fall into place on top of it, for the most part with blank spots. 00:31:23.359 --> 00:31:30.044 But I'm teaching you the search pattern and the solution generation pattern, as opposed to move, move, move, move. 00:31:30.384 --> 00:31:45.346 So would you say then, that one of the things that might help integrate evidence-based medicine into manual therapy, where the risk is still low, like we talked about at the beginning, it's much more relevant for a physician, it's much more relevant for a surgeon. 00:31:45.346 --> 00:31:51.592 It doesn't mean it's irrelevant, but it has a greater importance. 00:31:51.592 --> 00:32:28.481 So, in order to give it more irrelevant, but it has a greater importance, so in order to give it more weight, possibly in manual therapy, would one way to bring EBM or EBP into the light for us is highlight and focus more on the importance of assessment and effective assessment that is researched, which is hard to do, we already know that and then, once the assessment is well done, the treatment may be a variable, but the assessment becomes the key component, and that's the missed point, that's the shooting in the dark, missing your target, kind of thing. 00:32:28.481 --> 00:32:51.328 Um, because this is going to be the first of a series that I do on problem solving in the clinic, and for me that's that's one of the things that is very hard in a lot of clinics is assessment skills, because, you know, just teaching the pattern, you know that's really good for relaxation sessions, if you want to have somebody relax on a table and fall asleep and get us, and that's I, I, I. 00:32:51.569 --> 00:32:58.301 I have had people ask me in the past if I don't agree with that, and I think it's a bad version of massage without they're under educated not at all. 00:32:58.301 --> 00:33:05.752 If you need to relax, if you need stress reduction, if you want to sleep, if you need, it is so much better than anything I do, because I don't do that. 00:33:05.752 --> 00:33:08.240 It's what's the targeted need, right? 00:33:08.240 --> 00:33:10.426 If you're looking for therapeutic, you don't, you don get that. 00:33:10.426 --> 00:33:19.528 You come see somebody else, and so would assessment possibly be one of the ways to bridge that gap between the importance of ABM and EBP into manual therapy? 00:33:20.309 --> 00:33:35.724 So maybe I think the fundamental construct of ABM and EBP, as it's attempting being attempted to be imported, is the problem, because you're looking at drugs and you're looking at surgeries. 00:33:35.724 --> 00:33:38.151 It's not necessarily the same type of behavior. 00:33:38.151 --> 00:33:49.726 The thing that I spoke to in the talks that I did in Florida was utilizing the concept of medical ethics to better report data, right. 00:33:49.726 --> 00:33:55.144 So first, if you want to talk about an intervention, first you know you set up your study. 00:33:55.144 --> 00:33:56.752 You're like okay, what's my target outcome? 00:33:56.752 --> 00:33:58.760 What's my target behavior? 00:33:58.760 --> 00:34:01.307 Okay,

let's match them up, let's measure right. 00:34:01.307 --> 00:34:05.682 You have to have kind of a go-no-go measure or a good-not-good measure. 00:34:05.682 --> 00:34:06.682 So you need a discriminator. 00:34:06.682 --> 00:34:07.804 Did it change enough? 00:34:07.804 --> 00:34:08.706 Did it not change enough? 00:34:08.706 --> 00:34:09.445 Did it change at all? 00:34:09.445 --> 00:34:14.172 You could start binary like some change, no, change, right, start there. 00:34:14.172 --> 00:34:18.121 The question would be how often does it change in the desired direction? 00:34:18.121 --> 00:34:19.646 So that's your non-maleficence. 00:34:19.646 --> 00:34:21.492 Well, sorry, that's not true. 00:34:21.492 --> 00:34:25.690 The first question is how often does it change in the wrong direction? 00:34:26.699 --> 00:34:28.021 That's your non-maleficence. 00:34:28.021 --> 00:34:28.463 That's your. 00:34:28.463 --> 00:34:29.385 I'm'm safe. 00:34:29.646 --> 00:34:53.440 I don't do those things so if it never goes negative on target direction, okay, I can pass non-maleficence if it sometimes doesn't necessarily mean it's beneficial, no, just means it's not hurting it crosses non-maleficence appropriately, then what you do is you consider how often does it go in the right direction right Now? 00:34:53.581 --> 00:35:02.914 if it goes the right direction 40% of the time, then I can't trust that if I'm claiming that it's going to do what we want it to do. 00:35:06.085 --> 00:35:07.889 But I can say, listen, it may not do. 00:35:07.889 --> 00:35:26.980 What we want it to is, if I was to make an adjustment into what people are looking at when they're looking at research, especially medical intervention, I need to know how often it's going to harm somebody, because if it's more likely that it's going to harm somebody in some undesirable way, some people don't say side effects. 00:35:26.980 --> 00:35:35.989 Some people argue that you should say unintended direct effects, because you took the thing or you had the intervention and this thing happened, which we know happens at a certain rate. 00:35:35.989 --> 00:35:41.128 Right, like you're rolling dice or you're playing with odds. 00:35:41.128 --> 00:35:52.711 For me, I would want to see how often that happens, because if it can't cross non-maleficence, then it should not be applied. 00:35:52.711 --> 00:35:53.773 It is against ethics. 00:35:53.773 --> 00:36:01.742 So what I would suggest is that there are a large amount of healthcare interventions that fail basic ethics. 00:36:01.742 --> 00:36:13.552 So importing a concept that asks me to look at the agreed-upon standards that don't cross non-maleficence is a problem. 00:36:14.981 --> 00:36:26.927 Now I could agree with you in some regards, but I could also see in some regards how that's a tricky one, because some medical interventions bear inherent risk Absolutely, and you still chemo. 00:36:26.927 --> 00:36:46.490 It bears an inherent risk and yet the probability outcome of

