Jared Powell:
Today's guest is Nathalia Costa. Nathalia is a physiotherapist academic with roles at Sydney University and the University of Queensland. Nathalia has a keen interest in qualitative research, and particularly on the topic of uncertainty in medicine and health science. Despite what we're taught at university, uncertainty is everywhere from the foundations of physics to the complexity of pain. Quotes from Nobel Laureates in physics, Albert Einstein and Richard Feynman emphasize this.
Jared Powell:
Einstein says, to be scientific is to be uncertain. And Feynman says, what is not surrounded by uncertainty cannot be truth. Even William Osler, the famed pioneering American physician, recognized uncertainty. He says, medicine is a science of uncertainty and an art of probability. So why are we so uncomfortable with uncertainty in healthcare? And what should we do about it? Nathalia is here to give us some tentative but not certain answers before we start the podcast.
Jared Powell:
Without any further delay, I bring to you my conversation with Nathalia Costa. Nathalia Costa, welcome to the show.
Nathalia Costa:
Thank you. Thanks for inviting me to have a chat with you. It's an honor, Jared.
Jared Powell:
No, you're very welcome. We've worked a a little bit together, Nathalia, so, so we know each other. We've just, we've had a paper recently published together, which I can perhaps link to in the show notes, so we might even talk about it. So, your work has been on my radar for a long period of time. The central talking point of our conversation today will be on uncertainty, which might sound a bit vague and a bit hard to understand. Why do we need to talk about uncertainty on a physiotherapy podcast? But I'm sure that you will educate us on why we need to think about uncertainty. But before we get into the academic
Jared Powell:
Stuff in the conversation, I wanna know a little bit about you, Nathalia, and certainly our audience will as well. So, who are you, Nathalia, what do you, who, what do you like as a person? What do you like to do? And then what's your professional role?
Nathalia Costa:
That's a very profound question. . I always feel like Alice in Woodland when the Caterpillar asks who are you? Yes. Yeah, it's, it's a tough one. But I think, Hmm, I might, yeah, I might use some of the wording that I have used that I have heard actually previously from, you know, people who know me in both personal and, and professional contexts. I guess I have been told before, previously that I, I have that fire in the belly, meaning that I'm very passionate and determined. So maybe some would argue that I'm a bit stubborn as well, . But I think, yeah, I think that that's a way of, of describing who I am. And I, I think that underneath that there is a lot of curiosity. I'm very curious about the world. I love learning new things all the way from learning about art and, and history to learning about things that are more work related, like new methodologies, new ways of thinking about certain issues.
Nathalia Costa:
And I also think that I have a strong sense of social justice, and I blame my parents for that. And we were talking about parenting just before we started this recording, so there you go. They, they certainly shaped, of course, who I am. And with my mom being a social worker, that being a lawyer, I think that is a strong part of, of who I am. And also, you know, not only because I have watched them fight for what is right growing up in Brazil but also the experience of living Brazil, growing up in Brazil itself has certainly shaped who I'm, and how I see the world. And I think that is actually starting to come across in my research and, and in my teaching as well. It's hard for me to not bring these things up when I'm working. So it's hard to separate who I am as a person from who I am as a, a physio, I guess, because I'm, I'm not practicing at the moment as a physio, so I think that might be a bit more appropriate to describe myself in that way.
Jared Powell:
That's, that's a fascinating story. How long have you been in Australia for?
Nathalia Costa:
Nine years and nine years. Eight months. Yes. Almost 10 years now. Yeah.
Jared Powell:
And do you miss Brazil? Do you, do you go back often?
Nathalia Costa:
I do. I didn't, I didn't go home, obviously during the pandemic. I, luckily I had arrived just before the pandemic started, and then I didn't go home for almost three years for obvious reasons 'cause of the lockdowns. And I'm going again next year. So yes, I do miss Brazil a lot. And mostly I miss, you know, the people who I love and, and I still there. But Australia feels like home. I'm sort of in between these two, two worlds. Yeah, I feel like I do have two homes now.
Jared Powell:
That's nice. That's, that's cool to have two homes on different sides of the world. You mentioned the your positionality and how your upbringing and your parents have shaped who you are, obviously. And I think that's the case for, for all of us, and how that is now starting to pervade or come through in your work as a, as primarily a, a qualitative researcher. That's a key aspect of qualitative research, isn't it? And sort of acknowledging your positionality and how that may come through in your research. I, I want come back to that in a minute. When I ask you about qualitative research, but what, what's a normal working week for, for you? Like at the moment, Nathalia,
Nathalia Costa:
Ooh, . Really don't wanna know, am I getting in trouble? I do work a lot, to be honest. I don't think I only work the 38 hours that, that we are expected to do on paper. And I'm using quotation marks here. That's the fire
Jared Powell:
In the belly, right?
Nathalia Costa:
Yeah, I do, I do work a fair bit. At the moment I'm in a full-time academic role, meaning that I have teaching, research and service responsibilities. So I, I spend quite a fair bit of my time teaching, either delivering lectures or tutorials, you know, marking, doing the usual teaching related activities. And then I've been doing a bit less of research than I would like, mostly because yeah, you know, the teaching during the semester's a bit difficult to, to focus on that. But I still managed to, yeah, get some research done this year. And in terms of service I'm an associate editor for qualitative health research, which is obviously a qualitative, as the name indicates, is a qualitative journal. So I also have some responsibilities, weekly responsibilities in terms of, you know, reviewing papers and finding reviewers and that kind of thing. I also try to exercise and do something for myself each week. Do a bit of reading. I don't watch a lot of TV to be honest, but I do enjoy reading, spending time with my loved ones, with my cat, who is sitting here as we talk.
Jared Powell:
What's your cat's name?
