Jared Powell:
Today's guest is Ben Cormack. Ben is a musculoskeletal therapist out of the UK. Ben is one half of the Better Clinician Project alongside Adam Meakins. Ben also has an education company called Core Kinetic, which provides clinical education to musculoskeletal therapists all around the world. Ben often plays the chief provocateur on the internet, challenging ideas on all fronts and without regard to status, I believe criticism is healthy and necessary in order to fundamentally progress knowledge. Therefore, I love what Ben does. I got bent on the podcast to chat about the bio psychosocial or BPS model. The BPS model is off quoted and referenced in research, but what it actually is is obscure. Is it a model? Is it a framework? Is it a heuristic? Is it a philosophy or something else? What does it mean? What does it stand for and how do we use it?
Jared Powell:
Ben clarifies what it is, what it isn't, how to use it. And we also have some fun along the way before we get into the nitty gritty of this conversation, I've actually just returned from Sydney where I ran my first shoulder workshop. In a couple of years, I had a great time talking all things, shoulders and judging from the feedback. So did the course attendees. My next workshop is coming up in just a couple of weeks in Melbourne on the 4th of June. And there are still a couple of tickets remaining for this event. The course offers a complete distillation of the evidence base for shoulder pain management, equipping you with up to date, knowledge, techniques, and clinical reasoning skills that are clinically actionable. If this is something you are interested in, check the show notes for more information, without any further delay. I bring to you my conversation with Ben Cormack. All right, here we are with Ben Cormack, the, the infamous or famous Ben Cormack. Not, not sure which one you are these days, mate, everybody, everybody knows who you are these days. You are, you are vocal and I love it. You've got your opinions and you're not afraid to say to them. So thanks very much for getting up early, over there in the UK to have a chat with me.
Ben Cormack:
Yeah, no thanks for inviting me. And it's great to be included amongst some of the, you know, fantastic guests and yourself that, that you've had on previously.
Jared Powell:
Thanks mate. Yeah, it's it's always good to be able to, through the wonders of the internet, talk to people all around the world. So for, for the three people who, who don't know who you are, Ben, just give them a brief synopsis of who you are as a person, what you do professionally and what you like to do recreationally.
Ben Cormack:
Yeah, yeah. So my background originally is what's called sports therapy in the UK. I am, I do a number of different things, actually, what I, I do like to keep it interesting. So I do bits of clinical work still, maybe 10, 15 hours a week on a busy week. I run something called the better clinician project with another very shy and retiring gentleman at a kins. And then also I have my own kind of educational company called core kinetic, which is really just, you know, reaching out and, and, you know, trying to get some of the, some of the things that interest me out there into the public and see if that interests them as well. So, so I like to keep it pretty varied professionally something I've always enjoyed doing what do I do recreationally now? That's that? That's a great question. That's the real insight into the man, isn't it? so, you know, I'm, I'm a pretty active person. I enjoy, you know, going to the gym, doing my boxing. That's one of the big things that, that I enjoy both little bits of coaching and, and doing that. And then just, you know, spending time with my family and trying not to think about kind of MSK physio type of things, as much as possible, but that never happens.
Jared Powell:
yeah, it's a passion, isn't it? On boxing quickly, AJ and, and fury, is it ever going to go ahead?
Ben Cormack:
Well, this is the classic, isn't it? You know, it's the classic money and, and TV networks and you know, this guy and this guy, and in terms of, you know, the promoters and all those kind of things. So I think it's probably too big not to happen because who doesn't want that money. Right. You know, there's, there's a lot of money there when it happens and how it happens. You know, we don't look at Tyson and Lewis as a great example. They didn't meet until I think it was maybe the early 2000, 2002. I can't remember, but it was certainly when they both weren't in their prime, so it will happen. When does it happen? That's the
Jared Powell:
Question. It was the same with Mayweather and Paar talked about you've 15 years. Right. And Paar wasn't Paar and it was a shame. Yeah, yeah,
Ben Cormack:
Yeah. There you go. There you go.
Jared Powell:
So Ben let's, let's get onto the actual stuff, mate. Let's let's get on. Oh, that wasn't
Ben Cormack:
It.
Jared Powell:
That's well, we could have it now. I do wanna pick your brains about boxing, but we'll leave that for off air. I'm sure that's boring for others. Yeah, yeah. Yeah. I wanna talk to you about, yeah. The bio psychosocial model as proposed by George Engel. You, you are, you're kinda renowned for having an interest in this area and I'm ki I'm interested as into how this became an area of interest view in because there's lots of things to be interested in, in musculoskeletal physiotherapy or musculoskeletal medicine. Why did the biopsychosocial model stand out to you as something to investigate and to analyze
Ben Cormack:
Now? That's a great question. That's a great question. I really like that. Well, firstly, you know, I, I think it's certainly something that's not just me, it's certainly built in prominence over the last five or 10 years. You know, there's lots of papers that come out that say buy a psychosocial, this, or buy a psychosocial that I think the thing that really interested me is what it actually says. You know, what, what actually the main cut and thrust of, of what George general was trying to say. And that's this idea of humanism within helping people, this idea of the person as a person. And actually, I think there's a bit of a selfish reason behind my interest. And that's because that side of it has probably always resonated with me more than some of the more technical anatomical, these type of things. So I'm probably much better at dealing with people than I am at finding bony landmarks.