not doing it is greater than the risk outcome, and so it's a little hard to go down that road if it doesn't cross Maleficent's, because it's more, it does potentially cross Maleficent's but the risk of not doing it is actually a greater Maleficent's almost. 00:36:47.161 --> 00:37:03.389 Yeah, so and I'm comfortable with that discussion around again medical intervention or intervention by those with unlimited medical licenses, right, I'm I'm happier to have that conversation, because the question is if I do nothing, you're gonna die. 00:37:03.389 --> 00:37:07.822 If I do something, you might live, you might die faster. 00:37:08.583 --> 00:37:18.514 And this goes back to the beginning of the conversation that we were having, which is, you know, in in certain medical fields, ebm is a life or death scenario. 00:37:18.514 --> 00:37:21.320 It is not for us, you know. 00:37:21.320 --> 00:37:25.751 It may be I'm in more pain today and I'm in pain for a few more weeks. 00:37:25.751 --> 00:37:42.144 It may be I'm unhappy, I have a higher disability, but it's not you're dying, and I think that's the part with EBM that is really hard for the manual therapy haters as well as the manual therapy lovers to really get beyond. 00:37:42.144 --> 00:37:45.530 Is that, like you said, the bedrock of EBM. 00:37:45.530 --> 00:37:50.887 Ebp comes down to who is that designed for? 00:37:50.887 --> 00:37:56.262 And it was never truly designed for physio, for manual, for massage, for chiro. 00:37:56.262 --> 00:37:57.387 It wasn't designed for that. 00:37:57.568 --> 00:38:00.681 Yeah, so let's, let's move on to patient-centered care for a second. 00:38:00.681 --> 00:38:06.431 So, um, patient-centered care, similar to ebm, like ebm, we have a definition. 00:38:06.431 --> 00:38:08.682 We know it and it may be changing, but there is. 00:38:08.682 --> 00:38:10.067 There is a definition. 00:38:10.067 --> 00:38:13.543 Yeah, I did a series of podcasts a couple years ago. 00:38:13.543 --> 00:38:17.621 I did three series of podcasts on defining massage therapy and it's impossible to. 00:38:17.641 --> 00:38:29.793 There's over 250 recognized manual therapy techniques, modalities in massage therapy alone, copying istm, guasha, lomi, lomi, you know on and on and on, and so, with patient-centered care. 00:38:29.793 --> 00:38:35.773 It's one of those other things, too is that you can look at 10 different websites and get five different definitions of what patient-centered care means. 00:38:35.773 --> 00:38:54.795 They do have a core three components about communication and responsibility and things, and about sharing with partners and friends, but the majority of PCC talks and definitions vary between four to eight different things that are important to me. 00:38:54.795 --> 00:39:11.722 So how do you feel, because you talked a good amount about in your interview, your review with me, tell me a little bit about how you see PCC, both in its definition but its effective state and its ineffective state, because you talk about it as the third line of treatment. 00:39:26.739 --> 00:39:28.382 It sounds like a nothing burger, right? 00:39:28.382 --> 00:39:31.405 Also, autonomy does a better job with respect to medical ethics. 00:39:31.405 --> 00:39:32.686 So autonomy does a better job with respect to medical ethics. 00:39:32.686 --> 00:39:39.074 So, autonomy being the requirement to provide the patient the ability to say no. 00:39:39.074 --> 00:39:42.945 Even if it will benefit them, they have to be able to say no. 00:39:42.945 --> 00:39:54.485 The other thing that you have to have in there with autonomy is that unless the patient is incapable like provably incapable of making a decision, that they are the one to make the decision. 00:39:54.485 --> 00:40:15.284 When you see patient-centered care, you have the importation or essentially, the demand it may be a strong word, but the demand that you include family members on some level in the decision making, and that violates autonomy, decision-making, and that violates autonomy. 00:40:15.284 --> 00:40:23.351 The other thing is, you don't know, as the healthcare provider, regardless of the type of healthcare, whether or not you've invited an abuser or whether or not a position for future abuse. 00:40:24.092 --> 00:40:29.269 Exactly and and it plays into a whole power struggle, barriers that we may or may not be aware of. 00:40:29.329 --> 00:40:32.423 It plays into confidentiality, right, it plays into a lot of. 00:40:32.423 --> 00:40:35.536 It's one of the biggest complaints about patient-centered care. 00:40:35.536 --> 00:40:50.371 There are the ones organizationally it's incredibly difficult to get people on board, and with patient-centered care there's usually a team of medical practitioners and every individual member on the team wants to be the one making the decision and that becomes a complication. 00:40:50.371 --> 00:40:53.702 There are a lot of complications Now there are also a lot of benefits. 00:40:53.702 --> 00:41:02.228 The research shows that people who do receive patient-centered care tend to one if they don't get better, enjoy the treatment more. 00:41:02.228 --> 00:41:11.784 So let's say, terminal ill you know terminal illness and things like that their quality of care is higher, even if they know the outcome is a predetermined effect. 00:41:11.784 --> 00:41:34.764 We also see that there's some research with patient-centered care showing that there is a mild level of increased outcome compared to being told you will receive this treatment versus I want this treatment, even if it's the same treatment for the same diagnosis, and so it's tricky because there are major complications, but there is some good research showing that it is actually beneficial on the outcome pile. 00:41:35.344 --> 00:41:49.952 So, as far as satisfaction outcome, I have challenges with satisfaction outcomes, patient satisfaction outcomes not because I don't think there's value, but because I

