Pain Education, No Script Provided Episode 3. Social Determinants of Health

Without understanding social determinants of health, pain care becomes guesswork dressed as certainty. Monica Noy helps us separate influence from cause and shows why humility is a clinical skill.

• why private care creates privilege and access gaps
• how BPS gets narrowed and misused as causation
• influence versus cause across bio, psycho and social factors
• education gaps in neuroscience and pain mechanisms
• harms of structural narratives and “root cause” claims
• core social determinants: income, racism, education, work, sleep, access
• sex and gender biases in research and pain treatment
• racism and under treatment of pain 
• practical ways to center context without blame
• building trust through transparency and uncertainty

Pain Education, no script provided, is now available for purchase on my website, thecebe.com
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Chapters

• 0:00 Setting The Stage With Monica Noy
• 1:52 Why Start With Social Determinants
• 5:30 Privilege And Access In Private Care
• 9:49 Influence Versus Cause In Pain
• 17:41 The Limits Of BPS As Causation
• 22:13 Education Gaps And “Root Cause” Claims
• 26:53 Structural Heuristics In Manual Therapy
• 32:33 Patient Confusion From Structural Narratives
• 35:18 Building Context Into Pain Assessment
• 39:03 What Counts As Social Determinants
• 43:05 Sex And Gender In Pain Research
• 49:03 Curriculum Gaps And Slow Adoption
• 51:53 Racism, Bias, And Under-Treatment Of Pain

Transcript

Eric: 0:12

Hello and welcome to the Massage Science Podcast. My name is Eric Purves. I'm a course creator, educator, researcher, RMT, and advocate for evidence-based care. Today is episode three of my seven-episode series of Monica Noi. In this episode, we continue a discussion on social determinants of health, her concerns with some of the causal explanations of the biopsychosocial model, and some reasoning errors with traditional structural approaches to manual therapy. Monica's course, Pain Education No Script Provided, is now available for purchase on my website, the CEBE.com. Here we are, episode three with Monica Noy. We are going to talk about new course. And last week we had a very long and important discussion on healthcare ethics, and we went way off topic, but I think it was good because we discussed a lot of really important things that don't get discussed enough in our profession. Today we're going to try to talk about some social determinants of health, see how that's important and what that means, and why are we talking about it? What is it and what isn't it? I think that's an area of distinction. And then hopefully we'll get into some of the definitions and try and understand why these definitions are important and what they actually mean. So thanks again, Monica, for being here.

Monica: 1:38

Not a problem. It's happy to be here. But so yes, the social determinants of health. So that was one of the this is yeah, the second, is this the second deck? The second deck.

Eric: 1:49

The second, the second module, second deck.

Monica: 1:51

Yeah. And part of the reasons I front loaded the course with this was basically that and the context was basically because I think people jump into trying to learn about pain without actually understanding impacts of health, not just the context in which people find themselves in pain, but all of the other impacts that may be there related to their health. And a big part of this was because of the push for biosucosocial and the idea that BPS was supposed to be. I asked a question about this in one of the many social forums. And the idea was that social determinants of health are supposed to be part of BPS. And any of the descriptions that I've seen in relation to the courses that get taught from a BPS perspective, especially, well, actually not just in relation to pain, but in relation to health, is the social determinants are just assumed to be there and not actually provided to any degree of understanding. And I remember that even from education. I don't know if you remember from your education whether or not you really went into any sort of detail about public health matters and the social determinants of health.

Eric: 3:26

Never, not in massage therapy education for sure. It was never discussed. During my master's, I know we did similar, almost identical degrees. Actually, I think we did do identical degrees at different universities. It was the public health, the social impacts was something that was brought into pretty much every course, or at least it was discussed.

Monica: 3:49

Yeah, and I believe I was thinking about it at that time because I'm just like, what does this mean? Right. So there was uh the idea of this being a social impact or whatever it might be. I wasn't actually very well versed on social determinants of health and what that all meant. Other than it's one of those things like critical thinking. People tell you to go and critical think about this, or they go and tell you that this it relates to social determinants of health, and you could I articulate that? And I'm like, no, I could not articulate what that means. And when I can't articulate something like that, it it does tell me that I don't know enough about it. And what I saw in the, or what I've seen in descriptions of BPS courses that are provided is that they also gloss over what social determinants means. So if you don't already have that in your lexicon, if you don't have that in your education, you're not likely to get it through what would amount to a brief continuing education, a BPS style course, or some sort of other add-on type course that you might get in a particular setting.