Ben Cormack:
Right. So, so from that sense, it's something that says to me, ah, this kind of fits with who I am, how I like to practice. What I think is important, what fits my style, if that makes sense. So there's a bit of a bias in there, but you know, I, I, I think that I believe in personality and character and connection and relationship, you know, that's the way that I like to live my life, my values, my friends, my family. And I think that those things really, really resonate with me as a person. So, you know, as I said before, I'm much better at that than than many other things. And I probably hold that as a higher importance than many other things that I've learned before. Like what you do with these, or, you know, how much neurotransmitters are floating around in your brain or, or these type of things. So it's probably you know, in some ways, a little, a little selfish in that, that it just resonates with me rather than like a higher scientific reasoning type of
Jared Powell:
Thing. That's cool. That's, that's how interests emerge. Don't they? Yeah. So you sort of found something within it that, that you agreed with there wasn't some epiphany some moment when you were treating someone with a tight UL in their lower back and you go, there's gotta be something more to this
Ben Cormack:
. Well, I'm sure I've had, I dunno if I'd call them epiphanies, it's more like, I really, haven't got a clue what's going on here. There's gotta be something else going on, but there was this moment, that's the sunset in IBI. And I was looking, no, that's a lie, but it sounded good. Right. So there was never an epiphany, you know, it's like all these things, I think that they grow on you, you know, it's a bit like mold. They probably grow a little slowly along the way and, and you raise your interest. And, and the other thing was that I kind of kept seeing this word and it meant different to the other people that were writing it. So I'd read a paper that was like the biopsy psychosocial approach to exercise or this or that or the other. And I actually thought this doesn't sound like what this other guy was talking about when it comes to the bio psychosocial model. You know, I don't really feel like these things are one and the same. And that probably leads to me being a bit VO, vocal, or as we say in the UK a bit mouthy about kind of, you know, my thoughts in this area, cuz it was like, hang on a minute. That doesn't feel right. That doesn't sound right. That's missing the point. And you know, I don't wanna be that Dick who points out the point, but I do like to point out the point
Jared Powell:
It needs to be done. It needs to be done and you're, you're always there to do it. Ben. It's good. thanks. You keep, you keep me honest. I always think about you actually when I'm like writing stuff and I'm like, what will Ben say to this? So it's good. Keep it going. Ben, Ben can tell me what the bio psychosocial model is. Can we define it? And mate, what is it? Is it a philosophy? Is it a theory? Is it an ideology? Is it an algorithm? Is it a framework? Is it a heuristic? What is
Ben Cormack:
It? It's all of those things actually. And I've got a little quote from Engel because he, he, he said this and I think it's important. And, and as I was saying to Jared off air I've got a paper coming out with Peter Stillwell and Joe Gibson looking at this exact question, what did Engel say? And that's kind of, you know, the premise of the paper that, that we are right. Or have written and now it's going through the process. So this is what Engle said. He said a bio psychosocial model is proposed that provides a blueprint for research, a framework for teaching and a design for action in the real world of healthcare. So it's kind of all of the above, right? So when people say it's, it, it it's, you know, models, it's not a model, it's a framework. Well actually Engel uses model and framework in the same sentence.
Jared Powell:
Ben Cormack:
Do you see what I'm saying? So I don't actually, I don't feel Engel was there to say, this is how you do it. This is what it's all about. So I think it's much more a philosophy or a theory now people who've worked, you know on this since then, there's a, there's a great paper by barrel Corio from 2004 and, and that, that's exactly what they call it. They call it a philosophy of care. Right. So, so again, it's not a, it's not a, I don't like the, the word blueprint cuz blueprint to me sounds like it's, you know, a design, it sets out. Yeah. But certainly I like the idea of philosophy because it's, for me, it's about how do I approach the process of working with a person? So what's in my mind before I sit down like today, about 10 o'clock, I've got a patient and before I switch on my computer, fire up, zoom, get into it.
Ben Cormack:
You know, I'm gonna be thinking, what, what do I want them to feel? What do I want them to think? How do I want them to go away and say, you know, what was that like for me? So in terms of that, that is our philosophy. And our philosophy is just thinking, isn't it really, you know, we can get very, very technical with philosophy and talk about, you know, old German guys and some old Greek dude and all these other things. But it's very essence. Philosophy is just thinking, right? So our personal philosophy and I'm big on defining personal philosophy because I think it guides us. Doesn't it, it's our own kind of guide in the dark if you like. And so for me, it it's, it, it, I like that philosophy of care because it's saying, what do I want from this encounter for the other person?
Ben Cormack:
Not what do I want for me? What do I want for the other person involved in this? So philosophy, you know, a philosophy sits quite nicely with me. Now, someone else might say it's a framework or heuristic or a model, but I think Engle was really quite loose with this. You know, as that sentence showed, it was kind of a bit of everything. Yeah. He wanted you to have that thought in, in his mind when you worked with a patient, if you are looking to research something, he wants that thought in your mind to say, you know, how does this fit into that? And, and, and so, you know, philosophy fits quite nicely for me. Now, the problem with that is that then it throws up all these interpretations, doesn't it? Mm. And then people critique the interpretations and it all gets into a game of Chinese whispers. And I think it that's, what's happened with the biopsychosocial model a little bit is we've twisted it and turned it a little bit to suit what we are trying to do. And I act, this is gonna be controversial. I actually think the bio psychosocial model, it might even evade scientific exploration sometimes in it's in its essence. Does that make sense?
Jared Powell:
It does in its very controversial. Ben.
Ben Cormack:
Yeah. But what, but you know, his ideas were he, he, he, he thought he, he didn't like the ideas of dualism, right? So the mind and the body. And if you think about what the what's happened to the biopsychosocial model is it's been as, as Peter Stillwell would say, it's been trichotomy so instantly it's being reduced into these bits and then we reduce it into an outcome measure or we reduce it into a very discreet research question. And sometimes I think that, that, that it, it evades our current scientific methods to be able in. It's very essence. And so sometimes I think these two things are butt up against each other that actually that we are trying to research this by using an entirely different philosophy.
