Jared:
Welcome to The Shoulder Physio Podcast, a podcast dedicated to exploring meaningful topics in musculoskeletal healthcare. I'm your host Jared Powell. Before we begin, the primary purpose of this podcast is to educate and inform the views expressed in this podcast by myself and any guests are information only do not constitute professional advice and are general in nature. If you act on the basis of any podcast episode, you should obtain specific advice am a qualified health professional before proceeding
Jared:
Today's guest is Rani Lill Anjum. Rani is a philosopher from Norway. Interested in the philosophy of causation Rani is also the head honcho of the cause health project, whose mission is to improve how causal evidence is understood, produced and used in health science and practice for the benefit of individual patients through transdisciplinary, research, education, and communication. If you are not aware of the cause health project, please visit their website and download their free, a repeat free ebook, and it will have a transformative effect on and your clinical practice. I promise you, in this episode, I ask Rani, do we need philosophy in health science, we explore common schools of philosophical thought and how they might relate to health science. We also chat about complexity and emergence and how this differs from reductionism, which has been the dominant philosophy in medicine and health science for a, at least the past century. This conversation was originally recorded in August, 2021 for my YouTube show on the shoulders of giants without any further delay I bring to you Rani Lill Anjum. We are live here today with philosopher Rani Lill Anjum. Hello, and welcome to the show. Rani.
Rani:
Thank you. It's so nice to be invited, Jared.
Jared:
Yeah. Great. So, so you are over in Norway, right? And it's, it's early in the morning there on a Monday. So I apologize.
Rani:
It's Monday. Yeah, Monday eight o'clock yeah. In the morning. So what
Jared:
What a great way to start the week talking about some philosophy. So, Hey, say, Rani, do you mind giving me and our audience a little bit of an introduction to you who you are, what do you do? I mentioned that you are a philosopher now. That's cool. Cause you're the first philosopher on our show. So, so yeah. Rani, who are you and, and what do you do?
Rani:
Oh, I work at something that's called Norwegian university of life science, which is located just a bit south of us. And we don't have a philosophy department, but everyone in Norway, they have to take a course in philosophy in their bachelor. So that's why any university in Norway, they need to have at least one philosopher, maybe two or more just to teach every single student some philosophy. And when I took philosophy back in the old days, it was a full semester, but now it's a 10 credit course with a third of a semester. So I teach that. And also in Norway, if you do a PhD, you have to take a philosophy of science class with research ethics. So that's also one thing that one would normally have to teach. So, yeah. So I think because of that, I have been doing a lot of philosophy for non philosophers also in my research.
Rani:
Hmm. So me and my colleague OC, we started a center that we called center for applied philosophy of science at our university where we tried to engage students, staff, people who work here and people who are here in questions, some common interest. So that's why we say applied philosophy science because we do the kinda philosophy science that people notice so that people can, that it actually makes difference way of practicing and understanding your own discipline, whether or not you think in this or that way. So it's, I think the last few years I've been doing main philosophy medicine, but that's cause of my research. So I'm part of well I started this course health project a t-shirt there
Jared:
You go. Represent. Yeah.
Rani:
So it's where we work on the concept of Cause. So what does it mean that something is causing effect and so it's a causation and complexity and evidence in the health sciences. So we want to, we want to look at what counts as evidence in medicine and health sciences how do we generate that type of evidence? Why is there these kind of tensions in the disciplines over what is good evidence? And we want to say that there's no there's no one given answer in that because in philosophy of science, what we have seen is that these things, they change all the time and the evidence based framework, I mean, it was introduced in the nineties. It hasn't always been there. It's not like a broad given thing and that's the same with all types of scientific evidence. So that's the kinda thing that we wanna to convey to people.
Jared:
Yeah. Oh, fabulous. Great, great intro. So I'll, I'll give a shout out to your book actually, which the rethinking causality book that you released through cause health, do you have it? Do you have it on you? Yeah. You go good.
Rani:
Such a, I have it. Cause I've been home office thing.
Jared:
So I, I honestly, anybody who listens to this conversation or watches this conversation today, download it, read it, it will change your clinical practice. So I highly commend you and your whole team for releasing it. It's been very influential. So all that hard work that you've done is actually making an impact. And it's not just some ethereal philosophy that doesn't really impact the world as you were talking about. It really does make a difference. So thank you for that. And then also this book here getting causes from powers which came out in 2011, was it?
Rani:
Yeah.
Jared:
Was a is a really good book. Yeah. Go get your hands on that. So Rani philosophy and medicine or healthcare intuitively it might not seem like a, a real tight fit in a lot of people's opinion because here I'm, I'm from Australia and I did zero philosophy in all of my education. So I maybe did a little bit at high school. I certainly did zero in my university training and I did like a sports science degree. And then I did a business degree and then I did a physiotherapy degree and I was not introduced to a single for philosopher. Obviously I knew names like Aristotle and Socrates and all of these ancient Greek fellows, but did zero philosophy, which seems to be different from a Scandinavian experience. Anyway. So I graduated and the only reason why I ended up getting into philosophy almost 10 years later was when I started my PhD.