Nathalia Costa:
Leora. It's a, it's a great name actually. And it means compassion. So she's a lovely
Jared Powell:
Little
Nathalia Costa:
Reminder of, you know, trying to be a compassionate human being. We
Jared Powell:
All need those reminders. I know, I do sometimes. We've talked a couple of times about qualitative research now, I think, let's get into it. So I know a lot of your work that has been qualitative in nature, and that's I think, how I, I came across you initially. Maybe it was on, were you on Ollie, Ollie Thompson's podcast? Yes. Yes, yes. That's probably how I came across you on, on the wonderful Ollie's podcast. Yeah,
Nathalia Costa:
He's great. He's a
Jared Powell:
He is, he's a, he's a legend. He's helped me quite a lot as well. So what compelled you to go down the avenue of qualitative research? Was it something that was a natural evolution for you when you got into research? Or did you have an epiphany or light bulb moment when you went? What's this quantitative stuff? It doesn't really make any sense, or what, what what was your journey with getting to qual research?
Nathalia Costa:
That's a very good question. And, and I think it was a bit of both. You know, something to do with, yes, realizing that it was very important, but also, you know, some of the opportunities that came up because of the nature of what I was doing. So I guess if I go all the way back to when I started my PhD and why I started my PhD, it was because of the, I guess, qualitative data that I was getting from the people who I was working with. And I'm using quotation mark here because obviously I wasn't collecting qualitative data, per se, formally, but I was course paying attention to the things that people were bringing up doing their appointments, particularly when they were dealing with, in Portuguese, we say crisis of back pain in English, we, we use the term flares.
Nathalia Costa:
So it was through the experience of being a physiotherapist, dealing with people who presented with low back pain, who had these flareups that stopped them from doing a lot of the things that they needed to do or that they enjoyed doing. That really sparkled my interest in doing research in flares in low back pain. And I remember that at that point in time when I was a clinician, some of the people who I used to see had all the different sort of theories about what had triggered their flareups and others had no clue. And sometimes they would ask me, you know, what I thought, what do you think that triggered this fla? Why am I having it? Why now? I didn't do anything wrong. You know, I had been exercising and, and doing everything that you told me to do. And yeah, so that was why I decided to do a PhD.
Nathalia Costa:
And that was my overarching research question. It was around the nature of flares and, and the triggers pullback, main flares. And when I looked at the literature, there wasn't much about, you know, people's perspectives on mm-hmm. Triggers at all. And that's when Paul Hoss, so professor Hoss, my former supervisor, so that suggested that we should fill that gap. And I was very lucky because around that time, Dr. Jenny Scho was one of his postdocs, and Jenny had a lot of experience using qualitative methodologies. 'cause The whole PhD was on exploring with stigma in physio, drawing from qualitative methodologies. So Jenny helped me a lot with my first qualitative study, which was a fairly simple content analysis on people's views on low back pain triggers or triggers for flares of low back pain. And that study actually laid the foundation for some of the triggers that I investigated in quantitative studies.
Nathalia Costa:
So in case cross service studies that we conducted. So you, you mentioned something when you're framing a question, you know quantitative research doesn't make sense. I do think that it, it makes sense and I think it makes more sense when, you know, we combine these two different paradigms, I guess two different ways of understanding reality and, and knowledge. And yeah, so going back to like wow experience Jenny wasn't involved in these quantitative studies, but then they became my supervisor as well, and helped me with another qualitative study that I did at Delphi process to derive a definition for the term flat. And, and then we started working together, you know, in all the projects. I also worked as a research assistant throughout my PhD, and before I realized I had more qualitative publications than quantitative ones. So, as I said, it was a bit of both, you know, the opportunities that came up, me realizing that yes, it was important and falling in love with it. So, you know, the passion combined with the opportunities led me to, I guess, lead research that is, is mostly qualitative, as I told you earlier. I'm very curious. I love learning. And I feel like qualitative research really pushes me to think differently about things. It really helps me to expand my thinking. Mm.
Jared Powell:
Yeah. I enjoy the creativity aspect of qualitative research. So I, I love quantitative research. You're not gonna get anybody who enjoys a good robust randomized con control trial more than me. But I'm starting to appreciate the qualitative research method or methodology where you can be a bit more creative and you don't have to be beholden to these sort of rigid inclusion exclusion criteria, so on and so forth. So do you find that you enjoy that creative aspect perhaps, or more narrative based approach in, in qualitative research when you can, when you can use some of your
Nathalia Costa:
Sort
Jared Powell:
Of lateral or abstract thinking?
Nathalia Costa:
Yeah, no, absolutely. And I think what I like the most is, you know, using the data itself. So whether the data is coming from observations or, you know, from interviews or from images even mm-hmm. So whatever the data source is using that to think differently about the topic, the various topics that I investigate. So engaging that inductive thinking, we all go to research projects with certain ideas. But I guess if you try to truly engage in an inductive process when you're conducting qualitative research, you try to be as open-minded as you can. And I think that's where the magic happens from that openness, from that curiosity. Because then as soon as you start looking at the data, there might be things that you never thought about before. And if you're open enough to, you know, and embrace these new ideas I think often the results can be quite meaningful. And you mentioned trials earlier, I think there is a lot of potential to bring this two words together and even use instance qualitative research to design better trials, to improve trials even as they go, you know, as they happen. Not just, you know, by trying to seek people's perspectives on the trial after the trial has finished, which is what we see more frequently. But I think there is potential for more there
Jared Powell:
A hundred percent using qual research to inform clinical trials, not just like a, a retrospective, well, what did they think of the trial? And sort of, it's like a throwaway publication at the end of the end of the trial, which is fine. I'm not trying to dengate anybody or anything, but that's, that's sort of where qual research is used in quant research, isn't it? Like a secondary kind of analysis?
Nathalia Costa:
Yeah. I think it's different in different fields, but yeah, in physio, I think, is it still perhaps a bit limited to, you know, barriers and facilitators or,
Jared Powell:
Mm-Hmm,
Nathalia Costa:
Yeah, because experiences with
Jared Powell:
Yeah.
Nathalia Costa:
Participating in a trial, which as like you, I'm not critic. I, I, I conducted the studies myself. I'm involved in some of them, and I think they had their place of course. But I think it's important that we see that there are other ways, you know, in which we can use qualitative research, qualitative methodologies more broadly to expand our thinking.