don't think it should be the absolute target of the care provider. 00:41:49.952 --> 00:41:53.061 Now this applies way more again to medical intervention. 00:41:53.061 --> 00:41:59.402 You want the person providing you medical intervention to be exceptionally technically proficient. 00:41:59.402 --> 00:42:05.914 Challenges with bedside manner aside, technical proficiency is number one. 00:42:05.914 --> 00:42:13.311 The bedside manner is another thing that happens at the same time, but it's not the thing right. 00:42:13.351 --> 00:42:27.181 So the the study that I know was that they they one doctor was giving a diagnosis um to a group of client, a group of patients who had one condition, and another group of patients had the same condition. 00:42:27.181 --> 00:42:39.353 The only difference was the same doctor gave them the same diagnosis while touching their foot and they had a 30% outcome of getting better if they were touched during the statement of their diagnosis. 00:42:39.353 --> 00:42:45.672 That's one of the better bedside manner studies that was done to show just the effectiveness of just but it's during the care. 00:42:46.092 --> 00:42:48.809 Yeah, so it's again, it's a separate construct. 00:42:48.809 --> 00:42:50.204 It happens at the same time. 00:42:50.204 --> 00:42:54.085 Right, again, it's a separate construct, it happens at the same time. 00:42:54.085 --> 00:43:07.510 Right, but the you know, if it's, say, a less emergent situation, then yeah, how you interact with somebody happening at the same time as you're providing some kind of technical interface, it's going to have an impact right. 00:43:07.530 --> 00:43:12.684 When you say the bedside manner, that's an interesting one because I understand what you mean by that and I would. 00:43:12.684 --> 00:43:13.505 I would agree. 00:43:13.505 --> 00:43:17.882 But also as a self-employed sole proprietor, absolutely Right. 00:43:17.882 --> 00:43:18.722 Who? 00:43:18.722 --> 00:43:19.704 Suddenly? 00:43:19.985 --> 00:43:23.373 The bedside manner, you know, it is a fine balance. 00:43:23.373 --> 00:43:29.481 There's that thing of if I, if I have poor bedside manner but great outcomes, I'm only I'm going to lose some clients Absolutely. 00:43:29.481 --> 00:43:33.391 If I have a great bedside manner and no outcomes, I'm going to lose some clients absolutely. 00:43:33.391 --> 00:43:35.135 If I have a great bedside manner and no outcomes, I'm gonna lose some clients. 00:43:35.135 --> 00:43:36.157 And those are the places where you go. 00:43:36.157 --> 00:43:36.539 It's all show. 00:43:36.539 --> 00:43:39.106 You walk in and oh my god, this place looks amazing, and then the treatment sucks. 00:43:39.106 --> 00:43:43.679 And then there's the other one where you walk in you're like I don't ever want to get treatment here, but the treatment's amazing. 00:43:43.679 --> 00:43:46.402 It is a tricky thing, so it's interesting when you're like you don't. 00:43:46.402 --> 00:43:51.789 The the whole you know, bedside manner thing is something that you you agree with a little less. 00:43:51.789 --> 00:43:59.427 But then, yet, at the same time, for somebody who's like a self-employed individual, that's like, oh my god, I better be nice because I need to have these people sign a. 00:43:59.648 --> 00:44:07.572 You know, come back for another session well, it's more so that my challenge is the in emergent situations. 00:44:07.572 --> 00:44:11.862 Right, because again, they're separate constructs. 00:44:11.862 --> 00:44:21.306 They they have value, but depending on what we're talking about, or when we're talking about, or the timeframe that we have, technical proficiency is going to beat bedside manner. 00:44:21.766 --> 00:44:25.139 Yeah, the bleeding out individual kind of thing yeah. 00:44:25.900 --> 00:44:31.668 Whereas with respect to a self-employed, schedule-based practitioner. 00:44:31.668 --> 00:44:37.523 If you are a jerk, yes, you're not going to do as well, they happen. 00:44:37.523 --> 00:44:42.465 At the same time, you also have more time exposure between you and that person yeah interact. 00:44:42.827 --> 00:44:52.264 More time to have a positive interaction, more time to have a negative interaction there's a reason everybody loves I mean not everybody, but there's a reason so many people like the show house or bedside manner. 00:44:52.264 --> 00:44:56.193 But it's emergency scenarios, it's life or death scenarios. 00:44:56.193 --> 00:44:59.677 So they're like I don't care if you're a jerk, you made you, you helped me recover. 00:44:59.677 --> 00:45:01.864 You were a dick in the process, but I got better. 00:45:01.864 --> 00:45:06.282 Yeah, but if you had to see them every day for your general pt or p? 00:45:06.282 --> 00:45:11.311 Uh, physician, gp, you'd be a little frustrated yeah, yeah, and again, that's the thing. 00:45:11.411 --> 00:45:18.452 So to acknowledge that they're separate constructs and, depending on context, one becomes more important. 00:45:18.452 --> 00:45:28.032 They can become of equal importance or it's possible under certain circumstances where not maybe nothing is really say physically, mechanically wrong. 00:45:28.032 --> 00:45:36.097 Your bedside manner is going to become more important because you're not going to do anything positive for this person with a medication, with a hands-on therapy. 00:45:36.097 --> 00:45:39.507 You're going to do something more positive by saying, listen, I've examined you. 00:45:39.507 --> 00:45:45.085 Unfortunately, I can't find something that is relating properly to what you're experiencing. 00:45:45.085 --> 00:45:55.693 So if I don't have positive as a term bedside manner, then that's the thing that's most important in that situation. 00:45:55.693 --> 00:46:00.152 So it's the ability to identify when particular skills are more important than others. 00:46:00.152 --> 00:46:06.286 So you know, with respect to you know the team-based care. 00:46:06.306 --> 00:46:20.786 So to kind of