Eric: 5:10

I would admit I'm guilty of that too, with when I've taught. Some of my older stuff that's out there, I definitely needs to be updated. So sorry if someone has some access to some of my old course notes or old course material. It definitely needs to be updated. To me, it was always just a matter of yeah, this is a thing we know is important, but definitely myself included, I didn't know enough about it into how to teach it or how to incorporate it, other than this is a thing. And so I what you're saying there, how it being this kind of side note really resonates with my own understanding and then how I have in the past been uh taught this material or taught similar material.

Monica: 5:52

Yeah, it becomes a heuristic, which is sometimes how we do things, where we simplify things enough to understand them. But often what happens is that if you don't get an understanding of it, you just get the simplification. And so that was one of the reasons I wanted to dedicate like a whole, and not just a whole teaching session time, but to understand that will be integrated into what you do and so that you'd be able to, when it comes to making a pain assessment, you're making that pain assessment on the hypothesized biological mechanisms within a context that you understand has these determinants of health and health impacts or health influences. So that's what we're talking about. We're talking these about these key impacts and these processes that influence health in society. And there's a lot of them.

Eric: 6:50

And we'll get those in a second. Obviously, this is a huge component of the course. We could go into a lot of detail, but we'll just touch on, I think, on some of the key ones here so we don't digress too much. So we don't want to give away too much. We don't want to teach the course over a podcast because yeah, people so that people can get at least a taste of it, so to speak. Would you say though, that with the social determinants of health, that understanding these and having an awareness of this large body of literature or this way uh of thinking or understanding people and how social determinants impact health, would you say that better understanding those makes you better able to assess and treat and really appreciate the person that's in front of you? Is that the purpose of it?

Monica: 7:42

Ultimately, yes. I think what it does is gives you a different mindset within a private profession. We're in these professions where people pay for our services, yet we talk about ourselves existing within medicine or existing within healthcare. And I think that a lot of the time we don't really necessarily understand the context of what that means. Like we operate outside of that public health mindset. And the public health mindset, I think, is maybe a better understanding of context when people come to see us. Because then if we don't have that mindset, if we don't understand the context in which someone's existing in life, we have this idea of biosychosocial and this human being having all these dimensions, but we don't necessarily understand those dimensions. And then when someone comes to us in a particular way, one of the disadvantages that already exists within that is that there's a cost. So there's a whole bunch of people that already are not able to access our services. We exist in a place of privilege in relation to that. And some of these social determinants of health probably relate to people who we don't necessarily see a lot of the time. But we're also not ever probably going to see unless we do actually perhaps change something about how we operate or the mindset of the profession or whatever the case may be. And I think that's happening more and more, but it's not going to happen without understanding those determinants, but also understanding how they intersect with each other and how it's not one thing or the other. Nobody exists under one category, right? Nobody is influenced by only one thing. I think it's complicated. I feel like I tend to have a bit of a public health mindset, and that might be what drove me to look in this direction. Would I say I'm an expert on this? Absolutely not. I have if I had a public health degree, maybe I would be able to claim more expertise. But I am more knowledgeable than some within our uh private profession because I've looked into this and because I look at it from a research perspective. So I'm trying to find those resources that people can then look at to say, oh, this is what it means here. This is what the research shows, this is what the policies are, those kinds of things that people can actually start to get a better handle on it.

Eric: 10:36

You made a good point there, Monica. You said we we exist in a place of privilege. And for people that are listening, that's probably massage therapists or osteopaths or anyone else in the manual therapy world. That's a really important thing that we need to accept is that it's not what our services are not cheap.

Monica: 10:58

Right.

Eric: 10:58

They're very expensive. And if you don't have a third-party insurance, very few places have public health insurance. In BC, some groups get a little bit of money, but I think that's rare. That the people we're seeing that are coming to see us usually come from a place of privilege too.

Monica: 12:02

Yes, not always, but the majority, I would say. That's what I'm saying. Yeah.

Eric: 12:08

One thing I'd like to say is we don't want to say always or never. There's you're likely to be wrong then.

Monica: 12:15

But unless we're arguing with our partners, in which case exaggeration is required.