Jared Powell:
Yeah, no, I think we can be critical. I think critical is a, a massive is, for me, it's the most important part of science or a scientific approach to be critical, you know, and I think Dave Nichols says it nicely that all these qualitative studies that come out, it's re-investigating pain, and what do people say? It hurts. It, it affects my life, obviously. It affects everything. It affects my sleep, it affects my function, it affects my ability to participate in leisure activities and blah, blah, blah, blah. But we know, we know that, but we kind of, we've gotta go deeper, I think, anyway, so we can talk about that for a long time. I wanted to get to your uncertainty, which is why we're here today. You've written a number of great papers on, on the topic of uncertainty in healthcare and physiotherapy. I want to, I want to get to these papers, but before we do, I wanna preface it with a quote from John Lorna, who's a British doctor.
Jared Powell:
And I think it might neatly segue into our conversation. And so, John, Lorna, states uncertainty doesn't come occasionally singly or in isolated categories. It's the ocean in which we swim for most of our working lives. And he said this to a group of doctors talking about uncertainty. It's quite refreshing to hear that from a noted general practitioner about uncertainty, pervades everything that they do for their entire working career. I feel the same in physiotherapy as well. I don't think I was, I I don't think uncertainty was mentioned in my training over a decade ago at physio school. And again, it's not anybody's fault, I just don't think it was a priority. So I came out thinking that I was a clinical detective. I was gonna find pathology and injury, and I was going to institute a manual therapy regime or an exercise regime that was gonna fix everyone. And then a couple of years later, I had a crisis because it didn't exactly work that way. So that's a, a very long, long-winded and complicated introduction to you Nathalia, respond to that quote, firstly. And then, what is uncertainty and why should we care about it? And then mention your beautiful papers.
Nathalia Costa:
Oh, wow. There, there's a lot. To
Jared Powell:
. The floor is yours, 10 minutes
Nathalia Costa:
. Yeah. So like you you know, during my degree, as soon as I started seeing people really in placements, that's when I, I faced uncertainty for the very first time. And I still remember the case, you know, the person, the context in which that happened really. And yeah, do you, do you want me to elaborate on that?
Jared Powell:
Yeah, if you don't mind if you, yeah, if you don't, if it doesn't bring up any trauma. Yeah,
Nathalia Costa:
No, it's fine. It was a person who had back pain. She was pregnant and she lived in, in a, an area of low socioeconomic status in Brazil. And this was because I came from a federal, so publicly funded university, meaning that I got all my education for free. But when it, when it was the time for us to go to placements, we had placements in the public healthcare system as opposed to the private setting. And as expected, I ended up in, in areas doing my placements in areas of low socioeconomic status. And this specific woman was pregnant, I think she was about six, seven months pregnant of, with, with her third child. And she had a child with disability who was already around 15 and was bed bound, completely dependent of her to, you know, make transitions feed. And she had to feed the child and everything. And the husband was an alcoholic, was unemployed, was in a home most of the time. She was struggling, of course financially. So there was a lot of complexity there. And, you know, in my, and,
Jared Powell:
And a gl and a gluteal stretch didn't suffice for this
Nathalia Costa:
Person. Yeah, exactly. So the things that I had learned to do was, you know, that it was some medication, you know, maybe, you know, you can teach some exercises, whether you, you know, multi control exercises or just general activities or even orientations about how to do activities of daily living in a way that is, I guess, ergonomically optimal if, you know, follow that framework. So the things that I had learned they were not that useful in her context. And I remember, you know, delivering my intervention and, you know, one of them would be, you know, try to not leave to frequently, but, you know, she had a child who had, who weighed what, 40, 45 kilos and was completely dependent. So she, she, she didn't have the option of not lifting weights or, you know, making these transitions from bed to the bathroom and that kind of thing.
Nathalia Costa:
Yeah. So that was the very first time that I faced a lot of uncertainty. 'cause I wasn't quite sure what to do and what sort of care I should provide to that woman considering all these contextual factors. And after that, so, you know, there were other situations while, and placements where, you know, there was a lot of uncertainty, mostly because of this complex social factors that I had to navigate. So that, that was there. But then moving to private practice you know, it was a different context. Of course, I still, you know, had to deal with complexity, social and also emotional, psychological factors. But it, it was a bit less than during my placements. And that's, again, seeing people with back pain over and over again, and with all these various contexts and often, you know, these questions related to why am I having this flare up now?
Nathalia Costa:
That's what led me to, to the PhD. So the PhD itself was I guess a way to cope with the uncertainties of clinical practice. I went to the PhD wanting to have some level of certainty wanting to have responses. So I guess I have a long-term relationship with uncertainty. And I do see that in the students as well. You know, they, they do get into the degree of course, wanting to help people, and they often expect that, you know, they'll learn like, you, you know, I'll learn the tools, I'll be able to diagnose and treat and it's gonna work, and you know, I'm gonna make a meaningful difference in people's lives. But we know that that's not always the case. And some of them actually talk about how frustrating that is. 'cause They're getting to the degree thinking that they're going to get these responses. And that's not always the case. So on that note, I do think that we can do better in terms of helping them to not develop an overly negative relationship with uncertainty. 'cause Uncertainty doesn't need to be something that paralyzes us or that makes us become complacent. We can dig into that a bit further later on. Yeah,
Jared Powell:
I wanna, can I just explore one point there before we get into your papers about perhaps physio students being uniquely
Jared Powell:
Expecting certainty when they arrive into physio school? Either if they've come from an exercise science background or straight from high school? Typically they, they do well academically. If you get into physio school straight from high school, you are literally in the top one to 2% of academic performers, which is really hard to do. And even if you come from, you do it postgraduate, it's still very competitive to get into a, a, a physio position at a university in Australia. So with that context, students come in who are really good at science, usually really good at physiology, really good at chemistry, really good at mathematics, you know, high performers there. Where there is an element of certainty, there actually isn't. When you listen to some of the most famous scientists of all time, Fineman, Einstein, et cetera, all talk about uncertainty in their work.