backtrack a little bit, when you're talking about patient-centered care and that team-based care or that integrated approach, the thing that is more likely at play for improved results from that is standardization of approach between many individuals. 00:46:20.786 --> 00:46:29.242 So, whoever, if we do the same thing, like if we're on the same team and we know the process, if I screw up, you can see my screw up and you can tell me. 00:46:29.242 --> 00:46:32.208 If I screw up, I didn't know I was. 00:46:32.208 --> 00:46:40.032 So the standardization of process is the thing that primarily reduces medical error. 00:46:40.032 --> 00:46:51.088 There is not much you can do to an individual to reduce medical error outside of expertise accrued across time with the known commission and correction of error. 00:46:51.088 --> 00:46:54.266 So if you aim at the individual, you have a hard time. 00:46:54.266 --> 00:47:07.940 But if you talk about the thing that would accompany patient centered care being team-based care, the reason you may have a better outcome is because it's people identifying the errors of others, picking up the slack, making the fix right. 00:47:07.940 --> 00:47:14.059 So another term could be diffused computing power right. 00:47:14.079 --> 00:47:14.422 So you've it's. 00:47:14.422 --> 00:47:16.309 Uh another term could be diffused computing power yeah, yeah, you're getting it. 00:47:16.309 --> 00:47:17.054 You're getting a better average. 00:47:17.054 --> 00:47:17.315 Consistently. 00:47:17.315 --> 00:47:17.938 You're getting, or not, better. 00:47:17.938 --> 00:47:19.422 You're getting a better consistency. 00:47:19.923 --> 00:47:21.568 Yeah, uh, there's a guy on instagram. 00:47:21.568 --> 00:47:22.228 I follow his. 00:47:22.228 --> 00:47:24.702 Uh, his big quote is consistently average. 00:47:24.702 --> 00:47:32.730 You know, if you consistently eat well with occasional hiccups, if you consistently move with occasional lazy moves, you will consistently be healthy with occasional hiccups. 00:47:32.730 --> 00:47:36.112 If you consistently move with occasional lazy moves, you will consistently be healthy with occasional bad moments. 00:47:36.454 --> 00:47:41.527 But it's what you, ever you do consistently will be the outcome, and I'm a big fan of that theory. 00:47:41.527 --> 00:47:59.909 Yeah, one of the other things that is interesting when you were talking there with the positive outcomes was if I have a client who comes in and they're you know they're going to be an end of life care or they have a diagnosis that is incurable, and we know that this level of treatment is the best they can get. 00:47:59.909 --> 00:48:02.925 You know the bedside manner. 00:48:02.925 --> 00:48:14.949 Now, like you said, it plays this importance because now it's not about what else can we do for you, it's how can I support you in this place that you are at, and I think that's really valuable. 00:48:14.949 --> 00:48:20.713 I think it's also one of those things where it's tricky for people to understand is when does that happen? 00:48:20.713 --> 00:48:24.210 Because every therapist wants to be the one that helped the client who wasn't getting better. 00:48:24.210 --> 00:48:26.347 We all have the hero complex. 00:48:26.347 --> 00:48:31.329 We all want to be that person and it's really hard to admit we weren't able to do it. 00:48:31.869 --> 00:48:36.202 Yeah, that person. 00:48:36.202 --> 00:48:37.987 Yeah, and it's really hard to admit we weren't able to do it. 00:48:37.987 --> 00:48:41.500 Yeah, the so if, if we take the concept that I put forth of, depending on context, one skill set or one construct is going to matter more. 00:48:41.500 --> 00:48:57.684 So, technically, technical proficiency, emergency right, um, no emergency, no real finding bedside manner, no ability to apply technical proficiency to get desired outcome bedside manner. 00:48:58.588 --> 00:49:07.724 So you're probably going to be referenced in one of my future classes, because I actually teach a class called problem solving in the clinic, a pathway to clinical solutions, and I like that. 00:49:08.224 --> 00:49:23.923 That is something I've taught but I've never used it that succinctly and so I will definitely take this and I will be putting that in the class and you will be referenced because that is an incredibly good way of applying it, like in the moment when someone's in pain their first session. 00:49:23.923 --> 00:49:25.949 They're seeking confidence, they're seeking rapport. 00:49:25.949 --> 00:49:33.784 You want to show them you know what you're doing and long term, you want to make sure they know that you're still there with them doing it. 00:49:33.784 --> 00:49:38.623 And that's the transition from technical skill to bedside manner, even though the two are always present. 00:49:38.623 --> 00:49:49.483 It's the transition and I would see that for most therapists as transition from the treatment protocol let's get you healthy to maintenance, and once they're in the maintenance phase that's the bedside manner. 00:49:49.483 --> 00:49:54.532 Come back and see me if you want to for generalized care, but you actually don't need treatment anymore. 00:49:54.532 --> 00:49:59.949 But then they feel safe knowing okay, if I move and I hurt myself, I have an appointment already, things like that. 00:50:00.010 --> 00:50:16.666 And that's that transition to the next I like that I also have never said it that succinctly, and even to backtrack for myself to say you know, there are times when the technical skill is the most important and that's when there's an identifiable. 00:50:16.666 --> 00:50:26.119 To try to make it more succinct that's when there's an identifiable thing that will respond to technical skill, that's when that's the most important. 00:50:26.119 --> 00:50:32.331 When there is not an identifiable thing that will respond to technical skill, then that's when bedside manner is more important. 00:50:32.331 -->

00:50:37.612 So that could be no finding right or that could be you're going to die. 00:50:38.336 --> 00:50:51.744 There's nothing like it's only a thought, I don't think it's fully fleshed out, but I almost wonder if in nociceptive pain the technical skill would be more important. 00:50:51.744 --> 00:50:56.331 But then at the same time, if somebody comes in and nociceptive pain it's high enough they'd be in a fight flight freeze state. 00:50:56.331 --> 00:51:00.125 Your bedside manner might calm them down and it's good to threat vigilance. 00:51:00.125 --> 00:51:11.409 And then if it's neuropathic pain if you don't know that you're not, but at the same time, like in general neuropathic, neurogenic pain, I wonder if that's where the bedside manner gives that sense of support more. 00:51:11.471 --> 00:51:21.123 and that's just an interesting thought to explore, like that so the the three categories that I'm aware of are nociceptive, so possible or actual, uh, disruption of tissue? 00:51:21.123 --> 00:51:31.010 Yeah, then you have the neurogenic or neuropathic, so no possible or actual damage or challenge to tissue or whatever term no neuropathic. 