Eric: 12:20

Yeah. Lots of head nods right now on that for sure. So that's something that I really wanted to, I think is important for us to understand is that we come from a place of privilege. So if we're looking at the social determinants of health, we talk about these things, these are important things to understand, but we also have to view we know we're viewing these things from a place of privilege, and those people that maybe fit within part of these or maybe impacted or part of these overall social determinants of health, is may not be as applicable to us as we would think we are, because we're not in that public health space. We're in that privileged private health space.

Monica: 12:57

Yeah. And when we're talking about pain, uh when you look at statistically how many people have pain or chronic pain and how many people see us for that particular issue. And sometimes they see us because of some sort of desperation to try and get something dealt with because they're going through it at the time. We are going to be dealing with people from all walks of life who some of them won't necessarily be able to afford what we're doing. We're offering them something, or we're claiming to offer them something that will provide them with relief or provide them with even something curative or whatever their claim may be. You're going to pay me for that, and there's no guarantee. And also, to some degree, I'm making you this promise when you're in a state of need for that. And I find I find ethically it's very challenging to be in this position and making any kind of claim about anything curative or any kind of guarantee or anything like that. But it's it's without these social determinants of health, it becomes a little bit more of a narrowed perspective as well. Because we because if we don't understand how, if we only understand the people who come and see us and that privileged position that they might be in versus based on what meet we might be in, it's a very limited viewpoint. Once we start to widen our viewpoint to see all of the social determinants of health and all of the people who might intersect in that, and then we add that to something like pain, starts to become a challenging thing to think about in how we're operating.

Eric: 14:47

And this can become a bit of a problem too. When you mentioned earlier about the social determinants, is often part of a BPS idea module or like or course.

Monica: 14:58

Yeah. Supposed to be incorporated in that.

Eric: 15:04

The view of looking at the framework of the of everything that could impact the person. I would say, and let tell me if you agree with this or not, that we need to be careful when looking at these social determinants of health as these being causative of pain. Because the very thing that we want as therapists, we put generalizing as you and I, yeah, as humans is we want to have answers. We want to say, I hurt because of this. And that's so much that's that bio that purely biomedical, biomechanics view of oh, you hurt because or biopsychosocial, if we're gonna go there. Yes, and that's what I was just gonna say. Or it goes to psychosocial where it that gets blamed or that gets a causative thing. And so I think if we're talking about this stuff too, the social determinants, so going to a little more specifics about that, just because these things are influencing doesn't mean that they're causing it. And that is that causative thing, regardless of whether it's biomedical, biological, psychological, social, can be problematic because say their health care is because of some of the things we'll talk about, like poverty or their place in society or other environmental factors. Maybe those things are playing a role, but we can't say that those things are causing it.

Monica: 16:29

No, and they might be part of a causal understanding because there's a challenge to health or whatever the case may be. But to pin a cause of, say, pain or something like that on any one particular factor is hugely problematic. Because when you start to look at how many social determinants of health there are and how they intersect with each other, you can't have these definitive conversations about cause just because there are so many factors that might be involved that have an impact on how a person might have been more likely to get a particular disease, and then whether or not they are actually properly taken care of because they exist in a particular socioeconomic category, or race, there's racial bias within the medical system and all of those kinds of things. So we just have these elements, these factors that come together to become part of somebody's life, or that's how some of the choices are made, or how some of the things happen. And for us to this and this is where the I think this is what the BPS, what it has become really grinds my gears, is that when it gets narrowed down to these psychological components, which it often does, as the most influential of factors or something that can then be treated as a core as causal and then can remove it, it's so simplified to the point of being ridiculous. And it means that you are either ignorant of or choosing to be ignorant of or choosing to ignore all of the other factors that are involved in this person's life as this person exists as a human being, and you've chosen instead, which is where we go to what you were saying before with the causative, whether it's biomedical or whatever, where that just gets translated to BPS, where it's we're just gonna change the causal association with that. And I think if it's biomedical, if it's like biomechanical, some of the elements that we have with whatever the musculoskeletal or whether it's BPS, we are basically highlighting how little we know. It's basically saying, if I'm gonna take this and say, well, this is the cause of your pain or whatever it might be, what I'm doing is exposing my intellectual deficits. And if I'm saying, oh, if you do mindfulness or if you do this or whatever, if you learn more about pain, you'll have less pain. I'm exposing my intellectual deficit of knowledge about mechanisms of management of pain. And I think we've been doing this for a while. This is not undocumented. This is not, we know that we have these deficits, which it goes back to that first deck that we talked about. We 100% know we have those deficits. We have been flagging those deficits for a long time. And that's why this is called no script provided, because this is a it this is an intellectual process. In order for us to really have an understanding of the mechanisms of management of pain, there's a lot of work that has to be done.