Jared:
And I, I got exposed to terms like on ology and a epistemology and, and realism and subjectivism, and I was like, what the hell? I was completely dumbfounded and, and lost. So a subject on that, would've been fantastic. Anyway. So this is an experience that I think is very similar in Australia and the UK and even in the us as well, where we we're quite, we have a quite naive grasp on. So I guess I'm gonna, I'm gonna prompt you to, to try and give a defense of why philosophy perhaps should be included in healthcare. Why, why is it important that we know about philosophy of science and Cal Popp or Thomas co or, or Hume or, or something like this? What, why does dualism matter? Why does reductionism matter? Why do all of these concepts matter in healthcare?
Rani:
Yeah, so I don't think it's weird that you, that you were not exposed to philosophy. And I think if you, if you start reading philosophy on your own, you might not necessarily find the things that are relevant. And a lot of philosophy written today is pH is talking to philosophers. And even as a philosopher, it's hard for me to understand what they're talking about because they just start in the middle of a debate and they might all be Aristotelians, but they have a very specific debate that they're arguing over some details. And so unless you're given some kind of broader context into the debate, it's actually really hard. So that's why it's good to look at the classics instead. Like some of the people you mentioned, they have not written within, I mean, they have written for a broader audience. It seems because you can start from scratch and you can get something out to it.
Rani:
So I would want to say that in, in health sciences, in medical practice, in medicine, there's a lot of philosophy. There's a lot of philosophy that is there taken for granted. Yeah. And that's the thing about philosophy. You should never take it for granted. So when you talk about ontology, so that's the theory of what's the reality like, and many people have heard about dualism. So the mind body divide that the cult in introduced, and that is a philosophical assumption and it's a philosophical assumption that has been challenged. So when all of healthcare is divided into mental care and physical care, it's already just accepting it as a fact. And what you, you mentioned also Thomas Coleman and paradigms. And what he's saying is that these types of scientific paradigms is like frameworks that are philosophical also in nature, but they are frameworks where scientists, they just work within them accepting.
Rani:
This is the theory. That is true. So for instance, Newton's laws or evolutionary biology or biomedicine, we just assume these theories are true. And then we try to solve problems within those. So if this theory is true, what things are still the knowledge gaps? Yeah. So for instance, in the, in physiotherapy pain is still in knowledge gap, but you try to solve it within the framework. Yeah. So that's why it's saying that doing this type of science, which he calls normal science is just a puzzle solving thing. You just accept everything that your authorities and your science education has taught you and your playing alone. Then he says, sometimes there are problems that don't seem to be possible to solve within that framework, within that paradigm. And then you get the crisis and then people start questioning philosophical assumptions, because then they say, well, it seems like dualism, there seems like we're assuming dualism here.
Rani:
And we shouldn't. And then people say, what do you mean dualism? Are you talking? Of course there's a separation between mind and body. What's the alternative. And then, well, there is always an alternative. It's just that some people have to identify the philosophical, what we have started calling a philosophical bias, because then you can see what are the option. For instance, there is a big change in philosophy from an ontology that has always been looking at things and their properties to looking at processes and saying that well, what are these things? Anyway, it seems like that the world consists of things. It's just a result of lots of processes. And what we need to look at instead is the interactions and these open systems that these processes work within, and then the entities and the things are just bad way to describe reality. So, so this is something that people haven't thought on questioning very much. And you can say the same in medicine. If you look at like things and organs and individuals, but you don't look at the processes and what kind of things influence. Yeah. You know, you might miss out on the fact, we are all open systems that interact with infinite number of external and internal factors. You see.
Jared:
Totally.
Rani:
So those are philosophical. Those are philosophical debates,
Jared:
A hundred percent a quote is coming to mind. And I dunno who said it, so forgive me, you might know, but it goes a along the lines of, there's no such thing as philosophy, free science, just sort of science, that's done ignorant of philosophy. And that's kind of the same thing as medicine, right? Like, and I guess we can say in, in healthcare and medicine and physiotherapy, we're kind of in this biomedical paradigm and it's inarguable that that's still the dominant paradigm. People argue on Twitter, that the pendulum is swinging too far the other way. And that's absurd. I'm doing a, a systematic review at the moment about mechanisms in, in in shoulder pain, for example. And it's still overwhelmingly the majority of, of, of research is, is dedicated towards, by, or physical or, or observational things that we can see. And we attribute somebody's pain experience to those physical findings anyway.
Jared:
So, so the paradigm that we're, that we're operating in at the moment is this is this biomedical paradigm. And even if we're not familiar with it, our normal science or our normal day to day operations are, are within this paradigm. That's a, that's a very cuon thing. So I love how you sort of set that up that, you know, philosophy is underpinning or overarching sort of everything that we do, we might just not be aware of it. So, so if we do become aware of it, or if we are initiated into philosophy a little bit more, do you think that would change or sort of open our, our eyes a little bit more as to how we are practicing and perhaps make our practice a little bit better and you, and you, I guess this is kind of what the work that you're doing here with tael, you kind of, you're looking at the system as it is, and you're offering an alternative. Is that, is that kind of the objective of where you're at with cause health?
