Sula (00:00.11) Yeah sure. Like what I'm and so in the in in our introduction, what all do you want to hear about? Yeah, don't worry. I'll ask you the question. I give you a better into introducing yourself. So yeah, I'm really happy to have you both on the podcast and I can't wait to get into looking at patients as a whole when supporting people with pelvic conditions and bladder conditions. But I'd love you both to introduce yourself. So maybe starting with you, Katie, just talking a little bit about who you are, what you do and maybe what brought you into this area of supporting people with bladder and pelvic health. sure. so I am a nurse practitioner. I work at an integrative health center in an academic institution. and have been here for 16 years. We see a lot of patients that have what I usually say is sort of complex chronic pain, usually folks that have tried sort of all the things and for are still not feeling great. and prior to this, I was actually a massage therapist for many years. So in more of a holistic space, and then had sort of brought that sensibility into this more conventional environment. and you know, interested in this, I mean, first of all, you can't be a woman in this world without either having this yourself or having people that are close to you that have it. It's the, you know, prevalence is so high. So, and and it is you know, mm. Kathryn (01:33.678) All pain conditions are often sort of understudied, poorly understood, but certainly anything that is specific to women is extra in that category. So that we're sort of often in this gray space trying to come up with stuff, don't have as much guidance as we like or as many answers as we'd like. And that sort of is a lot of, you know, people often are seeking out integrative care. They're seeking out other answers because they're not finding them easily in another space. So that's I think how a lot of folks end up finding us and how. Because those are that's who shows up. That's, you know, what then we're meeting. Yeah, it's definitely been a theme coming up in this podcast so far and it's definitely something I see. I also work with people with complex pain presentations and that want for understanding things a bit more holistically, but of course the difficulty in finding that. I'm really excited to be exploring that with you both today. And Shelley, I'd love you to introduce yourself as well, a bit about you, your background and also if you're happy to share how you got into this area. Yeah, sure. So I'm a nurse practitioner also at an academic institution. Mirror with Katie at the same institution. So we do share a lot of patients. I went to Vanderbilt for my training as a nurse practitioner, but I as a nurse I was in urology previously. So I that flowed over into seeing patients in your in our urology practice. Primarily work with female pelvic floor reconstruction group that doesn't exclude men. We still see men. they have the same issues, but it's it we do see both men and women. it it with my practice and then our overlapping integrative department, we shared a lot of patience. And so that led Shelli (03:29.142) one of our psychologists to reach out to me because she was seeing some of my patients over there and doing some fabulous work with them, which also made it easier for me to take care of them, especially doing exams in such a delicate area and a situation. We don't want to increase more pain for these patients. So that was really helpful. And with that, that led to us actually seeing patients together. So now we do an integrative clinic just one half day a week. So we try to get as many patients seen as we can, which is difficult in that shorter time, but that's what we've been allowed. So we actually see the patients together in the same room, give that support for all aspects of care. So not just the physical side, but or the medical side of treatment, but also, you know, the mindful side of treatment. And I think that does help with doing exams, and then treatment and outcomes. Hmm. Sula (04:38.902) Yeah, absolutely. And I want to ask you more about that very specifically as we go through, but just the psychologist you were talking about was that Lindsay McKernan. Yes. So Lindsay, I think she's on our episode five and she was, you know, exploring a whole range of, you know, psychological factors that play a massive role. So it'd be really lovely as well for us to be able to reflect together a little bit about how that. Yeah, that's what's lensing. Sula (05:02.561) how that features in, like you're saying, Shelley, on your treatment as a nurse practitioner and in that medical setting too. Maybe just to start off though, I'd be really interested to hear both of your perspectives on what changes, Katie, at the beginning you were saying, you know, a lot of people find you after going in and out of treatments and bouncing from practitioner to practitioner wanting to find answers. then when they do find a center like yours, which I feel like is gold dust and everybody's going to be going at now, what changes for the patient when it goes from being bounced around to them being seen in this integrative setting? Yeah, I mean, I think it's it's not magic, all right? I think that it's something that can and should be implemented everywhere. But there really is something about, you know, our system is designed to find the problem and solve it. And it's so good at that in so many ways. I mean, we can cure cancer. If you need a heart, we can get you a new heart. I mean, it's incredible what this system can do from a, you know, disease. Mm. Kathryn (06:17.26) healing standpoint. But when we apply that same framework to a specif to pain, honestly, like just about any kind of chronic pain, but specifically you zero in on this one area, this little tiny square inch where it hurts, you're missing sort of the rest of the picture because we don't have a lot of answers. Our treatments for this are we're lucky when we 50% of people have a response to a specific treatment, which is so different than You know, when you get your treatment for a strep throat. and so when we have an opportunity to look at all of the different pieces, like we get to put the person back together again and look at it in the larger context. And oftentimes at that point, there's a lot more opportunity of where we can have some agency and do something to make someone help someone to feel better. And in our Yeah. Kathryn (07:10.638) context so often I am not an I mean if I had the cure obviously if I had the cure I would just tell you that in the first five minutes and then we could be done. But because I don't have the answers and because I don't have to, I'm not just picking the right treatment, we're really stepping back and going, okay, well, what could we possibly do that hasn't been explored in this larger system? So optimizing around whether it's sleep or nutrition or environment or relationships or coping or all of these different things. Yes. Sula (07:36.621) Mm. Which might mechanistically shift symptoms, but we're also holding space for, and what if we can't fix this? How do we play the hand that we've been dealt as well as we possibly can and focus on what we can control? So it's this it's this both and of I sometimes think of it like baby birding. It's like Mmm. We want to look for opportunity. Like, you know, if you if you have a baby bird in your hand and you like hold onto it too tight, you kill it. I think like we're trying to find the answer. Sometimes it's really hard to find the answer because we're sort of suffocating around this one specific outcome. If you just totally let go, then the thing runs away. You have to hold like what can we control control while also holding space for not being able to control the outcomes. That's such a great phrase. I'd never heard that before. I'm definitely going to, going to take that one forward. Yeah. It's such a tricky balance, but you've described that so well of looking more broadly to find the scope for agency and potential improvements whilst yes, not baby birding, not holding so tight that it gets in the way. Kathryn (08:46.558) Well yeah, and I'd want to add to that too, that as important and meaningful as lifestyle and integrative interventions are, they can't solve everything. And so sometimes I definitely get folks in that are eating the absolute perfect icy diet and like trying to do all these things, and and I'm meditating and I'm getting acupuncture and I'm doing all these things and they still feel bad. Mm-hmm. Kathryn (09:14.614) And it's almost like this internal shame of like, I'm trying so hard. because I'm trying so hard, what am I doing wrong? Is it sh it should be working? And so it's also a place to like create space for you could be doing everything right and you might still have a flare. You might still have a bad day. This is not like you don't have this condition because you did something bad or you know, it's your fault, but I think that a lot of people are interacting with it that way. Yeah. Sula (09:31.231) Yeah. Sula (09:36.567) Yeah. Kathryn (09:41.206) And that is sort of another layer of like stress and complexity when they're trying to seek care and prioritize what they're doing. because they're still looking for the, you know, if I do it right, then it'll go away. If I never eat a tomato, if I do all of my pelvic floor PT exercises, and it's it's focused on that piece versus holding space for the complexity. And I and I'll also say too, you know, almost you know, most, like least half. Yeah. Yeah. Kathryn (10:10.09) Of folks with bladder pain also have other types of pain. And so oftentimes, no, no matter what type of pain somebody comes into my clinic with, I'm gonna ask them about all of the comp you know chronic overlapping pain conditions. because so often they're focused on one and that's where all their effort is going. But it's like, well, but you also have migraines, we also have IBS, we also have, you know, chronic low back pain or something else in the mix. And Yeah. Sula (10:30.081) Mm-hmm. Kathryn (10:38.284) While what you're doing isn't helping this piece, even though that is the most distress for you, if we back up and try to get some of these other systems in a better balance, then either you'll have more capacity for dealing with the most challenging thing, even if it doesn't change, or if we can get the rest of the system into balance, we might get lucky and have improvement in that primary issue. Yeah, I'd love