Eric: 20:17

And that work is not common. It's not being taught anywhere in entry to practice, or it's not even common knowledge in the or common education in the CE world either.

Monica: 20:31

No, that's why I think Sheridan's the course I created for Sheridan might be a first of its kind in terms of it being just the whole semester. But again, we haven't, it's based on, I hope, a kind of foundational basic sciences and basic neurological mechanisms and consensus science, but there's no measurement tool to figure out whether or not this makes a person reasonable in their understanding of mechanisms and management of pain.

Eric: 21:02

That is coming, isn't it not?

Monica: 21:03

Isn't that coming, yeah.

Eric: 21:06

We will discuss that in another episode. There's a paper coming out looking at that.

Monica: 21:13

There are, and there are quite a few papers that I've seen that do measure when people have BPS courses and they've tried to measure the impact of those courses, but the design and reporting biases are fairly high because the plausibility of the education itself, and whether or not that education is reasonable to address the gaps that we know that are there, the knowledge gaps that are there, is not a consideration. The conclusion assumes the premise, basically, or the premise assumes the conclusion. It's like it's like BPS is taken for granted. So any outcome, any positive outcome that says, oh, these people held on to these characteristics of this education for the future is just a circular kind of a an argument because you've already assumed that BPS is the thing that will be a reasonable education in mechanisms of management pain.

Eric: 22:29

We look to confirm.

Monica: 22:31

But it's just not questioned. I think that's I think that's what we're doing with what I've been trying to do with this, and what what the idea has been is that if we have this knowledge gap, how do we bridge the knowledge gap? It's like, what are the knowledge gaps? The knowledge gaps, clearly, we talked about this before. Did you know the understood? Did you know the definition of pain at the end of your education? Did you know where to find that definition? Did you know how that was brought about? We didn't know these things. We we have so many causes of pain. We were told that this is a cause of pain, that's a cause of pain, that's a cause of pain, with all these tiny little things that can be causal of either health deficits or biomechanical problems or pain or whatever it might be. That basically is just again fundamental misunderstanding. The idea is to go back to foundational work, to say, here's the foundation about my knowledge. It's not absolute T truth, but it is the foundation, the scientific consensus, our basic understanding of how these mechanisms work before we leap off into any other blaming anything else for somebody having pain.

Eric: 23:55

The term that gets thrown around all the time, which makes me cringe, is the root cause. I see people all the time posting stuff online, advertising things, saying that this is the root cause of and that's actually the the way to find it and fix it. And as you said a few minutes ago, is that just really highlights your own lack of knowledge or understanding because that's not a thing.

Monica: 24:19

Right. Right, understanding of the root cause. Because when you ask that question, what is the root cause? And then we let's go back to the social determinants of health on that one, because now we understand that for us to have a root cause, not only do we need to take these determinants of health into account for how a person may present, but then there's the biomedicine, the biology, the physiology of what's happening as well. And if we're missing components of that, and I know in certainly in osteopathy and perhaps in some of the other manual therapies, I think neuroscience has been a big miss in terms of education that we've had. Not that it was deliberately left out, but I think it's a very complex subject. And that integration into the rest of the biology and the physiology has not been there. It's being addressed more, but it's a that's a big there's a big gap.

Eric: 25:19

Oh, it's huge. I would say that in the entry to practice massage therapy education, it is at some of the schools I work with, so it hasn't and have had a look at some of their curriculums and how they and their course outlines and whatnot. And it's still being taught. They're teaching neuroscience or teaching neurophysiology, but it's at such a level, a basic level, that it really doesn't address uh giving students the base knowledge, the foundational knowledge they would need to understand or have a better understanding of both these mechanisms these sensory mechanisms or how the biology of pain. Because there is a pain and stress course that's taught at most schools, and it's usually only a couple lectures, but it's not combined well. And I'm I'm saying I'm generalizing, so people are like, at my school, this is what we do. I'm not talking about your school, I'm talking about general feeling I've had from working in schools. And from yeah, well, we already know there's a deficit, so yeah, we know it's there, but there's the pain and then the neuroscience and all these other factors aren't put together for for students. Uh I I don't feel. I feel it's this piece and then that's left. And so when they come and take a course, or I do a lecture or a presentation and I talk about these things, it's completely new knowledge, even though the components of it could be there in I think in school, but they're just not they're not put together for them in a way that is cohesive, that makes sense. At least that's in my experience. That's what I find.