Jared Powell:
That's interesting. Okay. So, so let, so we're kind of, yeah. We're getting into like into ontology and epistemology here, right? Because, so, so perhaps using a biopsychosocial model is, is our view of reality as it were in, in healthcare and that's, that's, that's an ontology. So we just gotta accept that. Yeah. And then within that we can study things around it without governing or, or sort of being the overarching framework for how we acquire knowledge and that's, that's a epistemology anyway. I don't think we're gonna get anywhere down that line of inquiry. No, it's
Ben Cormack:
I don't wanna,
Jared Powell:
No, that's neither good mate. Good. Let's let's, let's shelve that. We'll leave that for the philosophers. But, but it's fascinating that you think that perhaps the bio psychosocial model might evade science and, and what I assume you mean by that is by, you know, quantitative science and
Ben Cormack:
Etcetera. Yeah. Yeah. It doesn't evade science, but does it, does it fit into our scientific philosophy and our scientific process in its very essence? Mm
Jared Powell:
Mm. Yeah. And, and kind of topical at the moment because I I'm hearing some rumblings and I'm reading some rumblings and I'm feeling some rumblings deep within my core band about physiotherapy is a, is it is physiotherapy too complex as a, as a profession. And I don't wanna say an intervention, but you know, how do we measure our effectiveness? Well, not effectiveness, efficacy. Like, can we ever compare physiotherapy perhaps, or even exercise, let's say exercise to a placebo. Does does that evade science? And I know we've kind of had some, some conversations about this on Twitter and a lot of people have got opinions, but can you distill, can you reduce something so complex as exercise because it works by its multidimensional. It works by so many different mechanisms. How can we then get a placebo of that? Because that's, that's quantitative science that you need a placebo controlled trial.
Ben Cormack:
Yeah. So
Jared Powell:
Any thoughts on that? I know it's
Ben Cormack:
Yeah. If we think about kind of like a placebo pill, right? You have an active ingredient don't you, and you know what that active ingredient is because you put it in the pill. So you are testing this active ingredient, you know exactly what it is, right. It's however many milligrams of whatever funky stuff they do. And you are gonna compare that against an inert thing. That's really what a placebo is, isn't it, it's an inerts, it's an inert object. It doesn't exert an influence in traditional chemical sense. Right. Problem with exercises. We haven't got a clue how it works. So what is the active ingredient? What is not the active ingredient? So I don't think we have enough knowledge about the intervention sometimes to actually be able. Does that make sense?
Jared Powell:
Yeah.
Ben Cormack:
And so I think that has to be again, does it come back to philosophy first in the, you know, how do we go about that process of designing that, you know, it's not, if you take an ultrasound machine now, if you look at ultrasound research, they kind of B tune it don't, they, they, they, they tune it differently to create a a dosage that's different. And they have, they have exactly the same process that occurs. Some dude goes like that and then rubs, you know, this ultrasound thing on you. Now, one is working with a precise dosage and one is working with an imprecise dosage of, of whatever ingredient goes into that. And we don't have either a precise or an imprecise dosage. We don't know what the active ingredient is. And I think that that makes it quite tough to be able to do so.
Ben Cormack:
I, I, I think that, you know, we need to know more about how exercise works to be able to ask the next stage of the question. So there's something behind the thing. Does that make sense? Now we can say that. So we could play with different dosages. We could play with different exercises in different areas. Can an exercise ever be a placebo? Is it always got an active ingredient, heart rate, blood flow, basic bio biochemical processes that are a, that are occurring within the body when I move it. So I don't know whether it ever could be described as iner or inactive.
Jared Powell:
I agree. I, I really don't think it's possible given our current understanding of the universe to, to design that. And I think that's interesting because therefore, if we just look at the hierarchy of evidence as almost deifying the randomized control trial. Yeah,
Ben Cormack:
Yeah.
Jared Powell:
We have to kind of rethink that. And that that's interesting. Anyway, when you started talking about evading science, that's what came to mind and we're gonna go down a rabbit hole, but I think, I think we might, again, just shelve that. Cause I do wanna just focus on the biopsychosocial model maker. Right. So stop, stop leading me down the garden path. So
Ben Cormack:
You're the one doing the leading buddy.
Jared Powell:
Agree. Good. The blind leading the blind perhaps. Yeah. So, so let me talk. So let's go back to 1977.
Ben Cormack:
I was born in 78. So 77 was just before me, but that's fine
Jared Powell:
Just, just before your time. But just before my, just before you came into the world, Ben, luckily you came into an earth that the bio psychosocial model had been invented. Otherwise it would've been Barb Barrack. It would've been, would've been the dark ages. So what, what, why did George Engel suggest the biopsy psychosocial model? What, what was it in response to? So the biomedical model was obviously the champion at the time and arguably still is today. Why wasn't that sufficient? Obviously that had led to great advances in medicine and, and health and wellbeing. Why replace
Ben Cormack:
It? Yeah. So I mean, let's, let's not, you know, Engle, he wrote this down, but he certainly wasn't the first person to think about these things. You know, you go back to William Osler in the mid 19th century, you know, so he was saying, listen to your patient, they're telling you the diagnosis, et cetera, et cetera. You know, one of those go, I love those pictures where you have William Osler in black and white looking out saying profound things.
Jared Powell:
So stage.
Ben Cormack:
But yeah, you, you had Osler, you had Soma vice, you had Peabody. You know, these are, there's a really nice timeline there going from the mid 19th century up through the 20th century to the late 20th century. So Engle was only building on what happened before these aren't new thoughts. And I think we could go back to, to whenever and wherever. And someone's saying actually there's a person involved in all of this. Right? And so I there's a video that's floating around of Engle talking in the eighties, maybe late eighties. And you know, he's an old, old guy by then and what he focused on when he was talking about, and this is really important. What he focused on when he was talking about it was this idea of humanism, this idea of it being a person, working with a person. And you know, again, our traditional models of science have focused on that reduction.
Ben Cormack:
Hasn't it? You know, if we talk about pain science, we tend to go into ion channels and, you know, magnesium plugs and, you know, pushing things across cell membranes and which is all fantastic stuff, but it's definitely falling down the hierarchy, right? We're definitely going downwards. If we look at Eng angles, the, the second paper, the the, the, the implementation paper, I think that was 78 or 79, he has this hierarchy and we can go up, we can look at two person medicine. We can look at family. We can look at society. We can look at the God universe, or we can go downwards. And we reduce things down into these smaller, smaller, smaller parts. Now science often goes one way when we are talking about many things, you know, so we do have big epidemiological stuff that does look at things from a higher level or a greater level, rather than a higher level.