to talk to you about the overlapping comorbidities and getting that system into balance. But I'd love to hear from you first, Shelley, a bit about an extension of that, right, as in your role from a physical health side and then having the context of people working to that wider picture. How does that change things for you and your practice? Yeah, that's I also get those calls. Yeah, I have a flare, I don't know what to do. so usually when I s when I see these patients on the forefront, it's okay, we know this is chronic, we know there's gonna be episodes. That's when we need a toolbox. So you keep in your toolbox your tools that you need for these flares. And that might be just a piece of paper to remind you to do your stretches. That might be your over your spasm pill or your muscle relaxer or you know the medical side of things that I want them to also put in that toolbox. That might be their oil that they prefer, or if it's a lavender rub or a heating pad, or just something like that. So they can pull those tools out and not have to think because when they get in that capacity of the pain's here, I'm having a flare. then that's where the anxiety goes up. Everything the the migraine starts, the they get constipated and that exacerbates their symptoms. You know, so it all falls into this chain effect. So that's why I feel like if they have their toolbox, they don't have to think about what do I need right now as these symptoms are starting. this is for my burning. this is for my muscle relaxation. yes, I need to breathe, take a step back and do some of my breathing, pull out my stretches again. Shelli (12:48.789) so just trying to lower their heightening of their symptoms. So by i having a easy access to their toolbox. Yeah, it's an interesting point that you make and one that reflects my experience in working with people to build that toolbox from a psychological side of things. You identified when they start to think, you know, that's when everything starts spiraling. And I talk about this quite explicitly of when you're in that threat level because of the pain flaring or the symptoms flaring, even if it's not pain, that increased urgency or whatever it might be. your brain starts processing in a different mode, which kind of flips you into that very thinky, spirally mode. And from there, it feels productive to think, but actually, as you say, just feeds, yeah, feeds all of these kind of internal threat processes. Yeah, the body gension from head to toe starts. Yeah, absolutely. Can I ask you as well about specifically when you mentioned having a psychologist work in clinic with you and that helping, what difference do you see that make? Because again, I think that's such a unique thing. Most places don't have that possibility of having a physician alongside a psychologist. How does that change things, do you think, from your point of view? Shelli (14:21.107) I do not that the patients don't feel heard with with just myself or just their, you know, medical provider, but I do feel like with us as a team, they they recognize this team approach. They feel a little bit more heard. I think that helps with the trust factor. So then that allows us to dig a little deeper. They share a little bit more with us. So we get to know that patient. Yes, we do spend an hour. at their at their initial visit with them. So we do have more time. But I think it just it helps break down that wall. Like a lot of these patients have seen so many providers before they even make it to myself or Katie or or i in Lindsay's lap. And so they feel disappointment. They feel like they're at their last resort. They feel like they haven't been heard. So I do feel like that helps that barrier. You know, now they feel like they have a whole team. that's going to help them. They have that s a bigger support system. So if I don't have the resources they need, Lindsay may have the resources they need from a psychology aspect. you know, living with a chronic condition is is forever. And they realize that and they feel dread. So I think that helps enlighten it slightly. Yeah. Sula (15:35.905) Yeah. Sula (15:39.65) Yeah. Sula (15:45.421) Yeah, absolutely. Cause again, it's another theme that comes up in the podcast comes up in my clinical practice. You mentioned about not necessarily feeling heard and we've had amazing professionals on. you know, I do think it's, it's a, an exceptional pool of professionals working with people that we've had on, but the norm often is that people aren't feeling terribly heard by their practitioners for all sorts of reasons, not always to do with, skill or anything like that, but to do with time constraints and just lack of knowledge around certain things. that element of feeling heard and feeling safe to open up, like you say, extracts important information as well as changing, I suppose, the experience for the patient in a massive way. Sure. Shelli (16:33.655) Mm-hmm. Yeah, I think I mean I hear like it's like I and also it's the feeling heard, but also many of them actually were not hurt. You know. Also, you know, symptoms were not necessarily explored. Or I mean, I can't tell you I because again, I I screen everybody that comes in for all the different C O P Cs. And so so often I'm seeing people for other stuff and nobody's ever asked them about bladder or pelvic pain. And so they've never had any kind of treatment for. And I'm like, Go on Katie. Sula (16:43.573) Yes, yeah, absolutely. Yeah. Yeah. Sula (16:59.127) Yeah. Yeah. Kathryn (17:04.226) well, you're gonna need to go see Shelly, you know. they're like, Well, I've I you know, I've been to my regular annual and you know, which is just sort of the the the pelvic, the pana, the birth control, what have you. And then a lot of the other symptoms sort of get just sort of shut aside and or they just didn't even know you could get care for it. So yeah. Yeah. Shelli (17:23.169) Yeah. Like if their trigger is pain with intercourse, you know, that that you don't have to live that way. It's not gonna be healthy for your home life either. So Yeah. Sula (17:30.785) Yeah. Sula (17:35.103) Absolutely. And actually we had an episode which has just recently come out with two psychosexual therapists talking about this difficulty that healthcare practitioners have around talking about sex, feeling like they can ask about it, feeling comfortable enough to ask and how that then can leave people feeling like they can't talk about it. And also like it would be wrong or that they're somehow, you know, yeah, the cake, Kate Moyle, who was one of the psychosexual therapists, she gave this example of treating breast cancer survivors and them sharing that they felt like they should just be grateful that they survived breast cancer. So why should, you know, it wasn't fair for them to also want to have sex still. And just the power of, yeah, being asked versus not being asked and the permission that gives and what it opens up for someone's life or not. Yeah. I guess, speaking of this, like looking at things in isolation and what impact that has on patient care. Could you perhaps speak to that? If somebody presents with pelvic pain or presents with a urological set of symptoms or condition, what gets missed if it's just looked at by the component part as opposed to from this broader picture? Perhaps Shelley, you can answer first. Yeah. So when I have those patients come in that they they say, Well, they told me I have IC or interstitial cystitis, but my symptoms are triggered by intercourse, or they've looked in my bladder and said my bladder's normal, you know. So that's when I I want to just take a step back and okay, well, what other symptoms are do you have? Do you have do you have constipation? You know, what what else is going on in that pelvic floor that can be contributing to to their flares or pain with intercourse? Are are they menopause? Do we need to add something for dryness? What are they using for lubrication? are they having urinary tract infections that are not being treated? or are they not having air force because the that triggers a you know flare or UTI. so it it I I do like to Shelli (20:00.871) Ask about more things. And I think that we all should do that when somebody complains. but that's that's what they usually say. Well, they told me there was nothing else to do. I have I see, here's a diet, go on. My bladder looks fine. or they have urinary frequency and they're going every hour, they're up all night, now they have lack of sleep. So that enheightens their symptoms. Mm-hmm. Yeah. Sula (20:23.511) Yeah. Yeah, just even asking those broader questions that unfortunately lots of people don't get asked. So then it can never be addressed if you don't know. Yeah. Katie, I'd love to hear from you as well. Yeah, I mean, and that's, you know, from that like medical management side, that's the expansion from the integrative health side, it would be. And we're gonna talk about, I wanna know about sleep. I wanna know about not just like what are you eating, but what's your relationship to food? I want to know about what is movement like in your life? Are you moving, not moving? Relationships, what's supportive? Are you able to do what's important to you? You know, sort of back up to kind of look at that. Yes. Kathryn (21:09.784) that larger architecture of what's happening. Cause I think un understanding the the context within which this is experienced is is significant to understanding how the path forward. And I guess there's another piece in there around I you know I am a a big believer in helping people to understand sort of the why of of what they're feeling. So, you know, understanding that there are different mechanisms that are driving bladder pain. Bladder pain is not just one thing. There are people that have more sort of that peripheral, you know, and there's and I this is a, you know, a growing area of research. It's exciting to see Lindsay's work and and, you know, other other groups that are starting to like help us to understand some of this phenotyping of pain. But helping somebody if they if they've got, you know, more of that gnosyplastic or central sensitization pain picture versus more Yeah. Kathryn (22:06.978) you know, sort of localized or peripheral symptoms, I think that helps them to know then which tool to pick up. why does it hurt? This particular pain, this is a bladder spasm. A bladder is a muscle, it's smooth muscle, but how would you h respond to any muscle that's in spasm? It can kind of help