Jared Powell:
But in high school physics, when you use Newtonian physics, it's very certain you get an answer, mathematics, you get an answer. But then you get into physio school and you're dealing with perhaps with pain and uncertainty, and you expect a cluster of shoulder tests to be able to diagnose a shoulder impingement in, in quotation marks. And then that will lead to, you know, a linear treatment plan that that will, will get that person better. And it doesn't quite sort of live up to that. So, so is that, has that been your experience firstly with, with physio students in terms of a desire for certainty? And then how do you navigate that as a lecturer, and what's the outcome being?
Nathalia Costa:
Yeah, that's a great point. Yeah, like you, I think I fit into this profile of, you know, students who, who wanted who got into physio wanting some certainty in order to, I guess with the intention of helping people. But I do think that having parents, as I said, who are more in the social side of things, more into humanities and, you know, who would give me books that I guess talked about different things that were a bit less certain made me a bit, perhaps a bit more open to other ways of thinking. So for instance, when I was 18, my dad gave me a book called the Turning Point from Fridge of Capra. And that book talks about, you know, it criticizes the Cartesian model of healthcare, for instance. Cool. It talks about the need for an ecological approach.
Nathalia Costa:
It goes on and on on many different societal issues, but I think that really helped me to perhaps be a bit more flexible in my thinking. I do notice that, yes. I, I often, it shouldn't often, you know, ask this binary questions. If we do this, the outcome is that, do I do this or that, or what is the exact order in which you want me to do the clinical assessment? Yeah. So, you know, they, they often want the certainty of, you know, all the, all the way from the order in which they should do things, things in, in terms of what to do if they get outcome A versus BI don't blame them for that. I think as it said, it comes from maybe, you know, it's, that is influenced by high school and how they're taught and the things that we learn even the way in which we assessed, right?
Jared Powell:
Yes.
Nathalia Costa:
To, to portray certainty in both you know, both in high school and also later on, you know, in higher education. I would love to, so there is a, a lecture in Norway, just got his surname used Wiin, I think, I'm not sure if I'm pronouncing his name correctly, but he did look at the profile of physic students in terms of their ontological and epistemological ways of, you know, understanding reality, understanding knowledge. Can
Jared Powell:
You quickly just define ontology and epistemology for our listeners?
Nathalia Costa:
Yeah, sure. So ontology by ontology, I mean ways of understanding reality. So for instance, do we think that there is only one reality, or do you think that there are multiple realities out there? And by, so that's a very simplistic way of defining ontology. And a very simplistic way of defining epistemology would be, you know, do we think that there is one way of knowing? So if we conduct a trial in a way that is, you know, as free, as biased as we possibly can we'll find one truth. And, and that's the absolute truth. And an alternative view to that would be this view that there are multiple truths, and that knowledge and truth can change. There are dynamic concepts that can change depending on context. And there isn't a single truth. There isn't a single way of knowing things. Beautiful. So, yeah, I can't, I can't remember the exact findings of use studies.
Jared Powell:
I'll link to it in the show notes as
Nathalia Costa:
Well. Yeah, yeah. But it's, it's interesting. I think it would be interesting even, I would love to do that research actually in Australia to see, you know, what is the ontological or, and or epistemological profile of people who getting into physio, you know, in terms of their ways of understanding the reality. Totally.
Jared Powell:
I assume a lot of it would be just objective realism, which is fine as a, as a single world. And we, we derive knowledge of that world via clinical trials, and that's you that sort of holds over time, you know, which is, which is, that would've been me five years ago, even. That's still, I I'm still a realist, I think, but I, I think my frag magic, yeah, my theory of knowledge will be that there's sort of many ways to come to know about reality, you know, and, and based on your context and where you come from. So, so that would be my bias, perhaps, which is okay. And I, I, I, we don't wanna denigrate right. Anybody's belief system or what they think about the world. Absolutely. That's the beauty of core research. We, we appreciate that.
Nathalia Costa:
Yeah. I'm still navigating these things myself. Yeah, yeah. And trying to reconcile different ways of understanding reality, different ways of Yeah. Producing knowledge as well. But yes, coming back to the student side of things, it, it would be interesting to see, you know, what sort of profile they have. But anecdotally, yes, I do think that the students who tend to get into physio, they, they have I guess this, this they're thirsty for, for certainty. And yeah, I think sometimes they struggle to think in non-linear ways. Mm-Hmm. . But maybe that's not just limited to physics students, right? Maybe that's just people overall, I dunno. Yeah.
Jared Powell:
I would say most of the people who come from sciences and, and mathematics backgrounds in high school would be, would go that way. So your engineering students in medicine, students, your physio students, so on and so forth, your compute it people, I think they would all be along those lines. And unless you've had any exposure to philosophy or arts or literature or maybe music or something, then you're not really gonna think too much about that stuff. So for me, I used to be like, not revolted, but I used to be, like, when somebody used to mention subjectivism and relativism and all, all that sort of stuff, I used to just like, make me feel a bit funny because I'm like, ah, there needs to be an answer. Like, don't, we can't just be fluffy with these questions. There has to be some certainty. It took me a long time to come around. But anyway, so what I'm trying to say is it's, it's, it's hard and I have a lot of sympathy for people going through it.
Nathalia Costa:
Yeah. And maybe that's, that's what what we could do, you know, expose health science, not only physio to more of these you know, humanities subjects or units for sure. Or topics or even, you know, social sciences, bringing them in. Mm-Hmm. I think that could offer a lot of potential because I did have the opportunity to teach social science students and also have policy students who may come from different backgrounds. And yes, I do feel like they, they make that shift somewhat, yeah. A bit more easily. Yeah. They seem to be a bit more comfortable. Overall, again, it's complicated to generalize with. I feel bad for doing that, but yeah, I can see how there is a different way of, of dealing with uncertainty and, and complexity in, you know, in different cohorts.
Jared Powell:
Well, let's go to one of your papers now, the ubiquity of uncertainty where you actually investigate or explore how clinicians, I think, cope with uncertainty in clinical practice. That's a, a nice segue, I think. So do you mind just talking, sort of introducing the paper and then perhaps exploring what clinicians do when faced or confronted with unc?