Ben Cormack:
You know, a criticism of a hierarchy is its hierarchal. So a flat ontology might be another way to look at it, but you know, really for me, there is some overarching principles. So firstly, you start off with this idea of humanism. So Engle suggested that the biomedical model dehumanized medical practice, that was his terminology, dehumanized medical practice, we have this idea of dualism. So Engle is a psychiatrist and this idea that we are separating mind and body, and you could say that modern approaches with the three balls, you know, the three domains, whatever you wanna call them, that is in its own way of reduction is way of viewing it. And then also this kind of idea of, of, of reductionism. So humanism, reductionism, and then also dualism as well. And I think those are the three things and actually Engel seemed to me always to be a little bit like not everything gum comes back to quantification, you know, that, that he's talking about in his sense, the tests that we, you know, blood gases and, you know, whatever else people send off for which are useful pieces of information.
Ben Cormack:
And they tell us about the disease, the problem that, that, that, that the person has, but there's this other ideas and people like Leventhal with the common sense model have built on this is that we have the disease, which is maybe something you can objectify. And then you can have the illness, which are the things that exist around the disease. Mm. And I think actually, you know, our modern perception of that might sometimes be that we've turned pain into the disease so that, you know, we're objectifying it, we are giving it numbers, et cetera. And, you know, what's more interesting. And if you look prognostically, I think if, you know, look at some of the wonderful prognostic research into, into muscular Al problems, it's nearly, always the psychological stuff that tend it. You know, I don't wanna reduce it, but it tends to be more prognostic than actually the, the, the more objective diagnosis side of things.
Ben Cormack:
Mm. So if you look at a prognostic model rather than a diagnostic model with definitely seeing some of the human factors and the thoughts and the feelings and the behaviors maybe maintain many of these problems more than the actual pathology side of things. So sometimes I think, you know, if we look at it from that sense, that humanism and understanding the person and, and how they behave and their thoughts and their feelings and their experiences do seem to have a profound influence on what happened. So I still think that, you know, even 30, 40 years later, 40, 40 odd years later now we're still only really touching the very, very edges of what angle was talking about.
Jared Powell:
Yeah. Yeah. It was quite ahead of his time really. Wasn't he? So, okay. So it was kind of suggested or proposed at least formally in response to his perceived thoughts on the dehumanization tendency of the biomedical model and also the, the dualistic nature of the, of the biomedical model and the reductionist of the biomedical model. So if we just think about dualism for a moment, so I guess, I assume you are referring to Cartesian dualism here. Yep. As you mentioned a moment ago, separation of the mind in the body, what is, what does that mean for a, for a normal physio? So probably, maybe just equate that to pain. What's maybe what's a dualist interpretation of pain and why, why is that relevant for the biopsy psychosocial model?
Ben Cormack:
Yeah, because I think what it does is it separates this sensation from the person, what I mean by that. So I always have a crappy little saying that I use it. It's kind of, it's not just the way it feels, but the way it makes us feel, if, if that makes sense. So it's not just the sensation. And I think we focus mostly on the sensation. Vas is about sensation. If you think about modern pain science, it mainly focuses on why the stimulus and the sensation don't always equate. So Herman harm. So why, you know, I can amp up, you know, the, the sensation at these multiple points with these multiple mechanisms that occur within my body to do with all these kind of fancy chemicals, your, your indogenous opioids or your NMDA or MDM, a I can't remember right. They do different things I've heard.
Ben Cormack:
So you, you, you know, it's, and I think that's, for me, that's, that's the main factor is that, you know, if we are gonna talk about separating the, and, and even then, you know, the mind and the body, sometimes we talk about the brain or the brain and the mind the same, you know, we are really getting into the philosophical weeds here, but, you know, thoughts and feelings, aren't just predicted by neurotransmitters. If that makes sense, you know, there's a secret source that we haven't quite worked out yet. I think there, so for me really, it's about not just the sensation, not just how much it hurts, but it's also, and maybe there's a term that people use called effect, which is starting to think about the emotion and these kind, and the valence and these type of things. But even then when people talk about effect, you know, they're talking about the unpleasantness, that would be a definition of effect, the unpleasantness of the sensation, but really can we boil down effect into unpleasantness that doesn't work for me, mm-hmm, , you know, that's too simplistic because we have lots of maybe different emotions or feelings that arise, not just according to the sensation, but my experience with the sensation, you know, whether that's with healthcare, whether that's with the media, whether that's with family.
Ben Cormack:
And, and that's the big thing is it's not just how it feels. It's the way it makes me feel. And then moving on from that, and this is where we get into kind of inactive stuff, et cetera, what does it make me do? And then even beyond what does it make me do? What are the affordances and the constraints in my environment, in that, what am I allowed to do? You know, or what, what can I actually do? Yeah. So we, we keep, it's like a Russian dollar, isn't it, we're just building and building and building and building. And I, I, I find that fascinating.
Jared Powell:
Yeah. That's, that's, that's very well said. It's, it's kind of like, what's that quote, there's a quote from Neil Degrassi Tyson that says as, as the area of our knowledge expand. So does the perimeter of our ignorance and it's kind of like that, isn't it, you, you study something, you learn something more and is it more and more questions that are revealed? I
Ben Cormack:
Love that. Yeah. Yeah. Or yeah, more ignorance comes up, but it's, it's more, if, what next, if what, you know, we, we, we are going through more logic gates. Aren't we, we, we are opening up one and then we're coming up against another and yeah. But you know, that, I think that's exactly what we need to be in response to this is rather than think, have we got it figured out, is it solved? It's just a journey and it's just one where you have to accept that you don't know very much, but we are just going a little further each time potentially.
Jared Powell:
Yeah. A hundred percent. And then, and then reduction is when we, we kind of mentioned that that's fairly self-evident in terms of reducing complex things, such as pain, such as experience such as physiotherapy, even down to its constituent components as low and, and as low and as low as you can go. And then, yeah,
Ben Cormack:
A great, a great example of that for me, would be something like a questionnaire is that we are reducing someone's fear, their individual, you know, feelings in response to an action such as a movement or whatever. Can we reduce that into a questionnaire? You know, that, that for me would be a classic way that we've taken the bio the bio psychosocial model. And we've done exactly what we did before. And I described that as looking at the, looking at the bio bio psychosocial through a biomedical lens.