demystify a little bit of what's happening and help people feel sort of less broken. Yeah. Cause a lot of the responses that the body is having with bladder stuff, it's like your body's trying to protect you, your body's trying to help you by giving you these signals. And if you can acknowledge where which quadrant it's coming from, you can better navigate that experience and and and the tools. Yeah. Sula (22:47.277) Could you, I guess just for listeners who aren't aware of those different types of pain, could you perhaps give a bit of an idea of the difference between noti- plastic, notis- yeah, that one. Yes. Yeah, yeah. you know, and and the and the literature on central sensitization and oceplastic pain really is coming out of the last, you know, 15, 20 years. So it's our under it's adding to our under previous understanding of pain and really I think has has given us the framework for understanding why we can't take a picture of pain, why we're not great at, well, your bladder looks fine. It's like, you know, what is happening with that? And and so I so I think of it as Yeah. Kathryn (23:32.034) you know, and there and there really are sort of these emerging, you know, archetypes of people that have, you know, this is true in some of the endometriosis research. you know, and this is like I think that's sort of the best, but sort of one of the best examples is of this is some of the data around, you know, when they go in and they do that laparoscopic procedure to remove the endometrial, you know, endometriosis. some people have significant improvement in their pain and their symptoms, and some people don't. And it's not like five percent of the time they don't. Mm-hmm. Kathryn (24:00.352) It really can be, you know, 50%, 20 to 50% of the time, people don't have improvement in those symptoms, which means, you know, and if you walk up into anybody on the street and said, hey, does like do bleeding lesions hurt? Everybody would be like, well, I bet they probably do. and then when they go and take those out and it doesn't change the pain, it really challenges our understanding of what's happening. And sensual sensitization is the mechanism through which the part of the parts of the brain that process pain are essentially really good at sort of Mm-hmm. Kathryn (24:30.614) they're on high alert, shall we say, for finding that pain. And so they are areas get sensitized. And it can be in one area, it can be systemically. And there's a number of different conditions where we think central sensitization plays a role. So fibromyalgia, IBS, IC, you know, a number of these different conditions where this is a piece of it. sometimes and and for some people it's most of where the pain is coming from and some people it's much less. But we are just you Sula (24:58.103) Yeah. We are just now starting to try to develop the understanding and the tools to distinguish those things. whereas the peripheral pain, like no seceptive pain, is sort of the more of the classic you stub your toe and it hurts right away, tissue damage pain, you know, acute inflammation in an area, which is, you know, a healing response, but versus sensual sensitization, which is more about pain processing. So signals come to the brain, the brain is what creates pain, that's true for all the types of pain, but in sensual sensitization. It is often things that shouldn't hurt that aren't causing damage are painful. So you barely touch it and it hurts. There's three drops of urine in your bladder and it hurts, even though the bladder lining isn't inflamed in certain cases. That is that central sensitization pain. And that really is, I I sort of think of it like, you know, the alarm, it's the pain is that harm alarm. It's the alarm system is just on a hair trigger for interpreting sensory stimulation as pain. Mm-hmm. Kathryn (25:57.236) And what what is often goes along with central sensitization are other sensory symptoms. So it's not only pain, it's also sensitivity to light or sound or touch or you know other things like that. The system is sort of processing way more information than it can handle. It also comes often comes along with brain fog, fatigue. like the body is sort of in overdrive, noticing and then trying to respond to pain. And and so Hmm. Kathryn (26:27.116) You know, this is where distinguishing between between these pieces is important because if you've got central sensitization and you're doing pelvic floor PT, like there's maybe like gonna be a little less successful versus if all of your pain is peripheral, then the topical, the trigger point injection, the pelvic floor PT is probably gonna be much more successful. you know, our medications like, you know, the ametryptyline and, you know, all those things that we sort of give to people for like that neuropathic pain stuff are probably going to be less effective in somebody where most of their pain is peripheral versus more likely to be helpful for central sensitization pain. So understanding even just those two buckets of pain can help people respond to them more effectively. Mm-hmm. Sula (27:13.535) Absolutely. One of the questions that I can hear everybody asking, because it comes up a lot in my practice too when talking about these different types of pain is, how do you distinguish between the two types of pain? How do you know if it's more nociceptive or if it's coming from central sensitization? Yeah. So well first of all you can have both at the same time. So sorry. but Mm-hmm. Mm-hmm. That's really important though, right? Because I think our brains are very good at dichotomizing and being like it's one or the other. And I think quite often actually there is both going on in lots of conditions. Yeah. Shelli (27:51.137) They overlap. They overlap. And and it's not a small amount of overlap. I mean, I don't know, you know, like the the you know, in for example, rheumatoid arthritis, which is sort of classic, you know, autoimmune inflammatory arthritis and and a lot of peripheral drivers of pain. About forty percent of people that have that also have central sensitization pain. And so you can see it all of a sudden how it can be confusing because you might be taking a medication for your rheumatoid arthritis. Hmm. Kathryn (28:17.822) And they're saying, your inflammatory markers look better, but your pain hasn't changed. And it's like, well, is the medicine not working or is it just not that doesn't treat central sensitization pain? So I think understanding what your treatments are getting are supposed to do. So for example, you know, ibuprofen or tylenol doesn't help central sensitization pain, but it can help peripheral pain. So you know, when I'm asking people about how to respond to different medications and treatments. Yeah. Sula (28:38.957) Mm. Kathryn (28:43.938) and they say, yeah, I take that, you know, Tylenol and I feel better. Then I'm like, okay, well, whatever that pain was, that wasn't your central sensitization. you know, things like lyrica and gabapentin and ametryptaline and nortriptaline, those are helping central sensitization pain. They're not helping so much with nociceptive pain. And I think one its best constellation of symptoms, because it's pretty much impossible to have pain without having a pain response. Mm-hmm. Sula (29:13.515) Mm-hmm. This is true regardless of what the pain is. And so a lot of the work I think that happens in integrative health and in mind body therapies in general is kind of teasing apart and unlinking pain response from pain. How do I calm my system even when there is this pain here? and that is easier said than done. and how can we maybe have pain but have less distress about the pain? and and so when I think about distinguishing those. Yes. Sula (29:38.974) Mm. Two types of pain. Part of it, it can come down to because if you have peripheral pain for long enough, you can then get central like so there's central sensitization, but then there's also just the sustained peripheral pain and then the patterns that develop in response to that. And there's something, you know, that's murky, right? We're getting into sort of gray area that could be hard to tease apart. But when there is sensory sensitization in addition to, Yeah. Kathryn (30:11.258) those other symptoms. So it's like, and you have brain fog and you sleep but you can you never feel refreshed and sounds feel too loud, everything you you sort of are wanting to isolate. I think of that sort of a little bit more in that more central process. Yeah. You can see how, how overwhelming it is for patients experiencing these things. And I keep going back to what you were saying about the baby birds, you know, you want to get that clarity. And so you can naturally start to grip tighter and tighter as you try and figure it out. But that also massively feeds into that pain response, which can then snowball. It's very hard, isn't it? Mm-hmm. It is. And and it oftentimes this is why I think you can't just say, do these five things because you've got to kind of understand what somebody's relationship to these things are and how they feel about it and what their story is that they're telling themselves about these different therapies and what their expectations are for it. You know, most of our medications for chronic pain we consider it's effective if it drops your pain score two point five to three points on a ten point scale, which for, you know, somebody that's actually living it is like Yeah. Sula (31:09.613) Hmm. Yeah. Kathryn (31:23.736) Was that success? I still hurt. And in the, you know, in the literature, we're like, hey, this works for pain. So understanding that we that how much we don't know and how much we don't have it figured out as a system, I think is a good starting place. But then for that baby birding piece, I think there's another layer in there of doing what you can control and letting go of the outcome. Right. And so, you know, some of like the, you know, behavior from like a behavior change standpoint, we always talk about like, Yeah. Kathryn (31:52.81) Sleep is a very clean example. you can do whatever you want, you don't get to decide how many hours you sleep. You can control when you stop drinking caffeine and whether you listen to true crime before bed, or you know, all these different things. But you can't so the if you link success to how many hours you sleep from those behaviors, there's a little bit of disconnect because you don't actually get to control that. So linking success not to did my pain go away. Yeah. Sula (32:15.415) Yeah. Sula (32:22.379) Mm. But did I focus on the things I could control and then feeling good about those things? Most of the stuff we're asking people to do is like in general stuff that like all of us probably should be doing. We we should all be having a nice sleep schedule. We should all be optimizing our stress resilience. We should all be eating vegetables. and yet oftentimes if we don't have to deal with if we don't have to do a bunch of this stuff, then it nice if we don't have to. I I saw I sometimes I call it the Yeah. Kathryn (32:51.01) The gas tank of youth, where it's like there's you know, some people are like, Yeah, you know, this person is 70 and they just smoked cigarettes and they never slept and they never exercised and they feel great, everything's going good. And I'm like, fantastic. Congratulations, you're winning the lottery here. because other folks are running out of their gas tank of youth is running out when they're 15 or they're 25 and they're not getting away with the stuff anymore. They can't just eat whatever they want, do whatever they want, you know, work work. you Sula (33:14.285) Mm. Kathryn (33:18.616) 10 hours, 12 hours a day, not think about stress resilience and still feel good. and oftentimes it be it's a pain condition or it's a chronic condition that forces somebody's hand to have to step back and look at the other conditions in life and go, now it's not like their fault, right, that they're like doing these things. You're just doing life, you're feeling good, you don't have to think about it, great. but it is often these pressure points where it's now it's like, okay, what can we optimize? Yeah. Kathryn (33:47.4) And and then letting go of whether it's going to control the thing. so so this is why it's important to know how somebody is doing on sort of that wheel of health. You know, there's so many wheels of health out there. The VA has one, you know, we've got one, but it's that idea of where are you doing well, where are the deficits when it comes to sleep activity, relationships, meaning, purpose, all this other stuff. And picking interventions that align with what's most important. Yeah. Kathryn (34:14.894) Important to you where the biggest deficits are. It can't just be this like blueprint for lifestyle that everybody follows the same thing and gets the same result. Yeah, and that's confronting as well for people to have been able perhaps before to assume that I can just do it without really thinking and it's all going okay and then it's only when an illness comes along or something and then you're like, now I have to think about these things that I didn't have to think about before and the brain makes comparisons of other people that don't and yes, that's a hard adjustment to make. Shelley, I'd love to ask you a little bit about the Vanderbilt model, the integrated clinic and what would it look like then? I was having an interesting conversation with somebody actually on the pelvic pain committee for the ICS talking about, you know, creating a model for multidisciplinary working and how do we do that so that... maybe not standardized is the right word, but people have some kind of idea of what that could look like in practice. So I'd love to hear how that actually works. You what does a patient get when they walk into that integrated clinic? How does it go? Yeah. So they do have two appointments on their schedule. However, we see the patients at the same time. So, you know, that might throw them off a little bit. So we still do it's the urology clinic, so we still do, you know, our vital signs. The patient gives a urine sample, make sure they're emptying okay, check their urine. and then Lindsay and I both go in together and introduce ourselves and explain. Shelli (35:55.799) From the get go, why they have two appointments, that they don't have to s tell their story twice. So then we take a history together, get the information we need from the patients. We both ask questions, we leave it, you know, nice and open for each other. and majority of the time, then I'll do an exam. so now that we built a rapport, Lindsay may offer. Mm. Shelli (36:23.479) to stay in the room, if they would prefer somebody to stay in the room with them, if they're concerned about pain. If they're not ready for the exam at that visit, we won't do the exam. We can plan it for another time if we feel like it's necessary. you know so just trying to build the rapport together. and then we both usually we'll we'll kind of chat to see what we feel like each of us need to offer the patient. that might be a referral to OSHER to see KD as the whole person, work on some other things that might be they need some psychology help outside of our our integrative clinic and for other issues, family issues or something like that. So giving them the resources, it might be that, you know, even financial resources that we need to discuss or find ways so they can pay for medication or something like that. just ways to lower their stress level too. if even if we need to give them some time off work, you know, that might might be a component of it just to be able to incorporate some of the referrals that we're going to do. Cause we don't want to overwhelm them. That's another piece that we try not to do is overwhelm them with too many appointments. But we know this person probably needs some physical therapy. And if Mm. Sula (37:44.161) Yeah. Shelli (37:48.469) they're not allowed to leave work for that, then it might be we need to do some FMLA for that. you know, that's you know, then I will usually prescribe whatever needs prescribed and we'll get the resources they need from a psychology aspect. What is FMLA? Sorry, that's family medical leave. So it might be related to even that patient that their anxiety at work that they can't go to the bathroom. We might just do it as intermittent every two hours. They're allowed to go to the bathroom if they need to. And so they're not, you know, the embarrassment for them to discuss their health issue with their adult, with their for supervisor or HR, then that. Yeah. Sula (38:24.375) Yeah. Shelli (38:37.171) burden away from that. We submit it medically. Hmm. Hmm. It's incredible to hear how just two professionals from different disciplines seeing the patient at the same time can actually open up so much. that conversation with you guys and the patients, and then you guys separately afterwards just add so much more dimensionality to the treatment. Yeah, the scope for treatment. I guess going back to that piece at the beginning, we were talking about, you know, helping them feel. heard and thoroughly looked at. Mm-hmm. Sula (39:15.351) Yeah. Go on, Katie. And I've had a lot of patients that have you know, of course, obviously seen you and Lindsay at the same time. And I feel like another thing that I hear from them sometimes is, you know, oftentimes when a psychologist has been brought up, it's like, hmm, I bet you're anxious, you know, like go see this person. and it's in your head, you know, sort of like a little bit of implying is in your head stuff. And the patients that see you both at the same time are like, like everybody is acknowledging that this is a, you know, this isn't Mm-hmm. Yeah. Sula (39:35.948) Yes. Kathryn (39:47.458) Because you're anxious, this is, I bet having to urinate 30 times a day is having an impact on your life. And who is the specialist that's helping us think about that? It's a health psychologist. and coming at it from this really constructive problem solving way together is powerful. Yes. Sula (39:52.746) Exactly. Sula (39:59.021) Mm. Right. Sula (40:04.258) Yeah. Right. Right. If you're up all night peeing and you're not sleeping, now your sleep is exacerbating your symptoms even during the day 'cause you're so fatigued and Yeah. So all those components. Yeah, that's such a good point because that is, as you say, Katie, it's such a big stigma coming from a lot of dismissing experiences a lot of the time. And a lot of these conditions disproportionately affect women as well, who we know are more affected by medical dismissal and problems there. So that's certainly a big reaction that comes up a lot when talking about psychology in the context of health of this is another person. trying to tell me that I'm imagining it, it's not that bad. So yeah, you're absolutely right. Just having that validation of the psychologist alongside the physician, seeing the same thing, commenting, kind of normalizing, yes, it would be stressful and take a bit of thinking about to navigate life now that these things are happening. Unfortunately in the UK, a lot of the time when psychology is involved in like a secondary care, physical health department like gastroenterology, urology, gynecology, which is few and far between. But when it is, it's like a psychologist down the corridor in a cupboard. They've only been assigned to patients who are like visibly upset. it's, again, it perpetuates that idea of, it's only if you're upset or quote unquote, having mental health issues, that's when you see them. Whereas what I really love about this approach is, Sula (41:41.527) They're very integrated from the outset and that makes such a big difference in how you see the role of those psychosocial factors. Can I ask you a little bit about, before Katie, you mentioned about comorbidity and systems imbalance. There's something about that term systems being imbalance that really resonated with me. I see a lot of patients with lots of different comorbidities, often fatigue alongside pain, alongside bowel issues. So yeah, could you talk a little bit about systems being imbalance and, you know, helping people, I guess, get a bit of a better understanding about what's happening with those overlaps? Yeah, you know, sometimes with in chronic pain, we and in in our clinic, we talk about this on sort of a continuum of care. And you know, the first one is stability. And so, you know, when I think about stability, like when you when you're in the emergency room, stability is like airway breathing circulation. In the outpatient world, I think of stability as Do you sleep at night? Are you awake during the day? Do you take in food and do you eliminate food? Are you able to do the daily stuff of life? And stability means something a little bit different to different people. There's like the core survival stability. And then there's, and if you have kids and if you have a type certain type of job or a certain type of what have