Rani:
Yeah, I think that's a really good a description because I mean, people can agree or not agree with the kind of framework that we offer. I mean, that's just, that's just one philosophical framework and there's no evidence ever that it's going to be the correct one. So it's more about getting people to understand, okay, first of all, where do the assumptions of evidence-based medicine and biomedical approaches come from philosophically? Because they, they are philosophical. It's not something you can prove by science. You can focus on it and you will find something, but you're not go going to like, make evident that there's nothing else worth focusing on. So what we're trying to do is to say that, well, if you are aware of the underlying assumptions of your own discipline and your own practice, and you also are aware of what the alternatives are, then you can, you can make reflective choice.
Rani:
Then you can say, okay, actually I am a reductionist. I do believe that the only thing that exists is actually material. I do believe that if something is mental, it's something that is produced by the physical. And actually I believe that one day we will find out everything we need to know on the level. I understand what are the limitations? I see the challenges I see, blah, blah, blah. But this is actually what I believe in. And then yeah, made the sense. If you just say that other people are idiots, because they don't believe the same, you have missed out. And I see, I see a lot of arrogance from science. I see a lot of arrogance academia in general, but I see a lot of arrogance from people who just accept what they learned. And they are just making fun of everyone who believes something else, irrespective of whether they know anything about the weaknesses of the theories that they were taught.
Rani:
Because if, than the people who came up with the theories, they were aware of the weaknesses of the theory. But the people who just learn about them from second, third forehand knowledge transfer, they don't learn about the weaknesses. They just learn about it. And this is what Paul fo up and says, he says, sign has become a religion. We teach this, we teach it like the Bible, but it's not the Bible. It's actually a lot of things going on in science that is quite dynamic where you need to be challenged and you need to and you come up with new things and you make new discoveries. Exactly because you are challenged and someone pointed out the weakness of your position and it, it forces you to look again. And, and if we don't keep that kind of humility, we are not really scientific.
Rani:
We're just like very dogmatic. That's not a good way forward. So yeah, I might be quite passionate about my own philosophical perspective. I write about it everywhere and people might say, I try to indoctrinate, but I would always say that people should make up their own minds about what they actually believe is the right philosophical framework, but doing it by looking at positives and negatives. Mm it's. The same thing with the, you see the, the debates on vaccines. You can tell people their idiots because they are worried about side effects of vaccines. Just because if you look at the numbers, it's a very small risk, but for some individuals, the risk might be really high. Mm. And maybe it's not irrational to worry about it, but if you worry about it, just from a numbers' point of view, it looks really silly. Mm. So I just think we have to be aware of what are we talking about? Which level are we talking about?
Jared:
Yeah. I, I kind of love your account of, of science there. It's not this omniscient, all knowing sort of power, right. That exists in the world and is, is revealing all its answers to us. It's, it's a process, it's a method it's being wrong and learning from your mistakes. And, and I, I like to think of science as kind of like, perhaps getting nearer to a truth by like doing things or engaging in research or engaging in experiments that like, perhaps rule out some really wrong things that might leave some things that might be a little bit more right. For a period of time until they're proved wrong. Right. and that's kind of like, you know, you look at Einstein progressing from Newton who progressed from Galileo or something like, like that, it's, it's a, you kind of perhaps getting nearer, but Einstein in another century will perhaps probably be proved wrong or in two centuries or three centuries or at some time in the future.
Jared:
So I, I kind of like to think about it like that. It's, it's dynamic. It's, it's not static. It's always changing and it's, it doesn't always have the answers, right. Like to be scientific is to be uncertain. And I think, I think that's a really important point, which kind of, I wanna get into now RH your theory of, of disposition. I, I can't explain disposition simply, so I'm gonna, I'm gonna leave it to you. I'm, I'm sure you can do it far more succinctly and articulate that I can. So disposition is a, a theory of causation. Am I, am I right in saying that,
Rani:
Well, the way that we do it. So in that book, you were mentioning getting courses from powers that we were wrote in 2011, even mum, Fred and I, we tried to say, okay, there is an oncology of these positions. So there is a way to think about reality in terms of this that come from Aristotle, because Aristotle has said that everything in the world has potentials and these potentials, they might actualize themselves. And this is how things happen in the world. So he was looking at the living world. He was looking at, for instance, you have Anot and it can turn into a tree. Isn't that weird? What is it? So, so how is it possible for enough to become something else? And he was talking about four cause of things or four conditions for things to change. He said there has to be something there in the knot that gives it the potential, for instance.
Rani:
And in that potential, there's also like a goal that it reaches towards. So there's this natural goal in reality, that he also had a lot of weird things to say about physics. He would say that this 10 it's, it falls down because it seeks home because it wants to go home to where it belongs timely to the earth. Yeah. So, but, but he, he was interested in change and that was different from many philosophers who cared about what is here and now. And they wanted things. They wanted choose to be something that was something that was the most true and in eternal non-changing things. And he said, actually, if we want to find the most universal principle of reality, it is that everything changes. That's the thing that doesn't change is that everything changes. And why does this happen? So he was talking about this.
Rani:
So for instance, we know that wood can burn. We know that it can give hit, but it doesn't necessarily do it now. So it's kinda a potential that, that is hidden there now. So how does it actually actualize this potential? It needs to come in contact with something else. It needs to have some external interactors. It has has to some, it has to have some internal properties. So there has to be many things working together. So I mean, the reason why we are interested in this, in, in medicine is because when you ask whether a treatment works, you might just ask whether or not in randomized control trials, it is shown that when people get this medication, this treatment, they recover. And that's an observation, it's a bit like saying, okay, so does would heat or burn. And then you see, okay, when we put it under certain condition, does it burn and does, does it give heat?