Monica: 26:51

And also I think to some degree overwhelmed by some of our traditions, maybe. And the traditions being if a massage therapy trigger points, definitely a big one, and postural assessment, and in osteopathy, it's very much the idea of whether something is rotated or upslipped or whatever the case may be. So there's these definite sort of structural or biomechanical kind of components, and and how things work, perhaps on a neurological level, isn't quite as detailed in that regard. Like why would it be that if you can do these tests that might show that something, say one of the hips isn't moving as well as the other one, and that person has pain in the SI area, and they might be standing in a particular postural association, and the structure is taken as the cause. It's well, this the this is out of place. So therefore, that's the cause. And it might definitely look out of place and it might definitely feel like the tissues have some reaction to that. Um, but then again, that's then taking this one thing as this umbrella, as this umbrella solution, right? As this is the root causes because this is not in the right place. If we put this in the right place, then it will change something about what is happening. And it doesn't then allow you to be wrong. Because what happens, let's say, if you treat someone and they feel better afterwards and they then tell you they have less pain in that area, and that's fine. They walk out there happy, you're happy, everyone's happy, but half an hour later, they're back to where they started in terms of the pain in that area. And it's like, what then? Did you do something wrong? Was your treatment bad? Did they do something wrong? Is it if we go to biosychosocial, did they think badly about it? Did they do something physical? So there's all these questions that come up that we can only solve in very limited ways in our thinking, because now we have to go, well, their structure's gone back out of place. So then we have to do something about that. And then we just get on this wheel or this cycle, or our patient gets on this cycle of I have to go and see my therapist because I have this thing again, and they're the only person who can deal with it. And then that becomes a bit problematic for them.

Eric: 29:31

And that's very common, particularly for people that live with ongoing pain, chronic pain population. The it's this constant cycle of searching and finding somebody and then having them treat it, and then you're having to keep come back, or if that doesn't work, then you go see somebody else, and every person gives you a different rationale, different explanation, that's actually structurally based of some kind, and the person doesn't get better. Well, how well uh the question I always like to ask, and when I'm speaking with with students or with new or experienced therapists, depending, I say, well, how does that make the person feel? Inevitably the answer is will make them feel confused, it makes them feel scared, it makes them feel unsure, it makes them feel untrusting, and exactly because we're putting a blame or we're putting a causative factor on something that is trying to be fixed when maybe we're looking at the wrong thing.

Monica: 30:29

Yeah, or looking at the it the wrong way.

Eric: 30:33

The wrong way is a better way of putting it.

Monica: 30:34

Yeah, and the wrong thought process along with it. And that's one of the it's one of the reasons for this is to when we get to making a pain assessment. Is to understand where we can place these neurophysiological mechanisms, these neurological mechanisms within a larger context. The social determinants of health is really about understanding an even larger context to that before that person even gets into the clinic or where that clinic is situated. So that clinic is situated in a building that exists in a much bigger world. So yeah, it becomes complex. I'm not sure if I'm making sense here. It's like I find once you start talking, it's like the social alternative health where there's just so many things that not only relate to it, to that, but also relate to each other. And so then you start to go, it's like I'm not keeping myself linear here. I just start to go off on little tangents. Oh, and then there's this, and then there's this. So it becomes a little more challenging to keep yourself a little bit more defined, which I'm gonna try and do.

Eric: 31:53

Let's talk maybe a little more detail about the social determinants of what is it, and what are some examples of what would fit within a social determinant of health? You mentioned poverty.