you, you have to do certain things to get through a day. and so I and I'm often asking patients, let's figure out what is stability for you. Are we there? Hmm. Kathryn (43:19.618) Then if we're stable, can we regulate? And regulate is you get a curveball, you get you get sick, you have a flair, you have a bad night of sleep. Are you able to course correct and regulate pretty efficiently, or does that throw you off for weeks or months? And then, you know, then we've got sort of capacity building. And when we're working on capacity building, that's like, hey, we've kind of got stability, we can regulate when things go sideways. Mm-hmm. Kathryn (43:47.956) Now we're gonna sort of, you know, reach for the stars, like try the new thing, you know, expand, increase, start add in strength training. You know, we're gonna like do a sort of a capacity building thing, do sort of a big thing with nutrition. You know, the nutrition is one that I often pick on is, you know, I love love vegetables. And if somebody's exhausted and they feel bad and they're in pain and they're overwhelmed, it's a really hard time to like sh it's hard for people to change how they eat when they feel good and don't have any health issues. much less so some people come in and they're like, you know, I need to figure out the perfect diet. And I'm like, Do you? Like, and even if we did, could you actually do it right now? like let's fit I mean, we're not stable, we're not sleeping. Let's focus on these basics before we think about you know, trying to get too aggressive with with different types of interventions. I don't know if that if that sort of yeah, I feel like I lost your question. Yeah. Sula (44:46.573) No, I mean, it was making me think actually, interestingly, just this week, I was talking with a client about this, how really not in a stable place, just come out of hospital. And, know, on on step one of trying to get back to stability and had been advised to do this very restrictive diet. And I was like, this makes no sense whatsoever. No Sula (45:11.679) It's going to add too much cognitive load. It's going to take away some pleasure that you otherwise won't have and you don't have very much right now. And so, yeah, thinking about that broader picture is huge. it took such a weight off. Intuitively, they had a sense of, well, as well of this probably isn't the right thing for me to do. the, you know, getting that advice at that time, you want to cling to what you're being told. Well, yeah. So it's coming back around for me now. Systems imbalance, right? It's like first we have to know if we're not stable, are we able to like what is our focus of our efforts right now? Are if we're gonna do a bunch of capacity building exercises, but you're not stable, everyone's gonna be. It's always if you go to the juice bar and order a steak, you're gonna be disappointed. it's just not gonna work out what the way you think. and so it's sort of knowing those pieces. And then I think there's something to be said. Mm-hmm. Sula (45:50.668) it. Kathryn (46:04.856) for like in one place. And this is where that whole health plate thing comes into play. So often when, and I notice this when we get like residents and fellows that come through and they've been in endocrine clinic and rheumatology clinic, all these different clinics, and they'll pick a red flag symptom that the patient sort of talks about and then they go down this very appropriate sort of like but reductionist pathway of coming up with the right answer to solve that problem. Mm. But in we're sort of doing the opposite in whole health. We're like, yeah, I get it that you have, you know, migraines and you go blind. That is bad. you know, and you know, there's a specific answer for So we have to back up and go, okay, we're holding in one space. It's it's rare that patients get to talk about their sleep and their nutrition and exercise and social support and pain and fatigue. Mm-hmm. Kathryn (46:59.278) And and and and all in one place. And oftentimes just that alone, I think, you know, it's not like I have the answer. It's the person is actually able to like go, well, you know, when you say it out loud like that, of course I'm only sleeping three hours. And so of course it's impossible for me to do all these other things that I'm trying to do. you know, and and then the path becomes more apparent when we look and say, yeah, of course this system isn't stable. But I think, you know, something what you said earlier of a lot of people expect that they should be able to like work fifty hours a week and sleep six hours and you know eat the microwave meal and not put any effort into stress resilience. I always I'm never trying to lower stress. I'm always like, stress is good for us. We want to like improve our response. We want it when we need it, and then we want to be able to move out of it when we don't. And you know. Yeah. Sula (47:50.561) Yeah. Exactly. We don't get to do all of have all of those strains and feel good forever. something somewhere it comes out of balance. We have to figure out what is that sort of that fulcrum that's throwing it in this other direction. And a lot of times it takes time. You know, it's not like we figure it out the first visit. We like try some stuff and a lot of times the first or second thing that people think is the thing for them, once they get out into the world and actually try to do something different, it's not the thing. and then it reveals something else. I Yeah. You'll remember early on when I was doing some like health coaching training and I was somebody we were gonna somebody's goal was to increase their exercise. And they had a treadmill. And so of course they were just gonna get on their treadmill and go exercise. And then when we got through like setting the goals and then having them not do it, we finally got to the point where they were like, Yeah, the treadmill is in my spare room and it's buried in like the boxes of all my ex's stuff. And so it was like the barrier to exercise was actually like having to deal with their ex's junk. Sula (48:49.645) Hmm. Sula (48:56.503) Mm. before they could get on the tread. And so was like, okay, let's walk out. Can we walk outside instead? You know, we had to pivot. But until you kind of try some of this stuff, because it's often this whole health stuff is not as simple as taking a medication if we have to think differently, move differently, and and you know, you know, try to be aware of where is our attention and awareness going. And Yeah. Kathryn (49:23.522) What are the opportunities for agency rather than overwhelm? And kind of right-sizing that in a way that's productive and supportive. And what I really love about that, again, you know, it's really resonating for me and in the sorts of things that come up with, with clients that I work with is the opportunity there is in discovery in the things that don't go according to plan. Because, you know, as you say, there's an expectation of I get told to do the thing or we identify, the scope forward and I do it. And then it should, you know, go linearly, even if we've got that thing bludgeoned across, you know, our brain of. progress isn't linear, we still kind of expect it in some way. So I'm always quite excited to unpick why didn't you do the home practice or why didn't it work as we expected. know, finding tone is essential because I'm coming from a place of genuine interest. Whereas how we naturally might interpret that is criticism or I've done something wrong, but that was a beautiful example, Katie, I think of. well, we discovered something there. And also it doesn't mean you have to fight, fight the boxes of your ex's stuff. We can find an alternative and make your life easier. And so much can open up just from those processes of discovery and welcoming. What doesn't work out? Shelley, can I ask you a bit about the role of hormones? Cause I'm thinking, you know, thinking about systems balance and then thinking about systemic factors in health, hormones being one of them. It doesn't always play a role in like the pelvic pain conversation or, you know, pelvic and urologic systems conversation, but it's been coming out more and more in the podcast as well, different professionals talking about it. We know that hormones can kind of shape tissue, inflammation, pain, vulnerability. Could you, yeah, talk a bit about your work with kind of localized vaginal or hormone treatments? Shelli (51:28.383) Yeah, so that is one why especially in not even just our patients that are menopause, but the patients that are even have been on maybe low dose birth control for for years since maybe they had endometriosis and they've been on those. And, you know, so not only when I do my vaginal exam, I do want to assess their tissue. Hmm. Shelli (51:52.645) to see if there is some issues going on with their tissue health. Does it look thin? Is it, you know, did are they complaining of dryness within our course? do they use have to use lubrication frequently, which is fine, but are they using the right lubrication? Because some of that's gonna alter the pH balance too. And so that's where incorporating vaginal estrogen or estradiol, you know, a lot of women are still afraid of Hormones. so we have to take that mindset, like this is a localized treatment, this is gonna help vaginal health. What goes in the vagina does not go systemically into our body. So it's just localized, it's safe, it's and and it's effective. So it will help plump that tissue, give it more elasticity, give you some more natural lubrication. Mm. Shelli (52:44.561) and balance that pH in the vagina. So it can also help protect the urethra and the bladder. And you know, if that tissue is thin, it's gonna pull on that urethra, it's gonna pull on that bladder. If that tissue is irritated and inflamed from intercourse, the bladder's gonna be irritated, the urethra is going to be irritated. And so there's a crossover effect there. So if we're not healing that tissue or helping that tissue to become healthy, they're not gonna have a good outcome either. Hmm So I do I do push for that if somebody is resistance. There is some over the counter hyaluronic acid versions now that do have some very good data that show that they also can improve the tissue thickness and elasticity and pH balance. So I'll I will recommend some of those if they if they are not interested at all. Just And what is the resistance do you think? What are the concerns people have? Think it's just the fear