Rani:
But we might want to say that, well, if a treatment works, it's because it has some intrinsic properties that makes it work, but it only works. If it comes in interaction with something else, the person who gets it. And if that person doesn't have the right properties or dispositional properties, it won't be what we call a manifestation partner for the effect. So for instance, if you take a paracetamol, but you don't have the disposition or the or the receptor, then you are not going to benefit from it. Mm. So I think that happens in all types of treatment. Some people benefit, some people don't, if you only look at whether in enough people benefit, then you might not learn about the dispositions of the things like what other things it can do. So for instance, paracetamol doesn't only have an effect. It also has side effects, and you might not be a manifestation partner for the effect, but you might be a manifestation partner for the side effects.
Rani:
Mm. So what, what Aristo would say is that the world consists of all these types of potentials and humans. For instance, we have a lot of different potentials. We also have political potentials for instance, and moral. So on the disposition list, ontology, you might even say that what something is, is almost given by its dispositions, what it can do. So you see, it's kind of, that's why it's called causal powers like humans. For instance, we think that humans have free will. So that is something we think sets aside humans from other things. If we think that also dogs have free, will, we might have to reconsider for instance, the way we treat dogs or the way we treat other animals, if we think they have free will. But if we think there's something about our rationality that makes us feel, then we could say, well, actually this is a good way to classify humans is to say, we have rationality and we have free will.
Rani:
And this is something Aris often would do for instance. So what we have tried to do is to say, if we assume the world is like this, that there's a lot of potentials that give things causal powers, then how would we think about cause and effect relationships in science? For instance, if we think that there are all these potentials that we cannot observe here and now, and that might be different, given which things they interact with, how would we go about studying it? And what we're doing in the course health project is is to challenge the way that we scientifically think of cause cause and effect relationships. By saying that what we're doing now is, is a very different type of philosophy that comes from David hum. We would say David Hu's understanding of causation because he didn like these potentials because he was what we called an empiricist and he only believed what we can observe here.
Rani:
And now, so for instance, if you say that the glass is fragile, he would say, how do you know it's fragile? It's only because you have seen similar things break in the past because you cannot know that you haven't this positional property until it manifests itself. So it's a bit like saying, you don't know if this not is going to, if it has a potential to turn into a tree before you see the tree. Sure. So you need proof, you need evidence. Yep. And if you just go around saying, oh, this as a dis dispositional property or potential to become something else, then you're justing. And that's the same thing about if you think a treatment works, you need to see the evidence. You need to see it happening many, many, many times because the evidence is just seeing it happening repeatedly under some certain conditions.
Rani:
So, so one thing that we said about causation from a disposition list perspective, is that okay? It is something that is potentially there, which already a problem. If you're an empiricist because you're not going to believe it. And, but it's also something that only manifests in contact with other things. So you don't know until it starts interacting with other things. And it also means that you should be a bit precaution about what you think you know about something, because you might have seen a treatment work in relatively healthy people with only one problem. But then someone comes and they get a really bad outcome from it or it doesn't work on them. And you think, well, well that's just one person. It doesn't matter. But from a disposition least perspective, you should be interested because you should think, what is it about this person that is so different from everyone else that makes them interact in a different way?
Rani:
What kind of properties do they have that makes this thing behave in a different way? That's really interesting. And that's where we can potentially learn something new. So we're saying that actually caus should be unique because it happens here and now in this unique interaction and he would say, how can you say that it's causation. Because if you want to say, it's causation, you need to see repeated incidents of the same type of conditions. And if you never have the same conditions, then you not even begin to talk about it. And then we also say that this GI, this means that causation is extremely sensitive to context and, and even Fu said the same cause should give the same effect under the same conditions. And then people who work with, you know, work in, in the clinic, they say, but everyone is different. So we never have the same conditions.
Rani:
So what should we do? Mm. So the only thing you can do, you can make an average patient, you can make a normal patient, or you could just focus on you know, you can, you can have a randomization and then you can see, you say, well, the same cause gives the same effect, even in these different situations, which is even better evidence of causation, you might think. But, but from a disposition, this perspective, actually that, that causation is sensitive to context just means that every process can be contracted by other things. So it could be something that contracts, whether or not you get an effect. So for instance, you strike a match, it should light, but not if it's raining or it's very winded. And, and that's from a disposition, this perspective, I think that could be a really good indication that you have a causation.
Jared:
Yeah. I, I, I, I love so much of what you said and every, the whole time you were talking, I was thinking of examples, clinical examples in my head, and there's so many. So, so in, in, in physiotherapy, the, the high, almost the highest form of evidence unequivocally that we have to help people in pain is with exercise. And that's, it's, it's pretty uncontroversial, albeit there's modest effect sizes with exercise. So it's not, it's not curing everybody far from it. In fact, and the disposition ontology, there can probably account or explain that, right? So not, not everybody based on their context or based on their individual belief system or how they've been raised or the culture that they're in is going to respond the exact same way to doing a squat because they have back pain, right. Versus somebody else is actually grown up in the gym is confident in the gym, wants to look strong, wants to be robust in inverted com is it they're gonna respond very difficult to somebody else.