Jared Powell:
Yeah. I've got a quote right here that says the biopsychosocial theory starts by trying to avoid dualism and then in practice becomes dualistic . Yeah.
Jared Powell:
So I guess that kind of leads us that leads us onto here. I, I wanna have a look at, or analyze or investigate or explore whatever word you want to use. Ben, some of the, the criticisms or the critical appraisals that have started to come in thick and fast, actually over the last few years towards the biopsychosocial model, which I guess is a good thing. And it tends to happen as things become more and more popular and more and more entrenched. The biopsychosocial model seems to be mentioned in every single paper that's published these days. And that's, again, that's a good thing, but, but, but there needs to be some analysis of, of, of how it's actually used in practice or how it's interpreted. And you've got some cool stuff to say here. So I think anyway, so the bio psychosocial model, commonly, and, and I think Peter Stillwell and, and, and Catherine Harmon said this commonly fragmented commonly dichotomized or even dichotomized right. It's bio and then psychosocial.
Ben Cormack:
Yeah. They're beautiful. Yeah.
Jared Powell:
And so is this, is this, so these are valid criticisms, right. But is that a problem of the conception? Is that a problem? Is that what angle actually meant, or is our, is that our problem of interpretation? Which is it?
Ben Cormack:
Well, yeah, a again, this forms the, the cut and thrust of the paper that me and Peter have and Joe have written recently is what are the interpretations now? I think there are two main interpretations here. One would be the causation model where we are trying to define causative factors for this person's problem. Is it a bio problem? Is it a psycho problem? Or is it a psychosocial problem? As you pointed out, it often doesn't even get trichotomy it's still , you know, just dichotomized. And, and so it, it's very, it's very much, if you pick up a paper about the biopsychosocial model, and if you re you know, we know an introduction to a paper is saying, why do we need it? What is it all about? Mm-Hmm now how many times have you ever read a good synopsis of that authors philosophy around the biopsychosocial model?
Ben Cormack:
Right. What they usually do is reference another paper. Now it'll say the biopsychosocial model commonly used in practice number four, right. And often that's the actual paper. So, so many people have cited the gap paper, right? 2007. I, I, I can't remember the title. So it's the biopsy cycle of social approach to chronic pain. And, you know, that would, for me fall into more of a causational model where we are looking at factors that have influence this person's pain, right? So what is driving their pain, what is causing their pain? And I think that that is quite a common approach that that's taken this causational model now there, among, and, and that tends to be pain around pain, right. Where it gets a bit interesting is where you start to look at doctoring models. So MD models, where they take much more of this philosophy of care approach.
Ben Cormack:
And that would be another interpretation, which would be this humanistic interpretation. So we see these two major kind of interpretations that, that, that are, that are out there. But I still think if you want to write a paper about the biopsychosocial model, you actually, in your first paragraph have to say what you believe it is, where are you getting these influences from? What, what has, you know, what, what are we talking about here? Because you could be sitting here talking about the biopsychosocial model. I'm sitting here talking about the biosocial model. We're using exactly the same terminology, mainly the word bio psychosocial, but we're talking about two different things. And I think that's fascinating. Cause I see these type of discussions where people are using the same terminology, but that terminology is leading to two different interpretations of what's being discussed. And so I think we need to start to define it, but definitely I think the two major things that we're talking about are this causational model, what is driving this person's pain? What can we identify that, that we can fix? You know, which I would say is a bit of a biomedical perspective. And then there's this other side of it, which is about who is this person? What is their problem? How is it affecting their lives and maybe how we're gonna approach it. So I would say actually the interpretation tends to drive the criticism.
Jared Powell:
Yeah. I agree with that. Let's, let's linger for a moment on this, this notion of causation and use of the biopsychosocial model perhaps to wrongly. And I, I think this is, this is what we fall, Vic. This is the, this is, this is kind of our common mistake in physiotherapy. I'm speaking general here, but I, myself routinely make this mistake. Somebody comes in, I'm trying to be well rounded. I'm trying to be holistic. And in my mind, I think in categories, so I'm kind of like, okay, like what's happening biologically here. When I say biologically, any, everything could be biologically, right. But I'm thinking structurally, I'm thinking cellular, I'm thinking molecular, I'm thinking in a reductionist manner. And then I'm like, what's happening here perhaps in their thoughts, feelings and their beliefs. Right. And then I'm thinking about what are the social determinants of health?
Jared Powell:
What's this, person's person's health literacy, literacy. What's their story. What's their background story there. And, and then I'm thinking of all of these, there's a lot happening, Ben. And then we're meant to, we're meant to what we're meant to ask a couple of questions there. How's your mood? How are you feeling today? Okay, cool. I asked about that, check that box. Where did you grow up? Okay. Check that box. Now let's go and do some exercise. Do you know what I mean? So it's like, it's very hard to get away from this reduction and fragmented interpretation of it. Isn't it?
Ben Cormack:
Yeah. I, I suppose it's, it's about again, we are talking about a process there aren't you, you're talking about your process, your internal process of dealing with a, a patient and part of that is driven by your education, your experiences, and the, the framework that all of us have to go through to get to the point we're at. You know, that was, that, that was, that formed the backbone of your training. Didn't it? So it got, it's almost an inbuilt way of working an autonomic response, maybe in some senses. So, you know, I mean, I haven't got an answer for you because no one else has got one either. And that makes me feel quite good. You know, so certainly that's, I think where it has to fall into a philosophy sometimes rather than, you know, how do we do it in a different way?
Ben Cormack:
I don't know how we should do it in a different way. Mm-Hmm . But I do think that you know, behind the process, there should be a philosophy that guides, you know, should your process change? I don't know. You have a framework to work in, you have a clinic structure, you have a medical structure, you have a legal structure, these are other social constraints that are working on you, but underlying all of that, what is your philosophy of care? And that's why I probably gravitate towards that as well, because I think we are trying to focus on the nuts and the bolts sometimes without focusing on the actual bigger picture of how do I make this constrained process, a better experience for the user.