00:51:31.050 --> 00:51:33.041 There is actually damage to the nervous system. 00:51:33.041 --> 00:51:34.025 That's what I was going say. 00:51:34.106 --> 00:51:35.771 But there's inflammation of the nerve. 00:51:35.771 --> 00:51:38.608 There's an identifiable pathology of nerve. 00:51:38.608 --> 00:51:43.010 Then there is, when both of those are absent, you have nociplastic pain. 00:51:43.179 --> 00:51:44.164 Yeah, nociplastic pain. 00:51:44.701 --> 00:51:45.483 It's more central. 00:51:45.483 --> 00:51:48.367 As far as we can tell, category shows up in 2017. 00:51:48.367 --> 00:52:03.847 We got work to do, right, right, but what I would say is that you can, based on technical skill, if you can identify especially a tissue that has a restriction in its motion capacity, then you and pain persists. 00:52:03.847 --> 00:52:04.527 Report of pain persists. 00:52:04.527 --> 00:52:06.467 It is either, then, likely neuropathic or nociplastic. 00:52:30.003 --> 00:52:36.445 One of the other ones I like for them is that if you can predict it and replicate it, chances are it's nociceptive Not always, but chances are. 00:52:36.445 --> 00:52:48.472 If it's variable and unpredictable, chances are it's neurogenic or neuroplastic and that it's we don't know when and why, and that's usually threat-based systems and perception and habituation and things like that. 00:52:48.472 --> 00:53:05.110 So one of the other things you talked about was the narrowness of the meta-analysis and the cognitive bias when it comes to, you know, doing a paper and coming out with these certain findings. 00:53:05.110 --> 00:53:08.360 Especially, you know, meta-analysis are like looked at as like these really really amazing systematic meta-analysis was done. 00:53:08.360 --> 00:53:13.286 Therefore, nobody can argue my findings, kind of thing like

that, and that's commonly how people talk about it. 00:53:13.286 --> 00:53:15.248 That doesn't mean you can't, it just means that's how people talk about it. 00:53:15.248 --> 00:53:16.679 That doesn't mean you can't, it just means that's how people talk about it. 00:53:16.679 --> 00:53:22.394 So talk to me a little bit about your restrictions or your dislikes or just your theories on meta-analysis. 00:53:23.000 --> 00:53:28.132 Yeah, so it depends on the meta-analysis If you don't intimately know the methodology. 00:53:28.132 --> 00:53:31.224 So usually you're going to see systematic or scoping reviews. 00:53:31.224 --> 00:53:37.844 Right, if you ever see a narrative review, that's just an expert saying I know the literature well here, here and here. 00:53:37.844 --> 00:53:41.913 But scoping and systematic are much more rigid. 00:53:41.913 --> 00:53:52.052 And then there's depending on the particular thing that you're looking at, there will be other acronyms that will be thrown on Like no, it's not coming to mind. 00:53:52.052 --> 00:53:55.630 There's some that I used to know well and would snap out, but I just don't talk about them enough. 00:53:55.630 --> 00:53:58.625 So you have to set up a question. 00:53:58.625 --> 00:54:02.233 You have to have clear inclusion and exclusion criteria. 00:54:02.233 --> 00:54:08.967 Then whatever is left over is your, based on your methods. 00:54:08.967 --> 00:54:13.795 You're saying it's close enough to your question that you will consider it. 00:54:13.795 --> 00:54:19.313 Then you have to have a way to normalize data, to extract and to see what the general thing is. 00:54:19.313 --> 00:54:28.713 Oftentimes, what you're finding is that the state of evidence is poor, so you can make no claim. 00:54:29.880 --> 00:54:48.110 Poor is a generous statement in my opinion, you were very nice to a lot of papers to say poor, because a lot of times it's shit and in the conclusion you often hear them say inconclusive, and people just ignore that part of the conclusions all the time. 00:54:49.273 --> 00:55:03.393 Yeah, so it depends on what you're looking for, but the result of a meta-analysis, while including large amounts of research under some circumstances, depending on what you're looking at, it's still a narrow answer, right? 00:55:03.393 --> 00:55:05.086 It is still a specific question. 00:55:05.760 --> 00:55:10.052 Specific question, specific answer based on what's been done, not based on what's real. 00:55:10.052 --> 00:55:11.804 Based on what's been done. 00:55:11.804 --> 00:55:17.083 So the limitation is what's been previously done, what's been found, what's been included, what's been excluded. 00:55:17.083 --> 00:55:23.949 Right Now you're providing rationale for that, but it doesn't mean that you've found ground truth. 00:55:23.949 --> 00:55:30.646 You have found the general phenomena currently contained in literature. 00:55:30.827 --> 00:55:31.530 You can read. 00:55:31.530 --> 00:55:56.686 It's interesting because for me that's usually one of the reasons why I mean I like meta-analysis, I enjoy reading them, I understand the methodology process, so for me it's an enjoyable process and in part of my blog you know I break that apart for a lot of my readers, but it's one of my favorites are usually task forces or narratives, because first of all, if it's somebody I disagree with, their narrative is going to be really good because it's going against my confirmation bias. 00:55:56.686 --> 00:56:04.612 And usually they're smart, they're usually pretty well educated people to give a narrative that's published because they have to have recognition for that. 00:56:04.612 --> 00:56:11.036 So usually that gives me a good sounding board to say am I completely just giving into my bias? 00:56:11.036 --> 00:56:16.340 Am I in an echo chamber or is this a good thing, giving into my bias? 00:56:16.340 --> 00:56:17.543 Am I in an echo chamber or is this a good thing? 00:56:17.563 --> 00:56:18.907 The other one for the task force is again it's a similar concept. 00:56:18.907 --> 00:56:20.108 Is it's not a research paper? 00:56:20.108 --> 00:56:27.733 It's a whole bunch of people who are considered experts in their field giving their generalized philosophy on the best practice. 00:56:27.733 --> 00:56:37.682 And you know, it's like with the at the CMC and the AMC when they do the panel, like with the at the cmc and the amc when they do the panel. 