Jared:
Who's not been exposed to that form of culture or exercise culture before. So that, that contextual is a really key point. And the same thing goes for the causation of pain as well. Oh, shoulder pain, for example, may emerge in one person. And, and their, their wide emerged in that person could be completely different from another person. But what we've been trained in this biomedical paradigm, what we were taught and are still getting taught is that we need to look for structural compromise in the tends. And then that is going to be as responsible for pain arising in that individual, or there's some sort of movement fault, or they've got poor posture and that universally leads to the onset of pain. And we're seeing that it's, it's far more complex than that. So I, I sort of love how you set that up in that contextual manner, that makes, that makes a lot more sense.
Jared:
I've, I've sort of as a bit of a tangent been reading a lot of Carlo Ravelli recently have you, have you come across much of his work? So he's a he's a physicist that is, is, he's almost interested in the exact same thing that you are with disposition, but he applies it to quantum mechanics. So sort of, he's got a relational interpretation of quantum mechanics. Anyway, it's, it's exactly what you're describing for disposition. So go check him out. And he is got some beautiful little books that are like poetry. He's a, he's a fabulous writer as well. Anyway, Rani we could probably talk for hours. I just wanna quickly go into another question, but I'm just conscious of keeping you too long on the concept of emergence. So emergence is a hugely popular topic right now in, in healthcare. And I know it's been popular in, or not popular, but talked about in philosophy for a, for a hell of a lot longer. So what's your sense of, of what emergence is and how can we describe emergence? Is there a consensus definition or is it a controversial topic? Where are we at with emergence? And then once you sort of set it up, I'm gonna try and apply it to pain as, as best I can.
Rani:
Well, so emergence, I have been working a bit on emergence and it's not an easy concept. That's all to navigate in, I mean, in philosophy it seems like there are so many working definitions of what it means, but I would like to have a concept of emergence that would give you some kind of distinct. So you could say that looking for instance, from a dispositions perspective, you could say the whole can have dispositions that none of its parts have. So for instance, free will. So a person can have free will, but if you try to locate it in one of its parts, you can try to say, is it a brain that has free? Will, is it like your heart? Is it your, is it your lungs? You're not gonna find it. I mean, some people might wanna say it's in the brain and they might be actually reductionist or saying, at least that you wouldn't, you wouldn't have free will if you didn't have a brain, for instance.
Rani:
So, but you could also say for instance, that a society is an emergent thing, it's an emergent hole that consists of things that are not society. So for instance I think toucher, or attacher said that there's no such thing as society, just individuals and the whole point about the society is that it's something else. And you might even say something more than just the individuals in the society. So I think when it comes to this kind of consciousness one would say that consciousness is an phenomena, and we try to understand these emergent phenomena. They are a problem because if we believe in the big bang, we know that from that assumption that there wasn't life before there was only life, less chemicals, then life emerged from lifeless. How was that even possible? That's why we think for sure reduction is ISRU because we think of course, something that is life can be produced from something that is known life and consciousness is something that emerges from something that doesn't have consciousness.
Rani:
So we know that for instance a flower is a living thing, but we don't believe it has consciousness. Language is another emergent matter that we believe you need consciousness to, to have. So it's, it's these dispositions or these potentials that emerge at what we might call a higher level because it's a higher level, cause it's a whole related to its parts. So, I mean, I know that I consist themselves and they have life there's life in the cells, but I also know that the cells, they have particles and atom that don't have life. And it's a very typical idea in, in in chemistry for instance, is to think that well, biochemistry could be reduced to chemistry and then some people have challenged that and said, no, I don't think biochemistry could ever be reduced to chemistry. And, and that would be maybe an argument real in emergence.
Rani:
So real ontological emergence, something that is not just surprising, but it's actually a new thing in the world. So the way that we talk about emergence Steven Mumford, and I, we talk about it in a quite radical sense that not many people agree with, because we say that the hole is an emergent hole. If it means that it's parts. So it only exists because its parts are interacting and actually changing each other. So the parts that were there before they emerge into something else in their causal interaction, so that if that would stop, it's not like they would go back to just becoming the normal parts that they were. So for instance, when you and I interact, we change each other. And that's what makes society a society. Cause we are not the same when we interact together as we are in isolation.
Rani:
I mean, try to place someone in prison. They're not going to be themselves. Yeah. As they were a normal being in society. So, so the interactions on our theory are crucial. So we actually call it the causal transformative model where we say that the emergent hole, it happens because of a real change going on. But then we also talk about something called the emergence. So we thought we should coin that term because then we could write the paper called emergence and emergence. And it sounds like you just have emergence twice. But the emergence would mean that the higher level thing can then change its part. So for instance, you now have consciousness and you can get education. You can read about how it's healthy to exercise and you can start exercising. And that actually changes something on the lower level in you.
Rani:
So you can change something on cellular level. Mm. So you make your own body more healthy because the higher level influences the law. And, and, and that is something that many people who believe in emergence, they wouldn't believe that because they're not really homeless, they're more reductionist. They would think biochemistry is dependent on, on the lower level, but we're actually saying, no, you could have this top down causation, there should be real change happening from the higher level to the lower level. So it means you also change when you get education, you change when you read something and you want to, to change something in you. So it, and I think that's, that's quite powerful because it means that our interactions are not just, it's not just to be nice. It's actually something that's costly. Powerful.