Nathalia Costa:
Yeah, yeah, absolutely. So that study was sort of like a follow up from the first one where we just observed clinicians, you know, during their clinical encounters with people who presented with low back pain, but we didn't really talk to them. So it, it was purely, mostly purely observing them, you know, and observing care as they came forwarded. And then we looked at the literature and there wasn't a lot about clinicians experiences navigating uncertainty. So I studied, for instance, interviews or focus groups where they actually talk about it. So that's why we conducted that one. And these, in this study, we took both qualitative approach, which in a nutshell means that we use theory to think with the data or data to think with theory to produce a new way of understanding a phenomenon, which in this case was the uncertainty that these clinicians navigate with people who present with low back pain. So we conducted interviews with them, 22 of them. And there wasn't limited to physios. To be honest, there's different clinicians including pain specialists and psychologists, ot. So there, there were a range of different clinicians there.
Jared Powell:
There was some doc, was there some doctors as well? Sorry. Yes. Was there a, is there a surgeon even maybe, or There was one,
Nathalia Costa:
There was one surgeon that's, yeah. And in that study we used, so I mentioned that it was a post qualitative, a approach, meaning that, as I said, we used theory, and the theory that we used was mo's theories on the logic of care. And in her book, she contrasts the logic of choice with the logic of care. Again, I try to summarize these concepts but, you know, if you really want to understand the better, I strongly recommend reading the book. 'cause It's quite fascinating. I learned a lot by reading it. But in a nutshell, the logic of choice is this linear process where we as clinicians, we limit ourselves to use insurance and presenting facts and informing patients about, you know, for instance, prognosis or diagnosis, just so they can make decisions about what course they should take. So in this framework of thinking, knowledge is a collection of facts and, and certainty, right?
Nathalia Costa:
You, you want to increase certainty. And in contrast in the logic of care, clinicians don't really treat facts as neutral information. So even the idea of facts can be challenged. And instead, clinicians try to attend to values or broader contextual factors that make their care practices a bit more flexible, a bit more adaptable, and even a bit more resilient. So it's, it's not so much about, you know, producing certainty, it's more about embracing uncertainty and trying to navigate care in a way that is attuned, for instance, with patient's emotions is attuned with their context. So when we looked at this interview data, we looked at the data with these two different concepts in mind. And you, you asked me earlier, you know, how would, could we define certainty? And I think it is important to highlight that is in this specific study, we didn't really define uncertainty for these clinicians.
Nathalia Costa:
We took a very, we didn't wanna limit them to a particular definition. So we let them, you know, interpret uncertainty as they wanted. So we took a, a broader approach. And in that study, it was quite interesting surprise, surprise. They described quite a range of context where they experienced uncertainty. And these uncertainties, they were often ent entangled with aspects like diagnosis, prognosis, and, and treatments. So they were entangled with this, I guess, biomedical aspects, but they were, were often related to human and non-human factors. So for instance, they described navigating uncertainty when they were trying to consider patient's personal and social context when they were trying to make the therapeutic decisions. So making ethical considerations about whether or not they should give a certain treatments such as nerve ablation, for instance. The pain specialist reflected about that. They talked about feeling uncertain when trying to navigate emotions, when trying to navigate mental health challenges, when communicating with patients, even when communicating, you know, things that we are encouraged to communicate based on the latest evidence when they were even trying to, I guess, educate patients when they were trying to understand the roles of different clinicians when they were trying to navigate patient expectations of treatment.
Nathalia Costa:
So there was a really wide range of, you know, context in which they talked about navigating uncertainty, and you just linking back to the quote that you used earlier. So that quote highlights how it's, it's, it's everywhere, right? That's essentially what the author is saying. And that was exactly what the clinicians that we interviewed said that is everywhere. And what they do is like their bread and butter. And that's why I guess the, one of the main findings of our studies that it is ubiquitous in clinical practice. It it's everywhere. And it's not limited to this, I guess, more mainstream biomedical aspects such as diagnosis, prognosis, treatment effectiveness is a bit broader than that. Mm-Hmm. . And from, I don't know if you want me to elaborate on a specific examples of the, of the paper, just speak more broadly. Yeah.
Jared Powell:
Broadly is good. I think. So what you're saying, it sounds like every aspect of the therapeutic or clinical interaction is imbued with uncertainty, hence ubiquitous. You can't escape it, it's omnipresent. It's, it's everywhere. And so what do, what do we do? Nathalia, in this situation where we are, where uncertainty is everywhere, we're not really trained for that. And so we go from a certain approach in physio school to an uncertain world where it's messy and complicated and complex. Do we, like firstly, can we resolve uncertainty by knowing more? I think I know what you're gonna say here, like, reading more research or accumulating facts and, and knowledge, or should we just yield to the fact that uncertainty is everywhere and accept it and try and incorporate that into our practice as best we can. And if that's your answer, then how, how do we do that?
Nathalia Costa:
Yeah. It's a, I think it's a bit of both. So going back to that paper, thinking through the data with Anne Marie Mo's Logic of Care in Mind, it really helped us to see how they did embrace uncertainty. They seem to be more attuned with the knowledge from people's lives, right? From their complex context. And they seem to be a bit more prone to attend to things like emotion and frustration when they took the time to acknowledge that uncertainty was there.
Jared Powell:
So what does that look like in, in, in practice, like acknowledging emotions and all of those things? Yeah. Is that just listening or is that what, what what does that actually look like?
Nathalia Costa:
Okay. I might give you an example from the paper Yeah. To give you an idea and give listeners an idea, and then I can expand on that a bit further. So we know that guidelines recommend that people should return to work as soon as possible, right? And
Jared Powell:
Yeah,
Nathalia Costa:
Even if a few years have passed, people are always encouraged to return to work. We know that that is associated with bad outcomes for people who present with low back pain. And that when they don't, when, you know, when they stay out of work for too long, this is often associated with some not so good outcomes when it comes to disability and and pain and quality of life and many other outcomes. So this is something that because we have the evidence for it, it is clinicians are encouraged to tell people to return to work, but this specific clinician reflected about a scenario where this person who he was working with had been out of work for a couple of years, but things were starting to improve after a couple of years to the point where this person was considering to return to work.