Monica: 32:04

Yeah, so the so interestingly enough, there is like Canada.ca has public health information pages. They provide a definition. And uh, what are the social determinants of health? They describe it as this broad range of personal, social, economic, environmental factors. And they have main ones. Things will be like race and racism, income, social status, employment, working conditions. And I know in our health histories sometimes we'll have blue flags where it's is there something about the working condition that may be impacting this person and what they're coming to you for? Literacy, health literacy, education in general, a physical environment that a person might exist in, any social supports they might have, various coping skills that may or may not be available to them or that they have, the kinds of we talk about lifestyle and lifestyle behaviors, but some of those might also be impacts. We know that the they can be cellular insults in relation to how lack of consistent lack of sleep, smoking, consistent poor diet, like consistent lack of exercise, all of these things end up being cellular impacts over time. So we know that's that can be physical, but it's also part of a social environment. Access to healthcare services, uh, when we go to say poverty or race and racism, we're talking then about even access within those healthcare services. So even if someone gets into a healthcare service, then what their access looks like about being treated reasonably. But people's culture and genetics is one of those things to consider as well. And then we might be talking about predispositions in relation to that as well. It's just what we can consider key impacts and how they are dealt with on a societal, economic, and then on a personal level. It can relate to an individual's place in their society and then that larger societal impact on that individual.

Eric: 34:13

One thing you mentioned in this, which is a topic that does not get discussed enough, at least in what I have seen. I've only seen maybe one or two other presentations very brief in my life on sex and gender and sex categories and how this influences not just research, but also pain and treatment of pain. Can you elaborate a little bit on that?

Monica: 34:37

Well, I think in terms of the research that's been done, most research defaults to the binary. If ever there's participant research, usually the categories that will be looked at will be both the sex category of man, woman, uh woman, and then the gender category of male, female. It will basically be just or man and woman. So we're just staying with that binary. So questions will relate to the binary. There's not, there's often not an option. You start to see more and more there is options when people sign up, but often when there's comparisons with relation to something like pain, it'll be more of a default to the binary. And again, some good definitions that come up with this in relation to sex and gender come from some Canadian websites as well, so Canadian government websites. And they did some defining of sex and gender in 2014, which is actually quite interesting because I think that number one, sometimes people confuse the categories. And number two, people think of these categories in terms of defining characteristics. And when we really explore these categories, there isn't necessarily a defining characteristic for any of them that would we'd be able to say you have this characteristic, therefore you fit into this category of man, woman, male, female, whatever it might be. Because there'll be something else that has that character or characteristic that would then also put it into that category, but we might not, like on a sort of an external level, you would be like, oh, hold on, no, that person wouldn't fit there. And I've heard other ways of describing these characteristics that, or these categories that mean that we don't have to rely on a defining characteristic to be in the category. But we still need to have a lot more options in terms of not only how people see these categories, what categories there are, but also the kinds of discrimination that occurs because people are not immediately aligned with one category or the other on an observational level, especially in a healthcare setting. Um so that's one of those determinants that that exists that has a real problem for diversity for people who just don't fit in that category or don't see themselves in that category.

Eric: 37:23

And you you shared too, and there's some research about their uh not being uh good enough, and we know, okay, this is a million times, there's this knowledge gaps about sex and gender in pain education, and there is some curriculum that's been developed, but it hasn't really been implemented yet. Is that correct? Uh what do you mean with regard to oh just with regard there was this one one uh paper you shared that looks at the a paper introduced to curriculum development to be implemented in medical school and other healthcare programs to look about inclusiveness and equal opportunities in health, about sex and gender. But the paper's from 2023, so it's right in pain education. Yeah, so it's very new. I guess I'm just kind of bringing up saying that there's this this conversation we had, but the actual application of this into education is has not happened yet, even though some of the background information on curriculum development and what to do with this information is there.

Monica: 38:18

The application well, a lot of the a lot of this goes back to our knowledge gaps. So when you see papers like this, where this one was gender and sex bias in prevention and clinical treatment of women's chronic pain. So it was a hypothesis of a of curriculum development, which I think is basically what we're doing with this pain course as well, as a kind of a hypothesis of pain development to basically try and address some of the gaps that exist in our not in not just in our knowledge, but in our management of people who have pain or have who might have another condition that relates and is seeking healthcare. I'm again definitely not an expert on the management of this. My goal here was to give people an understanding, definitions, a place to find those definitions. This is not an exhaustive list because I know there are places in within Ontario as well that have much more specific healthcare related to people who are transgender or genderqueer or whatever it is. So people are going to have a much better understanding of management with relation to that. My perspective comes more from what are our definitions, what's our research around it, all of those kinds of things. Where can we gain understanding? Where can we gain some knowledge? On a management level, this course doesn't have that within it, because that's not this course. Certainly, those courses will probably exist to some degree, but that's not this one. This is more on a knowledge base.