Jared:
Yeah. That's, that's a bit mind blowing actually. So there's like sort of, there's, there's bottom up and top down, emergence, deep emergence happening all the time in a state of flux. And we're constantly changing and you're not the same as who you were five minutes ago. And you're not the same as, as who you're gonna be in five minutes time. It's, it's it's a bit it's bit psychologically. Yeah.
Rani:
Because some people have been looking at genes to, to explain in behavior. So they have been looking for genes for criminality, you know, even genes for homelessness, just to avoid saying these are social matters, but wouldn't it be great if we were just genetically determined to be totally criminals. But we also know that crime is something that depends on which society or in, I mean, if I'm driving a car in Saudi Arabia, I might be arrested, but not here in, or, but just being a woman in the wrong society. And, and and then they looked before that they looked at brain structure and they tried to figure out why people were aggressive for instance. And they looked at brain structure and they saw, oh no, Reese, this the wonder this person is aggressive. Look at these brain structures. But then you might say like, this guy, Steve rose, he wrote a book called biochemistry.
Rani:
And he said, if we think of cause and effect, it might actually be that the more times you are angry, the more your neurons will go in a certain path. So it changes your brain. So the brain structure is actually an effect of behavior and your behavior might be an effect of your interactions. I mean, imagine being married to a psychopath, you're going to be angry a lot. And if that can change your brain and today we actually believe it can change your, your BI to be in a traumatic relationship then. I mean, yeah, you would find physical evidence that look like it's the cause of explanation, but we need to be, we need to at least ask whether this is the cause or whether it's the effect. So that's why I think this emergence and emergence quite important.
Jared:
Yeah. It sounds like a bit of a, a tangled web which is the messy reality of reality. Isn't it? It's not, it's not, we don't have this beautiful Newtonian understanding of cause and effect and we can map it all out and it's all beautiful. Yeah, that's, that's not really how reality works, although it's kind of how we're set up to think though. Aren't we as human beings, we do like to see things simply and coherently. It makes sense to us, we've got a world view and how dare you, you violate my worldview like this vaccination debate that's going on right now, you know, depending on the information that you're exposed to and what you, what your experience has been with healthcare or, or vaccinations in the past, you're gonna have a different opinion on it. And that's, that's totally fine. But if we just bring it back to pain for a moment, and then, and we're gonna, we're gonna finish up is pain.
Jared:
The, the best theory that we have of pain at the moment is that it's an emergent experience when a human, an organism interacts with their environment and, and a really popular theory is that pain may emerge when danger predominates more than safety. And then that, that pain may emerge in that particular situation. That's, that's a theory, but it's probably one of the most, most popular theories, which is, which is far different from what we're still being taught at many, many universities all around the world is that pain is simply a bottom up sensation where pain occurs in the periphery, the signal's transmitted to the brain, and this is dualism. And then brain goes, Hey, that's painful. Let's move my foot away from that. And it's just, it's been comprehensively disproven. We know that pain is a, a weird experience. It's not, it's not a linear experience. You know, a five centimeter cut doesn't hurt five times more is a one centimeter cut. You know, we know that with, with paper cuts, there's not this input doesn't equal output. So it's far more complex and, and nuanced than that. So is that, is that, is that kind of make sense to you from a philosophical perspective, is that is vaguely correct from, from your perspective?
Rani:
So I think I think really, if you look at the empirical evidence, looking at all the clinicians meeting patients, and these patients have been experienced chronic pain, and you can't locate it in, in the part that is painful, that would be something that is as close as possible to challenging a philosophical assumption, isn't it, or at least the scientific. So it, it looks like the experience of pain that we see and that you see in the clinic is really a counter example to the, to this reductionist understanding. And, and I think it is true that pain is, I mean, it's still being taught in this biomedical way, but, but what you're describing, I was a bit in interested in that because what you describe as the new theory is also bio medical, because you say you put it into an an evolutionary biology setting saying that we are, we have evolved to try to move away from pain and to, to experience threats in certain ways.
Rani:
And, and that actually shows that it's not necessarily the biomedical model that is problematic. And this is something that two of our call cells, collaborators Lynn gets, and on Kenya have been saying for a very long time. Now they have been saying that it's not the biomedical model. That is the, a problem. It's our concept of biology that is far too narrow. We just focus on molecular biology. We don't focus on biology as something that is widely contextual, because you can think of ecology instead, and you can think of the way we have evolved and the way that how we, and you have the fight or flight instinct, for instance. And, and if you over a long time experience stress, or what they call alostatic load you know, that can actually harm you on a very deep cellular level, which can again, cause a lot of chronic conditions, including cancer and heart disease.
Rani:
And so, so stress, it, it's such a, it's so weird that stress has been thought of as a bit of a mystery. I think it's because stress is an interactive social thing. It's not like it doesn't come from the inside. So why I can you get pain in your back from having bad colleagues? It just seems. Cause if you don't believe in top down causation, this is a mystery. It's just like the placebo effect. The placebo effect is just a mystery because how can thinking that you're going to get better actually physically make you better. It's such a mystery. And yet we accepted so much that every single treatment has to be controlled from placebo because we know the placebo effect is more effective than most treatments. And it's just so, so I think this it's the biological understanding that we need to really improve.