Jared Powell:
Yeah. Focusing on the finger instead of looking at the moon it's it's, that's, that's a really good point. So I like the second iteration, perhaps probably the wrong word in terms of the humanistic or the, the medical doctor interpretation where it's a philosophy of care you are taking into account that human, or you're trying to step into that individual shoes for a moment in time and try and figure out what their experience is and trying to facilitate and coach and guide and get that person back to life. That's do you think that would be a, a more effective use of the, of the biopsychosocial model perhaps, and when I'm speaking there, it's kind of sounding a bit more effective use. It's all scientific causation kind of stuff. It's hard to, it's hard. It's hard to get away from the vernacular, but is that, is that a more help me out?
Ben Cormack:
You're you are talking about patient centered care, aren't you? And that would be another iteration. And this, again, I can't remember that it was a Scottish guy in, in the mid eighties who who, who started talking about Craig? I can't remember his name. It's too early for me, Jared, but, but he started talking about patient sensitive care. I think his seminal paper is 86, even though I can't remember what his bloody name is, you know, and that is an iteration, a cyclic process of another cycle of the biopsychosocial model. It's an offshoot, you know, that's what patient sensitive care really is, isn't it? You know, that, that's the point. And, and another thing that we've tried to do in our paper that, you know, should see the light of day at some point soon is we've tried to actually say, how do we merge these things together?
Ben Cormack:
You know, how do we actually take this philosophy of care, this humanistic model as we call it, or, and this causational model and try and bring them together. And actually for me, I like the concept of a relationship centered model. So it's not about person or patient. It's actually about two person medicine and two person medicine again, is a core principle of the the biopsychosocial model and patient centered care. So, so this, this idea of we don't exist in a vacuum. We exist in a relationship in, in what we are doing, I, in terms of helping people and then we exist within a, an embedded society. And so how do we bring these things together? I think is important because we still have to think about causation pathology, the bio, you know, I hate that term. You know, we have to think about those things cuz they form part of what we are doing, but how do we integrate those into a, a wider sense of, of what we're trying to do. And again, it's all very bloody philosoph, philosophical, isn't it? But we all need a little bit of philosophy about what we think is important, how we work. And if we never think about that, I think we just get caught in this trap of just doing the same tick box exercises. And that is exactly what angle was talking about.
Jared Powell:
Yeah, I know. It's, it's embarrassing. Really it, the, the, the thing I feared Ben though, is you do all this work. You, you, you publish something it's, it's great. It's it has great success. Then somebody tries to use it in a clinical trial versus something else. And, and it's, again, it's, it's quantified again. It's like, and it's this basic outcome measures of pain and disability or range of motion or whatever it is, these, these biological, these physical outcome measures that perhaps don't exactly capture the whole point of the thing in the first place,
Ben Cormack:
Which is exactly why I said does it
Jared Powell:
It's exactly right. So where we at, how, how do we reconcile being a science informed profession and having an overarching framework that perhaps evades science is there's a paradox and I'm not sure. And it makes, it makes me, I, I have sleepless nights sometimes thinking about this because I'm, I'm becoming more and more, I'm becoming more and more aware of the, the restrictions and the restraints and the limitations of science when studying complex things. I think science is amazing and I'm such a quantitative guy in terms of my past, but it's, it's, I'm starting to see the shortcomings of it. Now that doesn't mean I want to abolish and get rid of, of the science at all from our profession, but how the hell do we incorporate that and reconcile that with this mysterious kind of non-scientific or qualitative or experiential based side of our profession.
Ben Cormack:
Tough. Yeah. So, you know, I, I, I think we have to view it as a different type of science don't we, and you know, that would, that would be the kind of premise. And again, even, you know, if we look at the randomized control trial and then you actually look at a patient outcome, you know, again, it's sometimes hard to, to, to put those two things together, you know, population level data versus individuals, you know, and they, people like calls health, Roger Carey, those guys, you know, they, they they've written some fantastic stuff. In this PLA in these, these kind of spaces, you know, much, much smarter than, than I could ever even hope to be. It's, you know, it's, I suppose it's something and I haven't got an answer for you of course, because I'm not, again, I don't think anyone else has, which makes me feel better, but at least you are considering the problem.
Ben Cormack:
So we do have to think about how does this outcome measure this piece of data fit into our wider philosophy? So the question I always ask, and, and this generally doesn't get good. Any responses let's take person centered care, patient centered care, relationship centered care. I don't give a monkeys what we call it. Right. And if we found out that it made no difference to disability, to pain, to healthcare utilization, is, is it something we shouldn't do get rid of these major, but we take these major outcome measures that we measure efficacy by, right? So, you know, the big, the big ones and we get a big trial and it says actually being nice to people, making their experiences good, made no differences to these outcomes. It doesn't work. What now, where next, do you see what I mean? Is it now something, well, it doesn't matter.
Ben Cormack:
Let's, let's just forget it. Because when you re, when you listen to a patient with long term persisting pain, who's had a terrible experience in healthcare. No one's ever been able to help them either in, in their, in their, how do they feel? Not just, how does it feel, you know, is, is that something that we don't worry about because it wouldn't have, it wouldn't have changed the outcome measure anyway, you know? So, so that's always something that says it to me. Is it how, you know, how do we measure the efficacy of something? What are we measuring? Does it relate to what we want it to achieve?
Jared Powell:
Yeah, exactly. Right. And that's, that's, A's kind of topical because of that reassurance paper that just came out recently by, you know, absolutely by Aiden Cashin. Yeah, yeah, yeah, absolutely. You know, we, we can, we can improve. We can make somebody feel reassured, however outcomes are no better, but you don't start reassuring people do. It's just a fundamentally human
Ben Cormack:
Thinking, you know? And I had a bit of a discussion about this the other day, someone would say, well, our intention is never to say, don't do it. But the way that people interpret research is it works. Or it doesn't work. That's that dicho diamond Fisher, you know, setting your alpha level. If you come up 1% sure we disregard it, we set the hypothesis, you reach, you know, you reach the threshold and if it doesn't reach that threshold, then it doesn't work. Let's, let's toss. It let's accept the no hypothesis. And you know, is, is that, is that the right way to measure some of these things? Now, some people will say yes, some people will say, no, it's all above my head.