of maybe if they're on birth control, adding another, is this gonna affect my birth control? If they're menopause or if they have a family history of breast cancer, they still have they've still fall into that myth that this is gonna trigger breast cancer. Sometimes it is you know, they don't like messy, they don't like creams. There is tablet versions, there is a ring version. Sula (54:01.079) Right. Yeah. Shelli (54:11.691) So there is some that we can get away get around that. If they just don't like a cream based. Hmm. Sula (54:19.885) And I mean, that will be really reassuring to a lot of people that there are topical things then that can be used. I mean, you just mentioned tablets as well, but topical things that can reduce any resistance around worry with systemic hormone intake. Yeah. I'm really keen as well to explore, because you were saying that kind of crossover effect of the Yeah. Sula (54:48.545) the vaginal tissue and how that can feed into these pain processes and similar to what we were talking about, how these things can layer onto each other. Katie, I was really intrigued about your massage background and working with the body from that means and the connective tissue, the way tension holds and travels. Yeah, could you perhaps talk a bit about the role of these things? Because I also, you know, there's lots of information about the fascia and holding trauma and perhaps you can dispel some myths and correct some thinking. Yeah, no, it's a it's a it's a great question. Obviously, you know, the location of the pain, like wherever pain is, it has its own sort of culture of what it might mean, right? So chest pain might mean something, you know, differ does mean something different in terms of the potential or the potential harm, then bladder pain, then foot pain, whatever. Hmm. Kathryn (55:51.522) So the context of pain is important as far as like from a just a like a musculoskeletal standpoint, I'll say that sometimes we say like in that world, like where it is, it isn't. So it's like you feel the pain here, but it's tightness, it's weakness in other locations that can be setting somebody up to have that be the pressure point. you know, connective tissue, fascia, they transfers force throughout our body. Right. Sula (56:13.005) Mm. Kathryn (56:18.99) And when anytime you have a scar tissue or a really tight muscle or something that's torn or weak or what have you, then the force doesn't transfer the same. Right. And like you can sort of imagine that becomes then a place where there's maybe going to be more problems. And and again, so you know, I always say like my bias is that I've already seen people like the people that I see have usually seen like five. you Kathryn (56:47.622) gone to pelvic floor PT five times before I see them. so I mean pelvic floor PT is fantastic. And a lot of times I send them instead to more of a whole body PT, but because when you just go to the place where the problem is, it can sometimes be just too intense. We kind of have to like surround it, so to speak, come at it from this distal area, work on again, like rather than focusing on the problem, turning towards what can go well. Yeah. Sula (57:05.227) Yeah. Sula (57:15.821) Mm. And and so, you know, building up strength in other areas of the body can also reestablish sometimes the trust and the relationship with what your body can do. A lot of people are like mad at their body. They're like, my body hates me. and trying to reframe that conversation into something that's more supportive by building up, treating other stuff that maybe is gonna go better, is it can be a good approach. Yeah. Kathryn (57:43.126) This trauma and the body thing, boy, this is a hot topic. I'm telling you. I have like taught and lectured a a number of quite a bit in the last month, and I keep getting this question. and I get it. because there's been so much sort of in pop culture around trauma in the body. And and then I think also just as the conversation around trauma and pain, all this other stuff unfolds. Here's what Yes. Sula (57:55.565) you Kathryn (58:08.108) And again, we don't know, like I don't have the answer, but I'll tell you how I think about it these days, informed by some of the more recent you know, understanding of how we make sense of the world in a sensory way. and I I think I might just start by defining interoception, which is you know, it is you Sula (58:30.177) Yeah, please. sort the stuff that we feel inside of our body. So it's noticing when you're like you're hungry or you're tired or you have to go to the bathroom or tension or pain. You know, emotions are also sort of getting expressed through the autonomic nervous system and that interoceptive awareness is kind of this bi-directional conversation that's happening with our bodies and our and our central nervous system. And I I don't think that you know like Your mom's narcissism is in your quads. I don't think that like there's like trauma is like in this very literal way stored in a particular tissue. I think of it more as like sensory information from our bodies as then getting processed by a system that has is operating off of what it's been taught. so you know the insula is taking in. You Sula (59:29.249) Yeah. information from the fascia. And it's not entirely like a brand new, you know, baby it's first day on planet earth taking in that information without context and without history. It's has biases and preconceived notions of what it expects to feel from a bladder or what it expects to feel from a foot or a a rib. And it then interprets what it's sensing based on those expectations. And so If you have a lot of trauma, have a lot of lack of safety, or have gotten really good at hypervigilance and keeping yourself safe in a certain way, then signals from the body might trip that off. Sort of in a similar way as like, you know, you smell something and it reminds you of your grandma when you were a kid, and you get all that memory back. It's it's not so much that that is like stored in your nostrils as it is. It's a it's a sensory sort of a signature or pattern that evokes something. and one of the ways that I think what one of the, you know, I'm again sort of biased towards movement therapies, hands-on therapies, tactile interventions, because one of the things that we're doing with therapeutic massage or with you know, yoga or movement therapies is we're Yeah. Kathryn (01:00:57.486) Putting new information in. We're creating putting new sensory information in. And then the body is having to interpret that in a similar way. We would like have to like challenge those thoughts. Like, do those people are those people really hating you? Are you mind reading? Or are really like you're projecting your fears onto what other people are thinking similarly? Are you actually unsafe in this moment? Or are you projecting that onto the senses that you're sensory stuff you're receiving? We have to sort of challenge that and go, hey, you know what? Yeah. Sula (01:01:13.303) Mm-hmm. Kathryn (01:01:26.902) I thought that my body was broken. I thought that I couldn't do these things to look what I can do can be new in information to expand the body's preconceptions of what's possible. and then of course, like if somebody actually has, you know, PTSD, whatever, then like do evidence-based trauma therapies. you know, go and do those things. and but there is, I think, of course, this gray area where somebody maybe doesn't meet all the criteria for PTSD, but they have. built up an expectation of pain from an area that, you know, and it's beyond their control and and it's distressing to try and expand their sensory experience to sort of challenge that idea of safety. So it's part, you know, like work on that comesophobia, work on that fear of what if it gets bad and I can't control it and it won't go away. And so the other thing I like about a lot of like movement therapies that our whole body or or massage therapy is that we are Yeah. Kathryn (01:02:25.08) cultivating a sort of, you know, tactilely cultivating a sense of safety in the body, which can counteract that message of your bladder's on fire. Even though we're not massaging the bladder usually. And you I like that like we're going around it. Mm. Yeah. Yeah. Mm-hmm. Sula (01:02:38.925) But that's really interesting that going towards the bladder, what you were saying there about, you know, going to a pelvic PT, actually that might be too intense at the outset because there's just too much of that projected threat and guarding and all of the things that come with that. So working outside in can establish a bit of that foundation of safety. Again, it really reflects what I see in clinic a lot of the time when there is so much threats and intensity in that particular area. actually one of the common responses is completely tuning out the body as a whole until it's grabbing your attention because of pain flair. So it makes a lot of sense to me. And I was curious, Shelley, just thinking about this in terms of like a trauma informed caregiving, well, what this means for trauma informed care really, and you as a physician and your colleagues, how do you navigate that? Well. Shelli (01:03:33.815) So if if we have that, if if we know ahead of time or if we see that patient in clinic in our integrative clinic, then Lindsay might do some relaxation with that patient before or just let them know we'll not do any examination until they're ready. if they are comfortable with putting things into their for vagina, if that's not too painful. Sometimes we'll start with even just using a diazepam suppository. And so I'll have them do that every night for a month before we even start PT or before they come back for an exanem. you know, so that that just to one, it it it it does absorb a little bit systemically using a vaginal, so it does help some of the ex you know, other muscles in the body, help may help for a good night's sleep. you Sula (01:04:11.277) Wow. Shelli (01:04:31.765) but it is about less than ten percent. So I do use a ten milligram of suppository. And here it has to be to a compomp pharmacy, but so but they're not usually too expensive. Sometimes I'll encourage the patients to make if we can't access them and and then have them come back for an exam, Lib Lindsay and myself. And I guess that then starts to potentially shift the association as well of like intervention in that area on a, on that sensory level as well, rather than it being very intense with, the DiasPAM suppository, there's