Rani:
And, and in cost we say, we want an ecological turn in medicine. We want to see ecology with its complex adaptive systems theory. It's wildly sensitivity, open systems. You know, you know, you can change the tiny thing in the context and everything changes in the prediction. And we also know it's unpredictable and there's a lot of uncertainties, but that's how it is with, with people as well and their health. It's not like you can say, okay, let's assume you're in a lab where you only have three factors influencing you. This is definitely what's going to happen. That's not the reality of the clinic. And it's not the reality that we live in, but it's the way that science it's, it's very easy scientifically to sync within models, but the models are only models. So we need to have the humility to think, okay, the real knowledge is in the discrepancy between our models and reality.
Rani:
That's where we need to understand things, not just saying, oh, the model should work. And if it didn't work, then you're a hopeless case. Or you're just few enough to not having to be very important. I mean, it's not even true because when treatment works, it might just work for 30%. So it means 70% of the people you're not helping, but you still have to give that treatment to everyone. Cause it's what works for most. But working for most just means better than other treatments. But if it's 70%, then maybe the treatment that works for 15% is what you should to this person. Yeah. So it's just, so that's what I don't like about this evidence based framework. It pretends that when something works, it works for 99 point 90% of the population, but that's not even true. Not even when we have applied your inclusion exclusion criteria. Yeah.
Jared:
Yeah, totally. It's what, what would getting at in, in shoulder pain just quickly is, is my area of interest is no, no matter what we do surgery, injections, physiotherapy doing nothing, for example, natural history, any of those things. And all of those things do work in about two thirds of people. And then in one third of people, nothing seems to work for right. And we're, and we're flumed and we're like, well I don't wanna deal with those one third of people. It must be in their head, right. Let's refer them to the psychologist. That's the dualist approach. But the, but the funny thing is all of those interventions, which I mentioned at the beginning, surgery, injections, physiotherapy, natural history, manual therapy, massage, anything, they all kind of work exactly the same. And this is the, and this is the crazy thing to me.
Jared:
And this is not the crazy thing. This is the interesting thing to me. And this is where the disposition concept becomes really, really, really cool to me is that all of those things probably have a similar, or might, might have a similar underlying feature or, or how all of those things work might suddenly be different in, in each person, but they all might have some form of mechanism which helps them on their, on their way to recovery. Or are we just like keeping them occupied well, while nature fixes them or are we playing with their confidence? Are we playing with their motivation, you know, blah, blah, blah, blah, blah. Or is it a placebo, as you mentioned a moment ago? So this is, this is why I just, I don't think we're gonna answer a question ever. I think you would vindicate my opinion here that there's like a, gonna be a universal superior treatment for all people with back pain or for all people with shoulder pain.
Jared:
And, and I, this is why I loved your book so much. Cause it kind of gave me a theoretical rationale or an ontology in which I can base all of these suspicions and limitations that I've found in my clinical practice by, by pursuing, you know, this, this universal or this treatment algorithm, that's gonna help 99% of the people that walk through my door and I just have to do this treatment. And if that treatment didn't work, that person didn't do their exercises or, or they didn't listen to me properly, it's their fault. You know? So this is why I kind of, I love where you're coming from. So I guess you can respond to that, but I'm just trying to say thank you for, for all the work that you're doing. And if you have any closing comments,
Rani:
Well, that's, it's, it's really nice to hear that philosophical work can actually give people something it's we never dream that call self project would be welcome so much in in the profession. So that's amazing. One thing that I have been very keen to promote in the call self project is that we should understand the real cause of things before we try to fix them. So if we only fix symptoms we're not really helping enough. And this is something that many people in, in this book is also arguing. And they're talking about people who experienced a lot of trauma and terrible things, for instance, growing up. And, but no one has ever been interested in those aspects because they only focus on what is here now, for instance, you're overweight. So you should exercise or you have pain here or you have cancer, so we should fix that or you have headache.
Rani:
And and let's try to remove it, but, but it, it does matter from a disposition or this point of view, what's the real cause of the pain. So if you have neck pain and it's caused by the way that you move and your worries and everything, because of traumas, you have experience, then you can give people a lot of pain killers, but at some point you need to also address those traumas. And, and it's, it's really a tragedy that some people that, you know, many people that am talks about, they have been in the healthcare system and yet got all the evidence based treatment that could be given for decades. But the only thing they experience is to get more and more chronic conditions because they get side effects from the treatments that are not really helping them. And no one has ever asked them.
Rani:
What happened to you when you first got into the healthcare system? So it's just not the focus. I think, even in, because what she's writing about in our book is that this is a person who's been in the psychiatry ward, and no one even cared about talking about those things there either because cognitive behavioral therapy, it's a lot about focusing on how you respond to your problems and, and in situation and how you, how we might change the way you think about and the way you react so that you can cope better. But at some point you need to tell people that will to experience is just not okay, and it's not your fault. And, and, and we need to process that because people who are obese, yeah, you might want them to eat less, but if they used to have anorexia, yeah.