Eric: 39:58

Yeah. Which makes sense because it there's only so much you can teach on the subject and in keeping it within something that's digestible for people.

Monica: 40:10

Yeah, and I wish I had more knowledge and I'm gaining more knowledge as I go. So usually I try and update these every time I review them. And it's like, well, what else do we know? But the knowledge has been around for a little while. It's just, yeah, you're right. It's not as well uptaken. I think part of it is because we see that if someone's got a hypothesis of curriculum development that will address these gaps, some of these gaps, we're not necessarily seeing that curriculum to a large scale degree in healthcare.

Eric: 40:41

No, not yet. But hopefully soon. Sometime sooner than later.

Monica: 40:45

Hopefully soon. Yeah.

Eric: 40:48

Yeah. I mean, because the kind of three main categories that you have here for in the social determinants, and these are not an exhaustive, are racism, sex, gender, and poverty. I'm assuming that those are the three big areas of the social determinants. I'm sure there's others.

Monica: 41:08

Well, I thought I I looked at these ones specifically because they have a relationship to pain as well. So we do know in some of the research that there's also a correlation there. So one of these studies, which is from again 2023, which is related to transgender and gender-diverse people, what they found was that the literature points to this increase in pain experiences. And again, there's a knowledge gap here. What does that mean for the increase in pain experiences and how are they getting treated? And what are there any effective treatments? What are the unique considerations? Some of that is an understanding of what's happening within within research in relation to that. So that's good. There's other transgender research or research related to transgender and gender code categories that's being conducted. The same thing with race and racism, because it's already a structural system that privileges some groups of people over others and ends up creating barriers to care because automatically the way it's set up is that someone will be disadvantaged within this structure. And also in terms of the research that we can see with uh racism and pain is that black people are not taken care of properly when with relation to having pain. They're not treated in the same way, and pain is often seen as not as bad or not taken as seriously. And we can see examples of that in news, we've had recent examples of that in Canada, and those are really big important things to consider. And I don't think that like we think of ourselves as good people, you know, we're coming from a white perspective here, but we're not if we don't understand our own privilege, not just our own privilege, but our own place in a privileged society, in a society that automatically privileges us, and that we're the education we're getting is structured to support that society. One of the things that happens with research and racism is that there's marginalization that occurs also within a research setting. So we're not getting as much of that career progression in academia. We're also seeing perhaps inequity in funding and also inequity in subject that might be studied. So then we're not getting the information that we need to address the knowledge gaps as well, and for people to be able to consider their own privilege and perspective when they treat someone who is gender diverse or when they treat someone who is a person of color with within our society. So social determinants of health is not necessarily just about understanding what they are, it's understanding where we fit within that societal structure that means that those determinants have an impact either on us or on the people that we see. And this is one of the probably the big intersections that we might see is that we come from a place where, oh, I was supported with my education or I am supported with structural elements within society, and I see these people who are not. But I don't necessarily take that into consideration. And also a level of untrustworthiness that exists if you're in a privileged position where you're asking for money for a particular service that you say will help somebody, but you're saying, well, you have to pay me first before I will help you on a healthcare level. So there's a lot of, yeah, a lot of these different things that are occurring in a lot of different ways, where it's these systemic issues very much are public health related. And we can be insulated from that in some way because we divorce ourselves from that public health mindset.

Eric: 45:24

Which is where we started the conversation today, too, about our place of privilege and the place that we exist in healthcare as as professions. And I think this these conversations are so great. I'm really happy we're having these because I don't hear other people having these conversations in our world, in our profession. I it's these other professions and in public health stuff and in medicine, but I don't think we're having enough of these in ours. So hopefully people are appreciating this and understanding the importance of this. But what I loved what you said is is it's not so much about just understanding, but it's more about acknowledging where we fit within these structures within the system. I think is something that we should all stop and reflect on because I I can pretty sure that's I know I haven't done much of this enough, and I'll admit that not done enough of that to really think how do I fit in this and where do I fit.