Jared Powell:
Yeah. me. It's. Alright. So good. Good to talk about it. Anyway. Okay. So let's, let's, let's say, for example, the bio psychosocial model in its current Carnation
Ben Cormack:
Iteration would
Jared Powell:
Probably be a decent iteration. Iteration is, is, is incomplete.
Ben Cormack:
Yeah.
Jared Powell:
What alternatives do we have? You're writing a paper now with Peter Stillwell. Peter Stillwell is famous for his in activism paper, and now affordances paper audiences, paper. So is, is this a viable, is this a superior alternative?
Ben Cormack:
Well, I, I look again, you know, is superior again, that comes back to the, there an, do you see what I'm saying? But again, it highlights the kind of, we take one thing and then we have to find something that's superior or better or works. And the answer is I have no idea, you know, I don't even know if my thoughts go to, it's going to work better, but it's another interpretation.
Jared Powell:
Yeah. Is it a better, is it, does it account for more? Is it more explanatory? Does it offer more? It's
Ben Cormack:
Complete. I feel it's a more complete explanation when we look at what angle was trying to get at. So I actually think, you know, that, that people have done wonderful work in this space. You know, some people highlighting things that it isn't other people interpreting things that it is. And at some point I think we may need to bring these things in together to form more of a complete interpretation that says actually maybe the best, the best approach is to, is to bring these things in, into harmony rather than say, it's this, or it's this, or it's this. And so is it better? I don't know. Do I believe that it's more complete given the interpretations given more angle wrote? I think so, but that doesn't mean that it is cuz I'm obviously biased in this one.
Jared Powell:
Yeah. So perhaps the philosophy in the ideology or the theory of it is more complete, but does it change our clinical practice? Oh
Ben Cormack:
God blind me now. There's the elephant in the room.
Jared Powell:
yeah. Will it change? Will it change me in the clinic tomorrow? First thing, if I adopt it in an activism approach,
Ben Cormack:
Fine. But what does that mean? What, you know, what is changing, what you do tomorrow, is that the way you handle a knee? Is it your philosophy? Do, do you see what I'm saying? That's the way
Jared Powell:
For me. Yeah. The way I, I practice as a physiotherapist.
Ben Cormack:
Yeah. So for, for you, I would hope that you sit down in your chair and you say, how am I gonna approach this encounter that you are gonna say, I realize there's another human there. And that actually probably exerts quite a large influence on what happens. And their experiences are important. And I would like to walk a bit of a mile in their shoes or whatever, you know, kind of little quote we can, we can throw out there. So how does it change your practice? Usually that tends to be how we approach a test or how we coach and exercise or how we diagnose a pathology. Maybe we need to see changing practice as how do I approach what I'm trying to do? What are the important things? What is my philosophy about the, the, the overarching process? Not just a, a technique or an exercise or a diagnostic tool, which generally is what is changing, you know, that what what's it gonna do for you tomorrow? Well, I've got this wicked exercise for lower back pain, or I saw this amazing new special test. Well, maybe it's actually the way that you approach how you do things and what is important to you and what is important to the other person. Then someone else may say that's a load of philosophical clap track. Yeah. You know, so again, it's in the eye of the beholder, isn't
Jared Powell:
It? Sure. Yeah, absolutely. And it obviously depends on the individual as well in terms of how they have been practicing. But it is interesting to think about if, if, if the biosocial model is enacted upon to use activism and biopsy psychosocial at the same time, he's enacted upon as angle intended, however he intended. And I think how, what he intended is actually quite a bit obscure, as you mentioned a moment ago, it's a little bit open to interpretation. Yeah.
Ben Cormack:
No doubt.
Jared Powell:
And, and perhaps that's the, what he wanted to do, but maybe he thought he was just starting a thought and, and would, would let the, his descendants improve upon it if, if we were practicing Ben in your opinion, and this is just your opinion here. Yeah, yeah. In, in a, in what you perceived to be a really good interpretation and application of the bio biopsychosocial model, is that an appropriate way or is that a way that you would recommend many people who are physiotherapists to try and practice and, and, and, and sort of, is that a sufficient philosophy to underpin their clinical practice? Or do you think it is incomplete to the point of it needs to be improved upon like immediately,
Ben Cormack:
Like right now, like
Jared Powell:
Right now, like yesterday
Ben Cormack:
Right now. So look, I, I personally believe, and again, this is maybe gonna come across as a bit of a new age, hippy pot smoking kind of thought process, you know, and that's generally what I try to do on a daily basis is be a new age hippy. You know, I, I believe actually we don't spend, I think your first week in therapy school, whether you're a physio chiro, osteo, whatever should be thinking about who you want to be as a therapist, right. Who are you, what underpins you? What are your values? What do you hold dear? You know, what, what is your way of approaching the world? So our personal philosophy, and I also believe we should look at the philosophy of evidence based medicine in the first couple of weeks, because that's gonna say, actually, what is EBM this thing or EBP, what is this thing that's guiding us?
Ben Cormack:
You know, how do we reconcile population data and individual data, et cetera. And I don't think we, you know, and this obviously changes along the way. So, but I don't think we give enough thought to who we are, how we want to practice, what underpins, what we are trying to do often. It's about, this is the way that you do it, this fits in. And I think so, I don't think that we should take angles philosophy. I think we should listen to angle and integrate it into our philosophy. And I think everyone should take five minutes to say, why do I do what I do? Who am I, what am I doing here? You know, what are my values? And, and so I think that that really is, you know, that for me would improve a lot of different things is think, and again, I suppose it's like epistemology, isn't it in a way, you know, what is driving, guiding, and defining how we are thinking about these things in that case knowledge, in this case, you know, you know, practice, but what underpins what we are doing.
Ben Cormack:
So again, it might be some people are driven by other types of philosophy stoicism or, or whatever else. I don't know mm-hmm , but I, I, I certainly believe that we, we don't take enough time to, to think about, you know, what, what we are trying to do and, and how we do it. And, and I think that maybe taking a moment to do that would probably have an influence on how you do things and, and, and, and how you guided through this process. Cause I think sometimes it's autonomic, isn't it, it's about just ticking the boxes, writing down the VAs, doing this, and then, and then, and then out the door. So, you know, we probably need a bit of a paradigm change in, in this sense, in that we should probably, we should probably force people to be a little bit more introspective about the way that, that they work in, in relation to other people. That that would be my thing.