Rani:
Then just eating less is not going to help their pain and it's not going to make them improve. So I, I was also, I was also invited to talk to people who work in these rehabilitation teams. And they said, the people who come to us are the people who are not getting help in the standard ways. And they usually need more time and they need to have an interdisciplinary team of people. But, but today with this, the, the way that care should be standardized and time efficient cost efficient, it means that we're not getting to the real courses. We're not helping people in the process that they need to improve because you see them, you diagnose them and you start with interventions that you are told to use, but there might be a whole bunch of things you need to do before they are even ready to start rehabilitate, you know, before they can start exercise, they have to realize that my life has totally changed after an accident. I'm not ready to start doing squats.
Jared:
You're like, honestly, my first two or three years as a, as a physio, if someone would tell me that they had, you know, they weren't coping with their pain, or they perhaps going down the pathway of depression or they were feeling anxious about it, or perhaps there was some sort of moment, some sort of childhood trauma or something. I was so uncomfortable in facing these truths. So I'll just go, oh, okay. That's interesting. Write it down, you know, and then move on to the things that I felt comfortable with. Right. Which was giving the exercise and doing the test. Oh, that does that hurt. Yes. That means you have this. And so where you're right. It's a, it's a system level issue where us healthcare profess and I, I will, I will say this about most doctors as well. Cause I have many friends that are are surgeons and GPS, et cetera, et cetera.
Jared:
They're just not really trained to really deal with those things, you know? And because they are in a system that's 15 minute appointments or 30 minute appointments, you know, and then at the end, I've gotta do so I've gotta provide an action because we are, you know, we are predisposed to action. I think as, as healthcare practitioners, we've gotta do something we've gotta diagnose, we have to treat, we have to send them away with a plan. And we're so quick to get to that, that little plan that we've got, that we were to lot that we kind of, we lose the story, we lose the narrative, we lose hearing this individual issues, actually, just trying to tell them your story and in our head, we're just like, this is just noise. We're just trying to, to get to the end of the consultation. So that, that really resonates with me. And I'm sure that will resonate with a lot of listen as well. Okay. Just finally, Rani, I've got one more question. What book are you reading right now? Or what TV show are you watching? And it can be a really cheesy TV show. That's totally fine.
Rani:
Well, I watch a lot of television and I don't read that many books. So I've been watching new Amsterdam on Netflix, which is a hospital series. It's fantastic. It's very cheesy. Yeah. But what has good about it is like some, I mean, it focuses on some structural problems in healthcare. That's true. And it gives some very easy solutions that if anything was possible, why on earth do this? So I, I can relate because in the hospital, for instance, there's a lot of you know, there can, there can be a lot of damages and you have compensation bobs to pay people off when they have been damaged. But those budgets are not the same budgets that you, you get to buy equipment that might prevent the damages, you know, so, so it's structural change. Structural problems are everywhere. The way that the way that money is allocated. So I, I really like that about the show I watch also the good fight in H which is have you heard of the good wife?
Jared:
Yes, yes.
Rani:
Serious. Yeah, this is enough. OK. So it's I really like that
Jared:
A good fight.
Rani:
I, I watch the good fight. Okay. Yeah. When it comes to books and I, we just signed the contract with, to writes science books. So now I'm reading up on competition to see what other philosophy of science books are out there. So one that I'm really looking forward to chat. So for instance, of course, I need to look at the very short introduction of some because is supposed to be quite small, but then it's also this Lisa, but who wrote the philosophy of science, which structured in a very different way from most other books. I'm very excited about that. Cool. But yeah. I'm not reading any novels at
Jared:
Time. What's the timeline for your philosophy of science book? When can we expect that? No pressure.
Rani:
So we will try to write it. We will try to finish it before the summer. So then it's up to the publisher. So maybe the Christmas after that. So maybe we don't know half year, but yeah. So it's, it's going to be a book on philosophical bias in science. So it'll be our take on philosophy science.
Jared:
Actually. I, I can't wait for that. Yeah. I'm gonna have to get you back on to have a conversation when that drops, when that hits the market. Because I I'm looking for more of these books. I I've read pop, I've read. I've read fire. I've read. Lakatos I've read all these guys. I can't wait to, it's
Rani:
A book that I would recommend though. Which is Nancy Carri and Jeremy hard. It's a book called evidence based policy, a practical guide to doing it better. And what they talk about is not just in, in medicine, they just say it's something wrong with the evidence based policy idea that you test something and you see that it works here, but what reasons do you have to think it works outside of the place where you tested it? And it's a book that's written in a very simple way, so anyone can it, and it's not very thick, very thin book. So Cartright and Hardy evidence based policy. Beautiful. Very, yes.
Jared:
Thank you. Thank you for the recommendation. And also thank you for chatting with me for the, for the better part of an hour. I really appreciate your time and your intellect and your opinions on things. I really, I, I really think you're doing meaningful work and you're, you're really having an impact. So, so thank you very much, Rani.
Rani:
Oh, thanks a lot for inviting me.
Jared:
Thank you for listening to this episode of the shoulder physio podcast with Rani Lil Andrew. If you want more information about today's episode, check out our show notes at www dot shoulder, physio.com. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The shoulder physio podcast would like to acknowledge that this episode was recorded from the lands of the Yu, Uganda people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning and working from every day. I pay my respects to elders past, present and emerging and celebrate the diversity of Aboriginal and Torres Strait Islander people, bulls and their ongoing cultures and connections to the lands and waters of Australia.