this kind of, yes, calming down around it, which maybe then puts them in a different space when they come to see you after trying that out for a while. Mm-hmm. Shelli (01:05:20.755) Mm-hmm. Yeah, or even you know, going to the physical therapist. Yes, yeah, of course. I think I'm right in you give a questionnaires before they come to your clinic to assess PTSD or trauma and that kind of thing. Is that right? We do. We do. One of our questionnaires just specifically asked about PTSD. And how does that then inform the consultation? So th we still approach initially the same, but leading into as we feel like they've let their guard down a little bit, then maybe we'll ask about it at that point. And before we do an exam, of course, to make sure that they're gonna be comfortable with a physical exam at that time. Sula (01:05:54.669) Mm-hmm. Sula (01:06:05.494) Yeah. Kathryn (01:06:10.166) Yeah, and I would say, you know, because we also collect that. And, you know, I while we have a bunch of health psychologists in our office, we're not seeing them together the way that you guys are. So it's a little different for us. I think of trauma-informed care in my realm because I'm not a psych provider, right? I think of it like psychological hand hygiene. It's like it's not just infectious disease specialists that wash their hands, like everybody washes their hands. Yeah. Kathryn (01:06:34.414) Trauma informed care is like you just sort of approach the world as like, hey, let's try to be safe and not re-traumatizing. And you don't have to know whether they have trauma or not to do that. But part of the way it shows up then when we do some of these, like when we do screens for primary care, like we do a primary care PTSD screener, ACOR, things like that, is not to then get into it, because I'm not the psych provider, I don't have a psychologist in the in the clinic visit with me, but to but it might be like, huh, you know what? has anybody ever Yeah. Sula (01:06:43.095) Yeah. Kathryn (01:07:02.914) Diagnosed you with PTSD? No. And I was like, well, I'm not going to do that. I'm not the psychologist. But you filled out this screener and you scored a five out of five. Like this might be an opportunity of something that hasn't been addressed that if addressed might help again bring the whole system back into balance. I might not necessarily gonna get rid of the pain. You can treat trauma and still have pain be there. It's not as like it's not a direct one-to-one link. but you Kathryn (01:07:27.522) Guess what? If you were sleeping better or overall had better stress resilience or whatever else, then again, we might be able to navigate the pain differently. and so it's an opportunity to sort of bring it up not as a like, let's talk about your trauma, but as a this is a factor that might be influencing your health that if we don't, you know, pay attention to it or might be missing an opportunity. Yeah, it was striking actually, because when we did have Lindsay on the podcast, she was saying, I think it was data from your clinic, Shelley, 42 % screen positive for having PTSD, which is such a startling statistic, really. And it shows, as you're saying, Katie, just how important it is to have. like, again, I love your phrases, the hygiene for everyone, not just the infection, infectious diseases. Right. Shelli (01:08:18.635) Yeah, so. professionals, because then we can assume like almost half, if I can round up by 8%, of people have had some kind of trauma. So we might as well assume that most people are dealing with something. Yeah. And sometimes that it's a medical PTSD. Yes. And another from like a clinician standpoint of how to respond to trauma like that, one thing that can often happen is people have a lack of control and they're off and then will they will try to give you control. And as a clinician, it's very normal sometimes to step into the role of, well, I know what to do and I'm gonna tell you. but for this stuff, it's act for for especially when somebody has trauma for everybody, but especially when somebody has a trauma history is to continue to give the power back to them. Sula (01:08:53.036) Hmm. Kathryn (01:09:07.074) Well, what do you think about this? How would you feel about doing this? And I you know, anytime I make a treatment plan with somebody, I give them the options and I say, Hey, this is what I'm thinking. These are the options. What sounds useful to you? so that it they're having to sort of reach for something and also reestablishing just their own agency. Hmm. Shelli (01:09:27.543) Yeah, shared decision making is important. Yeah. And as you mentioned, Shelley, when they, you know, when there has been medical trauma, I think even, even more so that becomes such a, an integral thing to, to lean into and to, um, to really be sure that you're getting that consent. Cause people react in different ways, of course, to traumas. And some people really, rather than feel, um, feel or display more guardedness. You know, they can go into that more fawn type of response where they're trying to please even more. You know, I see a lot of people with that sort of response in my clinic where outwardly it can look like they're absolutely fine and they're wanting to, you know, give the right answers and show that yes, I'm engaging. And actually what's really interesting when I've unpicked this with lots of different people actually in the last couple of years, There's something underlying that where they think if, you know, the brains made some calculation, if I would have been a better patient, you know, I would have got better care. And so what their brains reaching for is to try and be that better patient to make themselves as compliant as possible. But then that doesn't mean that they're always actually telling you what they, what's important to them, or they're not always on board. So as a practitioner. being explicit with your questions about is this okay? What do you think about this? Then can help them step out of that a little bit. Shelli (01:11:05.823) Yeah. We see them in Yeah, we just we see them come in and they've had multiple, multiple procedures, multiple surgeries and you know, they're still looking for that right one. So then but or they have a step back and they're terrified but they need help. So Mm. Sula (01:11:25.045) Yeah. Yeah. I always feel like I I always it's not like a red flag, but it's a little bit of a little yellow flag for me when we get to the end of the consult and the person says, I'll do anything. And I'm like, ooh, I don't know. I don't think you should do anything. I mean, it comes from a good place, right? It comes from wanting to do it right and that little bit of type A and I'm gonna do error, I'll do anything. You're well, it's like what I need to start doing is stop and reflect on your own experience and and then have some room for this not. Yeah. Sula (01:11:41.865) Yeah. Kathryn (01:11:58.68) To work and then what? You know, because then sometimes I feel like that is what we bump up against is especially people that have been dealing with this for a long time, is they've got to kind of I don't know if they have to, but one pathway is that we need to address the grief over what they've lost on this journey, right? Or how it's impacted the rest of their lives. It's like hard to move on with acceptance of where things are at. Cause again, I you know, we If we could help a hundred percent of people, like then we that we wouldn't even be sitting here right now. and so there are people that are gonna have really challenging presentations and again can be doing the right things and and still having you know, a lot of symptoms and a lot of symptom burden. And so it sometimes is like in order to even be able to engage in something that's gonna help a little bit, we have to let go of the cure. And to let go of the cure, there's like this process of Yeah. Sula (01:12:57.326) Yeah. know, going through the frustration, the anger, the loss, the grief, the whatever, the shame, you know, whatever it is, to get to a place where they can be in the present moment of, well, this is the hand that I've been dealt now and how do we play this hand? And that's something that I guess is particularly challenging. Like you say, Katie, it's a process that somebody has to go through of like, I have to let go of some stuff here if I'm going to make some traction forwards. But that feels really risky and scary. And there's a lot of grief associated with that. I'm thinking about, you know, that process for a patient and then presenting in the medical healthcare system and relating to their physician. And that can come out in different ways, Of like desperation, anger, frustration. Shelley, do you have any thoughts or wisdom to share as a physician when you're sensing that? How would you suggest that, particularly physicians and doctors and nurses might navigate that? Which is, know, a difficult question. The Shelli (01:14:11.531) The so say that again, the like the role of a scene. Yeah, how is a health care professional kind of navigate that when you can see there's a whole load of processing that somebody has to do about where they are, and they're really reaching and you can see that. And essentially, they're just asking you, give me the fix. how do you, because that's a really tricky position to be in. So I I do want us to collaborate, the patient and myself on on their care and and the decision making of it. so sometimes I'll I'll make a list. We're gonna we'll sit and make a list together. And it's just handwritten, the two of us, and I'm I'm writing down some options, but we're not gonna do all these options. So we're gonna start with a few things. We don't wanna overwhelm. Mmm. Shelli (01:15:08.176) the patient, we don't want to overwhelm their body either and exacerbate a negative response to any of the treatment. So or I'll say, okay, this is where we're gonna start and I'll make a list that way. So number one, number two, and and that goes back also to to the toolbox, you know, so that if they're in that fight or flight mode, they can pull out their toolbox. but I do feel like making a list with the patients is is very helpful. You can pull that list out. Absolutely. And so hope inducing as well, because it contextualizes, we're doing this now. There's lots of other things that we can still do. And it kind of takes that pressure off. Absolutely. Yeah, that's great. I mean, I could talk to you both for a very long time, but I'll start to draw it