Nathalia Costa:
And at the same time, he was very fearful because he was on a pension. If I return to work, I'll, I might lose my pension. I have been out of work, I'll need to reskill, you know, people who see my resume that I have been out of work for many years. You know, even the fact that I, I have had chronic pain, maybe there will impact on my employability. So he was very concerned, he feeling very uncertain about, you know, is this really the best decision despite of me feeling better? You know, there are all these things that might make things a bit more complicated. And rather than simply encouraging that person, no, absolutely, you should return to work. That clinician actually acknowledge, yes, it, I can understand why you are, you know, concerned. It, it's natural. Yes, there are a lot of uncertainties.
Nathalia Costa:
You need to upskill. You need to put your CV together. Yes, you may lose your patient. And, you know, 'cause this, this person was worried, what if I have a flare up and my pain gets worse again, and then I lost my patient and may not be able to get it again? So there were many concerns there, many uncertainties. And rather than simply saying, yes, let's do it, you know, I'll support you. And purely encouraging the person to return to work, he said, you know, yes, he acknowledged that there was a lot of uncertainty, but if you are willing to do that, I'm with you on journey. I'll help you throughout this return to work journey. So I think that's a really classic example, that it wasn't just applying sorry. It wasn't just applying the evidence and saying, yes, return to work. It was making time to acknowledge these uncertainties and also establish that partnership. You know, you're not alone in this. I'll, I'll support you to the best of my
Jared Powell:
Ability. Yeah. That's, that's really powerful. Yeah. Acknowledging, validating, supporting, not just going through the motions and saying, well, this guideline says go back to work. It's associated with better outcomes. Totally. Seeing the person rather than the guideline. That's really important.
Nathalia Costa:
Yeah. So I think, I think that's one of the examples. Mm-Hmm. And there are many other things that I could highlight here based on the research that I have done. And you know, what I have learned from people with back pain Mm-Hmm. And also what I have learned from these clinicians. So from the perspective of people with low back pain, again, their uncertainties don't seem to be limited to these biomedical factors. Mm-Hmm. They actually feel very uncertain about what is going to happen over time, even when clinicians actually sell certainty. For instance, some clinicians sell the certainty that you are going to get worse because you're aging and you have osteoarthritis. You're going to get your back pain is gonna get worse over time. Mm-Hmm. So that certainty actually triggers a lot of uncertainty about what future with back pain may look like. So, you know, when we are talking about certainty and uncertainty, it's very important that we reflect about what certainties and uncertainties that we're referring to. Because you may think that by giving certainty, you know, you are reducing uncertainty. But in that case, if you tell someone your pain is gonna be work get worse, you're doomed to being paying for the rest of your life. That is actually creating all uncertainties. That's
Jared Powell:
So true. Yeah. Double-Edged sword, isn't it?
Nathalia Costa:
Yeah. And then on that context, in that context, they were also they also described uncertainties related to, you know, not feeling like they were being taken seriously by clinicians. Mm-Hmm. Or even questioning, are clinicians really able to help me? Are they willing to, you know, am I going to put myself through more pain and spend more money for nothing? You know, is, is, is this going to, is this new treatment going to make me feel better? Really? Mm. Or am I putting myself through, you know, more pain and more financial strain unnecessarily? So when they were describing all these different contexts in which they experienced uncertainty, you know, uncertainty about whether you're taking, being taken seriously, uncertainty about whether clinicians can help or not uncertainty about the future, they often talked about the importance of clinicians being honest in face of uncertainty. So, you know, taking the time to acknowledge it, being honest, and even suggesting what the latest evidence based on population based studies suggests these things can be helpful coming up with a plan. You know, we don't need to let uncertainty paralyze us. In fact, a really nice quote from Arimo that says, uncertainty doesn't code action, so it shouldn't us, we can,
Jared Powell:
That's a great quote. I love that. That's gonna be, that might be the headline of this chat today. Can you say that again?
Nathalia Costa:
Say
Jared Powell:
That again. Sorry, what? What's the quote?
Nathalia Costa:
Doubt, uncertainty does not play good. Action.
Jared Powell:
Beautiful.
Nathalia Costa:
Yeah. It doesn't need to stop us
Jared Powell:
Because I, because I think, so clinical practice for me is, is based on trial and error. And, and I think that's okay, right? Because we have incomplete knowledge about a subjective, private first person experience, which is pain. And so they come to us and they, they describe their experience, and then we have limited resources really to try and help that person with pain, especially in physical therapies, right? We have often physical interventions, and that's the nature of it. So then we try some stuff, right? We, firstly you establish a relationship, you, you listen, you validate your support, and then you try some stuff. And now people will try different things based on what their approach is. And that's fine. It might be a manual approach, an exercise approach, or a psychologically informed approach. And then you sort of monitor that. You conduct a little in one end of one experiment, and you see how that person goes over a week or two or more. And so even, even that approach is imbued with uncertainty, right? Because you don't know the answer. You try something. And I think the best clinicians are, which
Nathalia Costa:
Kind
Jared Powell:
Of goes to that quote, is they try something, but then they, they honestly reflect on it. And then they go, okay, it's maybe not working. Let's try something else. Or the patient flared up, let's try something else. They don't just rigidly stick to their approach. And then if the person doesn't get better, they blame the person and not their approach, if you know what I mean. So they, they really, honestly and intellectually reflect on the situation. And so, so all of that is, is is pervaded with doubt and uncertainty and not knowing the answer straight away, but it doesn't prevent action, which I think is the really important point that you alluded to. Do you want to expand on that at all?
Nathalia Costa:
Yeah. You, you talked about reflecting, right? And I do agree that it's very important that we as clinicians, well as people overall reflect about, you know I tried treatment A didn't work, maybe I should try treatment B, or was it something related to the dosage? So reflecting about these aspects, therapeutic aspects are important, as well as reflecting about, you know, I was, in fact that was one uncertainty that some of the participants from the qualitative study talked about. And, and did I deliver the message? Did I communicate the message in a way that was, you know, useful? Or could I have tweaked my words a little bit in order to convey what I really wanted to convey? So, you know, reflecting even about your communication is very important. Mm-Hmm. But I think reflecting about, and maybe, yeah, I'll just say I would, I should say engaging in reflectivity is just as important as engaging in this reflective practice.