Monica: 46:23

And one of the reasons for me delving into this was this understanding because we went into this sort of BPS mindset where we went through these understanding of, well, oh no, someone's told us that they're stressed about something. So we have to take that into consideration, and it very easily becomes this bigger factor than it should be in the presentation that they're there, and we're focused on their stress and maybe trying to deal with how they can limit that, and perhaps that will be helpful in their pain and all of those sorts of things. But it was so, it just seems so limited to me because when we look at the amount of social determinants of health and the impacts that they can have and the ways in which they intersect, every time a person steps into our clinic, despite the fact that we might be in a privileged position because we're asking for money and they're in a position that they're willing to or have the ability to pay for that. Anytime someone steps into our clinic, any one or combination of those determinants will have some impact on how a person presents, on how a person recovers, on their ability to access our care, but also other forms of healthcare. If we're just talking about sex discrimination, the research shows us that just sexism on a level of a binary level between men and women, like women are highly discriminated against with relation to pain as well, in a healthcare setting, structured in that way. So their access to care is going to change in different ways as well. Our own biases, we don't even know that we have these biases, but we are educated in that societal structure. We're educated in that healthcare structure that exists in a society that is created to be discriminatory against a bunch of people and is was not just created to be discriminatory, but is sustained in such a way. And we are part of that. We actually are educated in uh maintaining that, not that it's not that overt, but because of the way we think, because of the knowledge gaps that are there, because of the kinds of things that we might say, because of the way we think of ourselves as experts within a particular field, and that we maybe have intellectual arrogance because we think we know everything within this small healthcare setting, that we are not taking into account our own implicit and perhaps explicit biases towards people from cultures that we're not familiar with, or who have genetic conditions that we don't have an understanding of, or who have exist within a place where they maybe don't have the supports that they need, or just being discriminated against in other ways. We're not looking in our own context. We're not necessarily looking at the patient context, except in really narrow ways. And I think that becomes very problematic when we want to when we want to claim that we are patient or person-centered healthcare therapists, because we are talking the talk, but we have no idea how to walk the walk.

Eric: 49:52

That was brilliant, Monica. And I think we'll wrap it up there because that was a really powerful and important way to end that. Next episode, we'll discuss some of the mechanisms, some of the definitions. I knew we weren't gonna get to that topic.

Monica: 50:09

No, there's no way I was I ram I rambled a bit today, so you can edit in post.

Eric: 50:15

I honestly think that the ramblings, the more unstructured, the more free thoughts that come out of these podcast episodes are the stuff that people like the most anyway.

Monica: 50:27

Well, I think it's also characteristic of our inability to grasp sometimes. Like even though I've set this up as a course and I've looked into all of these things and I have some knowledge about this, I still understand that my knowledge has limitations to it. So the more we know And those are the things when you're trying to articulate it, it's like it can take some time to really fully articulate that, and perhaps some education that I don't have as well.

Eric: 50:54

Well, the more we know, the more we know that we don't know. Exactly. And it is hard. I know from my own personal experiences when you're learning something, one of the best ways to learn it is to try to articulate it, to try to speak it, to try to teach it, to try to have a conversation about it. Because if you that's how you work through things and you understand it gives you an opportunity to try to explain things in different ways or try to get some feedback from somebody to say, does this make sense? Is this right? Is this wrong? What do you think of this? And and that's the way I'm viewing these conversations that we've had is just to listen to what you have to say, but also when appropriate, to try to reflect back some of my own understandings, just see where am I on this? Because either talking to a computer screen by yourself or to a brick wall is not nearly as useful as having these conversations. So I think it's great, it's real, and that's what we wanted with these. Yeah, I'm really happy with that. And yeah, I think it'll I think it comes out comes across really well for listeners. So next time, we're only gonna talk definitions, mechanisms, and our clinical plane pain descriptors next time, and we won't plan anything else, so that way we can get through that.

Monica: 52:07

Yeah, and we'll see if we can follow our plan.

Eric: 52:10

Yeah, okay. Well, thanks, Monica.

Monica: 52:13

No worries, thank you again, and I will talk again next week.

Eric: 52:18

Thank you for listening. Pain Education, no script provided, is now available for purchase on my website, thece.com. To listen to more of these episodes, please subscribe on your favorite podcast network. If you enjoyed this episode, please like and share to your favorite social media platforms. If you'd like to connect with me, I can be reached to my website, thece.com, or send me a DM through Instagram at Eric underscore pervis underscore C E B E. If you really like this episode and you want to support my podcast, please consider making a small donation. This can be done by clicking on the support button or heading over to buymeacoffee.com slash hello.