00:56:37.682 --> 00:56:45.724 You know, the panel, a panel discussion of expert speaking, is probably my favorite thing to do as an educator and speaker, but it's also my favorite thing to hear because you don't get. 00:56:47.909 --> 00:56:49.652 This is what the research says, do it, xyz. 00:56:49.652 --> 00:56:51.802 You get, this is what we think. 00:56:51.802 --> 00:56:58.346 And you get a lot of people who had experience who say, in general, we agree, we disagree, but this is what we would come up to. 00:56:58.346 --> 00:57:08.942 And that's probably where the most of the good outcomes lie is in, where people with time and experience in the profession, where they all would tend to go what they would tend to do. 00:57:08.942 --> 00:57:14.045 That tends to be a good approach and that's why I like the narratives. 00:57:14.045 --> 00:57:16.126 For me, they're really one of my favorites to pay attention to. 00:57:16.920 --> 00:57:17.782 Depending on topic. 00:57:17.782 --> 00:57:20.849 Narrative reviews are going to make me want to punch somebody in the throat. 00:57:21.592 --> 00:57:21.992 Oh, I don't. 00:57:21.992 --> 00:57:25.849 I'm not saying they don't do that, but that's usually when it's against my beliefs. 00:57:25.849 --> 00:57:26.871 No, it's not that. 00:57:26.871 --> 00:57:28.864 It's that the ability to reproduce. 00:57:28.864 --> 00:57:55.563 It is low right, so the idea with this systematic or scoping review is that if somebody follows your methods, they should get just about the same thing, and then that's why

you have higher confidence that it's probably on the right track, but you have to know the question. 00:57:55.583 --> 00:58:00.487 The other thing so I'm sure I've said this to you the term next thing to talk about. 00:58:00.487 --> 00:58:06.952 So go for it, because it's a mistaken thinking that the person thinking doesn't know they're making. 00:58:06.952 --> 00:58:07.731 So it's not. 00:58:07.731 --> 00:58:11.574 People are acting as if it's something that's easily identifiable by that person, or fixable list. 00:58:11.574 --> 00:58:16.538 It's this fancy list of descriptions of errors. 00:58:16.538 --> 00:58:18.465 They're just errors, right. 00:58:18.465 --> 00:58:20.086 So anchoring bias, right. 00:58:20.086 --> 00:58:22.539 Some cost fallacy, right. 00:58:22.539 --> 00:58:28.288 I already paid $10,000 into this thing, so I'm going to keep going, even if quitting now would make me more money over time, right? 00:58:28.288 --> 00:58:30.005 So it's an error. 00:58:30.005 --> 00:58:33.585 You don't know you're making it, but I can describe it. 00:58:33.585 --> 00:58:38.228 I can see a regular distribution of how often it happens, but you don't know you're making it right. 00:58:38.268 --> 00:59:05.780 So, lisa, lisa barrett feldman talks about that in her book called how emotions are made, um in the prediction error, where, essentially due to she calls it body budgeting, we would know this caloric, caloric efficiency and things like the interoceptive energy, that you're stuck in a loop because it costs less energy calorically to maintain that loop than it does to create a brand new loop, because that's going to consume a lot of energy so learning new things is much more expensive. 00:59:06.242 --> 00:59:07.503 It requires more attention. 00:59:07.503 --> 00:59:19.806 The the basic area that the cognitive bias research came out of was behavioral psych and it was really more about economics and it was the system one and system two thinking. 00:59:19.806 --> 00:59:22.902 That's not necessarily a thing, right? 00:59:22.902 --> 00:59:28.313 The my thesis supervisor and some colleagues have looked at at least in health care. 00:59:28.313 --> 00:59:42.150 One of the things that they find is if you the faster you seem to diagnose something, the more accurate you are, yeah, the primary explanation for that is you know more and you have done more. 00:59:42.150 --> 00:59:46.088 So then that, all of a sudden, is that system one thinking fast, right. 00:59:46.088 --> 00:59:51.009 So it's heuristic based or it's rule of thumb based but the fact that my uh, my students. 00:59:51.048 --> 00:59:56.795 I call it time and experience because a lot of people use the word intuition and I don't think intuition and healthcare matter. 00:59:56.795 --> 01:00:00.346 I don't think you should intuitively give somebody a surgery because you think it's the right thing to do. 01:00:00.346 --> 01:00:11.166 Time and experience has shown you that that's the right thing to do because you've seen it 10,000 times and 10,000 times it's worth, and that's exposure and time and experience. 01:00:11.166 --> 01:00:15.393 But that only comes with time and experience and that's a hard thing to reproduce. 01:00:15.954 --> 01:00:21.764 Yeah, so it depends on whether or not it's more of an implicit or an explicit learning process. 01:00:21.764 --> 01:00:26.643 So the implicit learning processes are slow and difficult to change, so they're probably the highlight of the expert. 01:00:26.643 --> 01:00:30.420 But the problem is the expert learns what not to do. 01:00:30.420 --> 01:00:42.563 So if the answer is in the thing that the expert learned what not to do, the expert will make that error, but they won't know they made that error right, whereas the novice feels like they can't sense anything. 01:00:42.563 --> 01:00:47.362 They don't know what to do, really what they sense everything, like absolutely everything. 01:00:47.362 --> 01:00:49.070 They don't know what not to pay attention to. 01:00:49.492 --> 01:00:51.925 They and they don't know necessarily how to qualify it. 01:00:51.925 --> 01:00:55.117 They, they sense everything, but they don't know where to put it in their brain. 01:00:55.358 --> 01:01:00.480 Yeah, so it's the general error of the novice is the error of interpretation. 01:01:00.480 --> 01:01:04.692 So like a pet peeve in hands-on therapeutics is your hands will wake up. 01:01:04.692 --> 01:01:06.887 I'm like your hands are as awake as they're going to be. 01:01:06.887 --> 01:01:10.070 You just don't think you know what to do with what you're feeling. 