Nathalia Costa:
And by reflexivity I mean really taking the time to reflect about the assumptions of some of our choices or the motivations for some of our choices. For instance, there is a quote that I really like from Professor Barbara Gibson is actually a question that illustrates reflexivity. And the question is, what am I doing when I'm doing what I think I'm doing? Why am I doing this? Who am I doing this for? Mm-Hmm. . So if we think about a context of uncertainty, you know, why am I offering this approach? You know, why am I so uncomfortable with this uncertainty? So critically reflecting about, you know, why do we feel uncomfortable with uncertainty in first place? I think it's very important, and I think that it's one of the ways to, to navigate uncertainty in a more skillful manner. Mm-Hmm. It's engaging this yes. Reflective questions, but also engaging in reflexivity which goes a bit beyond and is really about scrutinizing our own Yeah. Ideas and assumptions. And so I'm, I'm happy to refer, give you the citation from Barbara for Barbara Gibson's work as well, because it's quite enlightening. Yeah.
Jared Powell:
I love that. A deep interrogation of, of why you do something and how you act in the face of uncertainty is sounds. Absolutely. It sounds like a, a dark and cathartic thing to do a little bit, which is good. You need to, you need that right. To kick you up the sometimes and get you to think about these things. Yeah. 'cause Sometimes you get into autopilot, and I do a hundred percent of the time, not a hundred percent of the time, but when you're in clinical practice and you've got a busy caseload, you go into autopilot and you don't stop to think, or, or not just reflect, but, you know, engage in reflexivity, like you said, and really interrogate why you're doing these things. And that's, it's hard, it's so hard to do Nathalia for busy clinicians though, right? I know. 'cause There's so many pressures from the system, from the patients, from your bosses, from, and that's putting, earning an income, it's hard.
Nathalia Costa:
And that is one of the reasons for why we need to have these broader discussions about our advocacy and, and changing. I might sound a bit too idealistic, I don't know. But I, I do think that is important to reflect about the healthcare systems that we are in and how they may promise us to certainty, and as you said, how they may get in the way of us engaging this reflective and reflective practices. Because it's not easy. So that's where, you know, I think we need to reflect about our policies, problematize these policies, scrutinize the assumptions embedded in these policies. Yeah. And be creative and think of ways in which we can, you know, reimagine our systems our work context. It's, it's not easy, but I think we need to start somewhere.
Jared Powell:
Yeah, I agree. So we've already been talking for an hour just about Nathalia and I, I feel like we could keep going for hours. Yeah. We'll start to, we'll start to finish. So what, so clinicians feel uncertainty in clinical practice in the decisions that they make, not just from diagnosis, prognosis and, and selecting treatments, but in pretty much every facet of a clinical interac interaction, patients feel uncertainty, obviously, because that, that pain sort of makes you feel like that. When's it gonna end? And how's this person gonna help me? So on and so forth. What does my future look like from my experience as a clinician for 12 or so years in private practice? The whole time just about this is, and and I've also read this in qualitative studies as well, that patients do look for clinicians who are confident, who are experienced, who may portray or communicate certainty.
Jared Powell:
They, this person has had 10 years experience, they're a shoulder specialist, they know what they're doing, they're gonna, they can detect it. They gave me this diagnosis, I feel better. So that's a scenario where certainty has helped a patient. What should we, should we refrain clinicians from communi from communicating or acknowledging that uncertainty in clinical practice? Or how do we draw the line between, 'cause I know I go to a doctor, I do feel better if they say, I I'm pretty sure it's this, or actually as I'm saying this in real time, , I don't think I would like it if they say it's, I'm certain you have this. I would like them to say on the, the balance of probabilities on the tests that I have conducted, I think it's likely that you have this. And then I would feel better with that than them saying, oh, I'm, I'm not sure. We need to go and order 15 tests. That would make me worry like you would not believe. So how, how do you, I'm not saying how, I'm not asking you to tell every clinician how to act when faced with uncertainty, but how do we navigate that? Because patients, I'm sure you'll agree with me, will respond well to certainty at times. But how do we sort of not be entirely certain when we are uncertain? If that, if that makes sense.
Nathalia Costa:
Yeah. That's a, a really good question. And I think if we reflect about the two examples that we, you gave us mm-Hmm. They're both expressing uncertainty, but they're expressing uncertainty in different ways. Mm-Hmm. One is really being, you know, I'm not sure, and then, you know, we need other this and this and that test. And the other one is saying it is likely, which is also an statement of uncertainty. You know, it's not saying it is this, it's likely that it's this mm-Hmm. Based on the physical examination that I just performed. So I'd looked at it, I have asked this question myself and I looked at the literature, you know, to see whether there are different ways of framing uncertainty. They're a bit more successful than, than others. And there isn't really a lot of information out there about this. So that's one of perhaps the next steps, you know, trying to identify ways in which uncertainty can be communicated in a potentially more helpful manner.
Nathalia Costa:
That said, I don't think there is a one size fits all approach. I think this is very dynamic. Different people have different levels of tolerance to uncertainty. So it does require us to, you know, really take an approach where it would depend on the person in front of us. I think it's, it's also fluid. I think even within the same person, you know, at the start of your pain journey, your level of intolerance to uncertainty may change, you know? Mm-Hmm. as Spain progresses over time. So I, I don't have a black and white answer. I do think though, that there are more helpful ways of communicating uncertainty than others. But yeah, I do think that it is, it is something that we need to critically reflect about and really engage in reflectivity when we're making these decisions. And for instance, if we reflect about, you know, when we say that was one example from one of our observations actually, you know, there was this specific physio who suggested that the patient should use prolotherapy.