to a close. I guess I'll start with a question for you, Katie. thinking about a patient that's overwhelmed can see that there's a role of lots of different factors going on in life that might be having an impact. What would you want them to know or what do you think could help them, I guess, alleviate some of that pressure and feeling like there's so much to deal with? Where do I start? Well, I think encouraging folks to think of it as a process, it's not getting the right answer. It's trying thing out throwing things out and seeing what's real. And timing is often a big factor. and so, you know, having done this for a long time now, I definitely have seen people where initially they tried something and it didn't work. And then when they were in a different place a few years later, my goodness, this was now the thing. So it's it's Kathryn (01:17:05.258) It is trying to get a framework for evaluating what the expectations are for different interventions and efforts. And then and then just being realistic around what is important to you and and you know what makes the most sense for you for where you're at. and Kathryn (01:17:32.138) And sometimes we have to address that overwhelm piece on its own to be able to and just get clarity, to be able to like clear the map, to be able to see a way forward. and so it's it's a process of sort of checking back and checking back. And what about now? And what about now? You know, prioritize one or two things, try it out, and then reassess and go from there. Because so often what happens is that you get you get. Yeah. Kathryn (01:18:01.848) the biggest fire to calm down a little bit and something else emerges. So that is typical and that's why I think of it as this sort of unwinding process. and Kathryn (01:18:15.884) I would say too that as much as possible, getting a little having a relationship with the just sort of that myth of control, of like, what are you, where are you trying to control and can you really control that? and then again, like when you are doing some of these things that you're supposed to be doing that's supposed to be helping, really trying to link it to a larger framework of wellness versus getting rid of a problem. because if you work on sleep and sleep gets better and your pain doesn't, that's a little disappointing, but there's so many other benefits to having your sleep be better. or, you know, similar things with, you know, it's it it it's sort of like the way I invite people to think about like people come in and they when they have weight loss as a goal, I'm always like, okay. Yeah. Sula (01:19:10.51) You You don't get to control the number, just like you don't get to control numbers' hours of sleep. You don't get to control the number on the scale. Can yeah, can it's and some people have come come in because they have been told, have actually been told, or have a belief that if they lose weight, their pain will get better or something else better. And unfortunately, that's not often not always the case. it's not like again, weight and pain are directly proportional to each other. So it's like, can we work on Mmm. Kathryn (01:19:36.332) you know, our relationship to food and nourishing ourselves and giving our bodies what it needs to be healthy. Yes, let's focus on that and not so much on the outcome. because we're playing the long game here. The first day that you, you know, eat the icy diet and go to bed on time is not the day that you feel better. And it can be hard to keep up with some of these sort of subtle things, even you Kathryn (01:20:02.036) know something like a diaphragmatic breathing practice or whatever. Like it can be frustrating to keep up with, I'm just gonna breathe and my problem's gonna go away. It's like, no, actually not really. you're going to retrain a system and get it into a different place. And then you will have some benefits down the road. but it is can be hard if you're pinning a lot of hope on that one thing solving stuff, then you're probably going to be disappointed. And so seeing if you can link it to something You Sula (01:20:23.043) Yeah. Kathryn (01:20:31.544) Where you do have some more agency. I think that's one of the ways to get out of that. And then and then, you know, focusing on the biggest fire and making a treatment plan that's proportional to the impact on your life. If you're able to do most of the stuff okay and you do have the symptoms and these flares, but for the most part everything's going all right, well then this is like we're gonna do a couple tweaks. But if it's like I can't do my job, I can't function, I can't get out of bed, well then we need to like pull together a more comprehensive plan. Yeah. so making it proportional because I'm always looking through the lens of function and quality of life and assessing those things. I never ask somebody what the what their pain is on a scale of zero to ten, but I I am assessing function and quality of life and then opportunities. so so that would be my message to people is to try to get out a little bit of that boom and bust cycle with healthcare of like, okay, we're gonna go in and fix it and solve the problem and see all the things and see all the people and do all the tests, and then getting disillusioned, frustrated, and then like sort of like giving up, you know. And that I think a lot of people you're in that cycle. and so trying to soften that a little bit, I would say is often the approach that I'm taking with somebody that is kind of feeling like they are on their, you know, last resort. Yeah. Sula (01:21:48.59) Yeah, proportional, multi-dimensional tweaks that you can be consistent with over this big kind of push for one big shift. Yeah. Thank you. Well, and that's when that when they come in with many components, that's one thing we'll we'll ask is, okay, so if we can help with one thing today, what is the most important? So, you know, then we have a direction also to start. Hmm Sula (01:22:19.33) That's a really clarifying question as well, isn't it? It could be really kind of crystallizing of like, okay, well, this one thing, if this one thing shifted then, and that can help people detach from the big thing of like pain being gone. Yeah. And Shelley, my question for you, because unfortunately integrated care isn't standard, we'll keep... pushing for it and hopefully we'll see changes. There's definitely a huge appetite from it professionally and obviously from patients, but because at the moment it's not standardized, would you have any advice for, I guess, clinicians that are not in that integrated care setting? I mean, yes, not in that integrated care setting. Maybe some shifts that they could make that might help towards... some kind of integrated care with limitations that they've got in not being in a multi-dimensional team, multi-disciplinary team. Yeah. And and there is more I mean, if if I could have the best integrative center, we would have, you know, GI or colorectal, we would have GYN, we would have, you know, physical therapy. so, you know, it i it is not reality. everybody's not in one place. But I f I feel like if if our if they feel like their met people are working as a team at all their healthcare providers Hmm. Shelli (01:23:49.766) You know, so I do if if you are seeing a psychologist outside of our department, I'm happy to talk to them. you know, let them know this is what I recommend and see if that aligns with what your therapy is with them. so then that way it it does still sort of collaborate. if they're already going to physical therapy, let me send an order to that physical therapist so I can add, make sure that I feel like we are assessing these needs. This is what I find on exam. and so if if I know time constraints when you're seeing patients, but you know, a quick five minute phone call or, you know, it doesn't have to be that an email, you know, I'll I'll email with a psychologist or a physical therapist or a text just to have combined therapy with to coordinate their care as a whole. Yeah, absolutely. I, yeah, like you say, that the time consideration can put people off, but in my experience, because that's what ultimately I have to do. in a private practice, but I have so many pelvic physios, gastroenterologists, urologists that I collaborate with. And it actually doesn't take very long. You're writing a letter or some kind of clinic summary anyway, if you've got the consent from the patient, which often they're very happy to be like, yeah, you guys, please talk. Noin. Shelli (01:25:16.636) Right. then it doesn't take that much to drop an email. And yeah, and like you say, it can really open up so much. So I think that's really helpful just to recognize that's always an option. And to really reiterate, when I do do that with patients, what's surprising to me is how surprised they are that I would do that. They're like, really? Like, would you do that? I'm like, well, yeah, it makes, it's so important, of course. So I think it can... Yeah. Sula (01:25:49.294) You mentioned that Shelley about just this sense of feeling like there's a team, know, some kind of collaborative approach to support them. I think just even that feels much safer and more cared for than if it's them going from one to another and trying to figure it out. Yeah. Mm hmm. Absolutely. Thank you both so much. Honestly, I'd love to talk for hours more, but you're both at the beginning of your days. I'm coming to the end of mine. But it's been such a great conversation. know this is going to resonate so much with so many clinicians and people with their own lived experience. Good. Thank you for having us. Pleasure. Yeah. Thanks for having us. Sula (01:26:33.87) It's been lovely. think in terms of, should see like something about uploading a percentage somewhere, mine's at 91%. Yes, it's ninety nine percent, I think, in the upper right hand corner. When it's a hundred, you're released. So you're, you're imminently free Katie. What about you, Shelley? Hello. Shelli (01:26:53.85) I'm ninety nine percent. Okay, yeah, you can, you're very close. Have you both got busy clinic days? No clinic for me today. I've just got meetings and I have to do like all the work. I have to do the work. nice. Yes. Yeah. You're at a conference. Oh, wow. Is it full on? Shelli (01:27:07.43) Yeah. Woman DC conference. Mm-hmm. Shelli (01:27:17.776) Yes, full on. Are you presenting or just trying to absorb everything? tomorrow at six forty five AM. I don't I'm I apparently I didn't look at the time when I agree to that.