01:01:15.960 --> 01:01:19.333 And that's an interesting one, because in most things that involve hands, like I do, I do a lot of construction and stuff like that. 01:01:19.333 --> 01:01:44.108 And in the beginning, or like, let's say, you're a rock climber both my brothers are rock climbers, um, one of them a very, very well known rock climber and in the beginning, when you're off time, it hurts your hands, you're ripping your skin off, but over time you desensitize as you blister, and over time what happens is you get a better feel for where the grips are, but you actually perceive less because it's you're trying not to be in pain, and I would actually say it's the same. 01:01:44.108 --> 01:01:48.784 In the beginning, as a novice hands-on practitioner, you probably perceive more. 01:01:48.784 --> 01:01:57.661 You just don't know how to categorize it and that, as you age, you probably perceive less because you categorize it prior to touch. 01:01:57.661 --> 01:02:00.086 Oh, I see what that piece of skin looks like. 01:02:00.086 --> 01:02:05.393 The weeness of your elbow is going to feel like this, so you don't pay attention to what it actively feels like. 01:02:05.393 --> 01:02:09.306 You predict what it feels like and so you categorize it prior to touch. 01:02:09.586 --> 01:02:15.063 Yeah, and that's the challenge, right, it makes some things faster but it makes

another error more likely. 01:02:16.164 --> 01:02:19.789 It's not absolutely exceptionally likely, but if it's going to happen, that's where it's going to happen. 01:02:19.949 --> 01:02:37.068 Right, it's going to be in the thing you learned not to do, the thing you habituated out of, to leverage the benefit of the novice and the benefit of the expert, right? 01:02:37.068 --> 01:02:38.291 So the benefit of the novice is to be more procedural, right? 01:02:38.291 --> 01:02:45.239 Okay, I got to do this step and I would tend to apply that to assessment, right, obviously, motion-based assessment, or yield to pressure of soft tissues. 01:02:45.239 --> 01:03:00.496 It's like check, find an area that seems like it's not moving, zoom in, check that more, figure out where you want to apply most, and then the expert is going to learn which tests don't really matter, unless I found nothing with the normal tests, right? 01:03:00.496 --> 01:03:04.849 So it's like, ok, I threw these ones out but I found nothing, so I'll bring this one in, right? 01:03:04.849 --> 01:03:18.472 So the idea on the sensory side, or the idea on the body budget side, or the idea on the statistical prediction, so you can have different terms, but, like you know, humans are really good Bayesians, right? 01:03:18.472 --> 01:03:23.349 So, like Bayesian distribution, certain types of distribution I've heard people? 01:03:23.369 --> 01:03:24.231 Yeah, I don't know. 01:03:24.231 --> 01:03:25.313 I'm not familiar with Bayesian. 01:03:26.240 --> 01:03:32.192 It's Bayes B-A-Y-E-S, it's just kind of like a statistical general prediction type of model. 01:03:32.192 --> 01:03:50.552 People are currently arguing that one of the reasons that large language models seem to be able to pass the basic Turing test to make it feel like you're having a conversation with a human is because most human speech is statistical prediction. 01:03:50.552 --> 01:03:52.481 Yeah, so I've. 01:03:52.481 --> 01:04:03.117 And now the thing is that I hear some people maybe over-indexing and suggesting that it gives us really clear things about cognitive architecture. 01:04:03.117 --> 01:04:05.086 I'm like, ah, you might be overdoing it there. 01:04:05.086 --> 01:04:10.867 I've heard somebody argue, and again, so this is where I can differentiate that between a bias and a preference. 01:04:11.568 --> 01:04:18.786 Okay, so I hear somebody say what it means about human thought and human cognition to have an LLM seem like a human. 01:04:18.786 --> 01:04:23.643 Is that we're really doing statistical predictive models, which is fair enough? 01:04:23.643 --> 01:04:31.027 I think that's fair, but that it also means that cognition and memory is really auto-regressive, so we just regenerate the memory. 01:04:31.027 --> 01:04:31.949 We don't actually remember it. 01:04:31.949 --> 01:04:33.340 Right, and it means this, that and the other. 01:04:33.340 --> 01:04:50.965 Then I hear somebody else suggest that, yes, most human conversation is essentially a statistical prediction model, but what that means is that we do have intelligence, but we use it as a last-ditch resort Because it's energy-consuming. 01:04:51.360 --> 01:04:56.353 If you haven't read Lisa Vera Tillman's book how Emotional is Great, it's probably the book I recommend the most. 01:04:56.659 --> 01:04:58.706 I think I was the one who introduced you to her. 01:04:59.369 --> 01:05:01.347 Oh my God, it's such a good book, I love it. 01:05:01.347 --> 01:05:09.572 But again it comes down to that it consumes energy to do something new as opposed to just habituation. 01:05:09.572 --> 01:05:13.411 Habituation is rote, it's instinctive, it's reflex. 01:05:41.019 --> 01:05:46.434 It's low consumption of energy and, as much as we don't like togressive it's, you know it's almost like you have no free will is because my personal experience in conversation is that under many circumstances I'm hard to predict, so I'm like it's one. 01:05:46.454 --> 01:05:59.153 It's one of the fun things about talking with you, though, yeah, it is one of the more entertaining things that's why I had you try to repeat that sentence or say it differently is because you use wording and phrasing that is not foreign language to us. 01:05:59.153 --> 01:06:03.940 It's just not language that's used frequently, so it takes people a second to go wait, what did he say? 01:06:03.940 --> 01:06:05.065 That sounded. 01:06:05.065 --> 01:06:05.927 That sounded. 01:06:05.927 --> 01:06:08.657 I mean you could just like when you said LLM. 01:06:08.657 --> 01:06:20.847 A lot of people are going to be sitting here still scratching their head about what that means not knowing it means language learning model, and so it's just one of those things where, yeah, if it's not predicted, it consumes energy to pay attention. 01:06:20.847 --> 01:06:24.670 It's like listening to music in the background versus actively listening to the music. 01:06:25.599 --> 01:06:42.344 Hey, listen I yeah, I have to go, but I want to summarize here quickly because to me this was a great conversation and and you know, we'll see each other in Saskatoon and I'm sure we'll talk more. 01:06:42.344 --> 01:07:14.184 So for me, I really like how you talked about evidence-based medicine and that its core model is designed for people who are doing care that is possibly more threatening, with a higher risk level, and I think that that takes a level of responsibility and stress away from the evidence-based model for manual therapists, because we are, you know, in general it is, as manual therapy becomes more and more insurance billed and more and more recognized in healthcare, we are being pushed down that road through protocols, and protocols technically follow evidence-based practices. 01:07:14.184 --> 01:07:18.190 So I really like that you said that, because I think that's a core thing. 01:07:18.711 --> 01:08:10.903 I also really enjoy the idea that when somebody comes into your care,