Nathalia Costa:
And then she asked, you know, she confronted him, do people get better with this treatment? And said, oh yes, people like you do because you have an issue with your ligaments. And Mm-Hmm. And then he gave this thorough explanation about why he was so certain that prolotherapy would work mm-Hmm. For this person. But bear in mind that prior to to that, you know, that there was month eight of being pain or progress, husband came to one of the consultations. 'cause I watched them more than once. Mm-Hmm. . And at that point, he, she started crying when he presented this new option that no one had told her about. And you know, I, I obviously, I, I haven't discussed this with the person, but I could sense or perhaps imagine that she was really uncertain, you know? Mm-Hmm, is this really gonna help me?
Nathalia Costa:
Or is just another, you know, suggestion that came out of the blue. So I think as a clinician, again, it's important to reflect, why am I saying that this is their treatment that is gonna work this time for this person? Is it because I'm uncomfortable with the fact that this person has been seeing me for months and is now getting better? Is it because, you know, I, I truly believe that this is likely to work, even though there isn't a lot of evidence from from trials saying that, you know, it would. So can you see how really scrutinizing how we say things, why we say things might be a way, but yeah. I'm sorry I don't have a black and white answer.
Jared Powell:
No, that's, I I didn't expect one. But that's very well answered. And I think, I think I'm, I'm satisfied with that personally. I think that is, it is definitely a case by case basis. I can, and
Nathalia Costa:
Also, sorry,
Jared Powell:
You're, you're
Nathalia Costa:
Just, just also, you know, tying back to what we talked about earlier, is this fine line between embracing uncertainty in a way that we don't become rigid or we don't paralyze ourselves and we also don't become complacent.
Jared Powell:
Yeah.
Nathalia Costa:
And, you know, can, can we do that in a way that we are also not assuming that this is what people really want? 'cause I think if we listen to people with the lived experience, they'll also say, oh, they told me that this was going to work and it didn't work. So they, they will often say, I wish someone had told me that there was a 30, 40% chance or whatever, that this return wasn't going to work. I wish I knew that before. And I have heard this from people who had surgeries and they were told that the surgery was going to work and it didn't. So I think it's, it's more about, you know, not assuming that certainty is really what people want and really trying to use uncertainty in a, in a positive way. Perhaps even taking the burden away from that individual and putting the burden on science. You know, there are these things Yeah. That we dunno, but this is what we know. Yep. And this is the plan that we can follow.
Jared Powell:
I think that's very powerful. Like, there are ways of communicating uncertainty without leaving that person thinking that you're unprofessional or you dunno what you're doing. You know, you can, I think it comes back to, to us as a clinician to confidently express that. And also you can't express certainty and just lie flat out lie and say, this is going to help when you don't know, because we don't have that data. We don't know how an individual is gonna respond to a certain treatment or we don't know their clinical outcome because there are so many factors that can influence that clinical outcome. So we should never be a hundred percent certain. Like, I know enough about probability that the probability is never zero, like nothing's gonna happen, or the probability is never one that it's always gonna happen. It's always somewhere in between, you know? So I think as a basic moral imperative of being an ethical clinician, you can't be a hundred percent certain at any time. Right. Like, even if you have, apart from the fact that you, if you have a chest infection or infection, you might need an antibiotic when it comes to pain, it's a little bit different.
Nathalia Costa:
Yeah. Yeah. It's, it's very contextual and yeah. As you said, even in, in research, right, we, when we interpret the data from these trials, it's based on averages and we also have confidence into vows. You know, 95% confidence in our Exactly. Gives us a degree of uncertainty 100. So how can we, you know, oversimplify this, you're
Jared Powell:
Preaching to the choir. I love it. Like, like literally there's some, there's something called Heisenberg's uncertainty principle in physics, which means that uncertainty is baked into the foundations of physics and how electrons move. And so if we don't even understand how electrons move, which is what we're kind of made of, then how the hell do we think we have certainty about something as complex as pain? It's absurd. And so I think we just need to be okay with that. And I think everybody needs to read your papers firstly and, and sort of start to think about it in the first place and start to be an inter intellectually honest and reflexive clinician and start to have these hard self interrogating thoughts. I think that's a really good place to start. Is there anything else you want to finish with Nathalia?
Nathalia Costa:
Yeah. what you're saying makes me think of I think his name is Jet, so I can also refer you back to this article. There's a paper called the Human Biology. And in this paper there also talks about genuine complexity. So it's this idea that, 'cause I think we do that a lot in clinical practice. We try to separate things into boxes you know, know these are the biomedical aspects, these are the social, these are the psycho psychological aspects. And I think it's important to acknowledge that things interact and they change each other through these interactions. I think we tend to isolate them and we think that we are being multidimensional because we are looking at different parts, right? In isolation. But I think if we really are to embrace, you know, us things like uncertainty and complexity, we really need to look at the whole and try to appreciate and understand that various things are interacting and changing each other as can unfold as you know, life unfolds.
Jared Powell:
I wholeheartedly agree. Nathalia, where can people find you? Are you on the socials? Where, where can people find you?
Nathalia Costa:
Yeah, I'm trying to not use Twitter as much anymore since a certain person took over . I'm trying to use LinkedIn. I still use it. I, you know, I, it's such a nice way of, you know, learning more about what other people are doing. So I'm still on Twitter. My Twitter handle is Nathalia, see Costa one. And I'm on LinkedIn as well, which I'm slowly trying to make that transition. And it's just my name Nathalia Costa. And I have emails from both the University of Sydney, which is my primary affiliation, but I also, the University of Queensland where I, I am a another jet research fellow. So I can, I dunno, do you want me to give you the addresses and then we can
Jared Powell:
No, that's okay. We'll, we'll spare you from the, the putting your email out in public, but I'm sure people can find you on LinkedIn and Twitter. Nathalia Costa, thank you so much for coming on the show.
Nathalia Costa:
Thanks, Jared. Thanks for having me. I really enjoyed our conversation. I knew I would.
Jared Powell:
Me too. Cheers. Thank you. Thank you for listening to this episode of the Shoulder Physio podcast with Nathalia Koa. 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 listening. I'll chat to you soon.
Nathalia Costa:
The
Jared Powell:
Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ang people.
Nathalia Costa:
I
Jared Powell:
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 peoples and their ongoing cultures and connections to the lands and waters of Australia.