Jared Powell:
I love it, mate. I love paradigm. We're bringing up Thomas. We can't get any more philosophy than this, but I do. I do. I do love what you said there you're so right at university we're taught there's one objective reality. Yeah. Right. And then it's your NA it's your job as a detective in health to go and find that objective reality that is causing that person's pain. And then you intervene and you solve it. And the way you intervene is actually gonna lead to a specific outcome. For example, if something's tight and you loosen, if something's weak, you strengthen, et cetera, et cetera, et cetera, it's this very, this positivist type of interpretation of science, isn't it? And yeah, just a basic six week, perhaps module start on the philosophy of science or the philosophy of evidence based medicine and just introducing all these topics, realism on ontology epistemology, the Koons interpretation of science and poppers interpretation of science and all these things. It'd be a fabulous place to start. Wouldn't it? Cuz then you could go on and you could actually critically appraise the things that you learn because I don't think we should stop learning about special tests and things. Cause it's kind of, it's important to know how to do things and, and turn the arm this way and that way and screen range of motion, et cetera, et cetera. But it'd be nice. It'd be nice to do it from a philosophically enriched background. Yeah.
Ben Cormack:
And then you have all these students asking all these questions and questioning you and so I can, I'm sure why . So you hold 30 people in a class who are all philosophically woke, and that must be a nightmare for six
Jared Powell:
Weeks.
Ben Cormack:
So look, I've, you know, one of the things that's always been said to me is, oh, you are just gonna confuse them. You know, you are gonna, there isn't enough time or you're gonna confuse the students or, or whatever mm-hmm. So I don't know whether that's a viable way of, and again, do you come up against a system? So we have the system of education and that is its own social constraint. Isn't it? It's, you know, it's within, within how we do things. But personally, I believe that would make a, a, a, a big change. I'm sure. You know, I'm a, that pop smoking hippie part of me, the utopian, whatever, you know, people are out there going then. That's ridiculous. But I do think that that may change from within how people start to approach the, the, the, the consumer experience.
Jared Powell:
Well, as you said at the start philosophy is just thinking, mate, and if we're not, if we're not gonna encourage thinking then where are we as a profession? So I, I think it's it, what harm can come of it apart from a little bit of a friction in the lecture room for the first couple of years, perhaps. Yeah. It's gotta do good for the profession in the long term. All right, Ben I could talk to your day mate, but I I'm gonna, I'm gonna wrap it up. I'm gonna ask you a couple of questions. What book are you reading right now? And be honest. And what TV show are you watching with the, with the miss right now as well?
Ben Cormack:
So I just was I I'm reading exercised by Daniel Lieberman.
Jared Powell:
Mm cool. How's that?
Ben Cormack:
So, so, so I got that and actually my Kindle broke, so I bought it as an actual book. So, so I have that. So in the UK, it was really sunny up until about a week ago. Now it's just rained for the last week, cuz obviously that's a British summer. So I love sitting in the garden in the sunshine reading my book. So I haven't done a lot of, a lot of reading in terms of the last week, but exercise is the book that I've got about a hundred pages through. And, and it, it's an interesting read. I'm not sure. I always agree with everything Lieberman has to say. Or I, I dont always know if I like even the way that he says it, but it's definitely an interesting an interesting book. But the other question was about a TV series, right?
Jared Powell:
Yeah. You'rewatching anything on TV.
Ben Cormack:
What have I been watching? So me and my wife always have something on the ghost. So we just finished watching something called Mera east town, which was a HBO American thing.
Jared Powell:
Totally.
Ben Cormack:
Yeah.
Jared Powell:
Yeah. How was it with
Ben Cormack:
A, with, with, oh, I've forgotten her name, the English actor, Kate Winsley, which is like a detective thing. Someone dies, they have to work out and did it love it? Seven part, you know, easy watching. So we've been watching and obviously we are watching the football cause obviously it's the big European championships a year late England are playing Germany tomorrow night, so that's gonna be, you know, huge. Yeah. So it's a bit spicy. It's a bit fruity. I think we're up to the, and Wimbledon starts this week.
Jared Powell:
Yeah.
Ben Cormack:
I do like a bit of tennis must stay
Jared Powell:
Wimbledon is because that wasn't on last year either Ben, so everyone must be absolutely, absolutely looking forward to that. All right. Brilliant mate.
Ben Cormack:
So let's where
Jared Powell:
Can people find you, Ben? Are you, what's your social sort of choice?
Ben Cormack:
Well, I'm very shy and retiring and it's very difficult to find me. I'll have, you know, no, no, I'm a right mouthy, you know, trumped up little boy. So so you can generally tend to, I, I I'm quite, you know, prevalent talking crap on all the social media channels, just under, under core kinetic, which is just people ask me what does core kinetic mean? Well, it was just call ack movement so core as in Mac and then kinetic as in moving. So, so that's that really quite simple stuff.
Jared Powell:
Good. All and, and I absolutely can recommend to, to everyone to go follow Ben even if, even if you don't always like what he says, I think you'll be better for it because it's about, and, and what you do really well. I think Ben is, is you just challenge and I think you do it from a good place. And I think it's, it's, it's never personal. It's always about the subject matter. And I think that's super important because, and, and what I like is, is you can kind of do it to yourself as well. And, and that's, that's really important. So, so keep doing you. I really appreciate what you're doing and thanks for coming on and having a chat.
Ben Cormack:
Yeah. Thank you for inviting me. It's a real, real pleasure.
Jared Powell:
All good. Cheers mate. Thank you for listening to this episode of the shoulder physio podcast with Ben Corma. If you want more information about today's episode, check out our show [email protected]. 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 listen. I'll chat to you. Soon. The shoulder physio podcast would like to acknowledge that this episode was recorded from the lands of the GABA 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 stra Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