instead of passively offering treatment and just doing what you always do, pay attention as a therapist to what am I doing right now, versus between my technical skill set and my rapport skill set, my bedside manner skill set, what is the individual in front of me requiring and I think that leads into, you know, a lot of trauma informed care, because I've really changed my practice for the past few years to really integrate trauma informed care, and I have quite a few clients who, when they come in now we like they come in with a problem, which is their original reason for seeing me, and it may be five sessions before we address the problem, because they're wanting safety based on their trauma and that's the bedside manner first, even though I may be able to help them with their shoulder dysfunction or their neck dysfunction or whatever it is. 01:08:11.445 --> 01:08:14.713 And so I read those two takeaways from this conversation for me. 01:08:14.713 --> 01:08:27.506 I really hope the leaders pay reader, listeners, pay attention, because to me those are two really important things that you brought up that I think have great value and could help people be more effective with their clients but also long lasting in their careers. 01:08:28.248 --> 01:08:38.546 I think the thing that I'd like to try to wrap up with is to say, if you're looking to build a base of evidence, you don't necessarily need to use the term EBM or EBP. 01:08:38.546 --> 01:08:49.033 What you want to do is try to figure out what needs, what questions would be valuable to answer with some kind of experiment or research or whatever you want to do. 01:08:49.033 --> 01:09:09.692 So let's figure out maybe a set of questions that we can start answering for hands-on therapy based on actual need, as opposed to import something that looks sexy from somebody else I'm not going to fit into somebody else's clothes, right, so let's build our own, but based on sound principles from a scientific model. 01:09:09.692 --> 01:09:17.162 Make sure that we're using medical ethics, so the terms being non-maleficence, beneficence, autonomy and justice. 01:09:18.204 --> 01:09:21.152 As far as patient-centered care, I would just I would dissolve that. 01:09:21.152 --> 01:09:25.413 That's autonomy, because you need to pay attention to that person. 01:09:25.413 --> 01:09:31.296 No two people are going to respond the same to any intervention, so you have to pay attention to that person. 01:09:31.296 --> 01:09:32.521 That's a technical skill set. 01:09:32.521 --> 01:09:48.162 You up-regulate what they seem to be responding better to, you downregulate what's given them problems, and then you don't necessarily need terms like evidence based medicine, terms like patient centered care, terms like trauma informed care you get to the bedrock terms. 01:09:48.162 --> 01:09:50.889 They say I need to pay attention to how you're responding. 01:09:50.889 --> 01:09:52.972 I have a goal, you have a goal. 01:09:52.972 --> 01:09:54.877 Let's do our best to how you're responding. 01:09:54.877 --> 01:09:55.498 I have a goal, you have a goal. 01:09:55.498 --> 01:09:55.958 Let's do our best. 01:09:55.958 --> 01:09:56.180 I love it. 01:09:57.362 --> 01:09:57.823 Awesome. 01:09:57.823 --> 01:09:59.988 That's hey. 01:09:59.988 --> 01:10:01.591 Man Cheers to that. 01:10:01.591 --> 01:10:02.292 That is awesome. 01:10:02.292 --> 01:10:06.569 I'm going to share a drink with you in Saskatoon at the Canadian Massage Conference. 01:10:07.039 --> 01:10:10.070 Sam will be there with us, and then anything Do we have two separate cups for that? 01:10:10.091 --> 01:10:10.271 drink. 01:10:10.271 --> 01:10:13.207 Yeah, we definitely have two separate cups Okay. 01:10:13.207 --> 01:10:23.141 I for that drink, yeah, we definitely have two separate cups Glasses, by the way, and then anything else. 01:10:23.141 --> 01:10:23.905 I mean you run a school in Toronto. 01:10:23.905 --> 01:10:25.756 Do you want to talk anybody about your stuff so that my listeners can possibly follow you? 01:10:25.756 --> 01:10:26.940 Pay attention to some of the stuff you're doing. 01:10:27.582 --> 01:10:31.761 So the school that I run is for people with prior healthcare background or training. 01:10:31.761 --> 01:10:38.365 It is the osteopathic Lyceum, so we train people who again have a background to become osteopathic practitioners. 01:10:38.365 --> 01:10:40.270 It's in Hamilton, ontario. 01:10:40.270 --> 01:10:44.207 I do have a YouTube channel, which is where you'll find most of my stuff. 01:10:44.207 --> 01:10:47.180 I do have what I call a podcast, but I focus more on the video. 01:10:47.180 --> 01:10:48.963 It's the Osteopathic Lyceum podcast. 01:10:48.963 --> 01:10:51.065 Osteopathic Lyceum YouTube channel. 01:10:51.065 --> 01:10:56.432 I do have an Instagram account same name Osteopathic Lyceum but I don't do much with it. 01:10:56.432 --> 01:10:57.635 Maybe I will, I don't know. 01:10:57.635 --> 01:10:58.695 I'm doing enough. 01:11:00.640 --> 01:11:04.889 And I'll make sure to link those in the podcast on Buzzsprout. 01:11:04.889 --> 01:11:06.072 Awesome. 01:11:06.072 --> 01:11:07.413 Thanks so much, Sam. 01:11:07.413 --> 01:11:08.060 I had a great day. 01:11:08.541 --> 01:11:09.402 All right, my pleasure man. 01:11:09.402 --> 01:11:10.002 Good talking to you. 01:11:10.002 --> 01:11:10.462 We'll see you soon.