Freakonomics Radio - 21. Bring on the Pain!

Episode Date: February 9, 2011

It's not about how much something hurts -- it's how you remember the pain. This week, lessons on pain from the New York City subway, the professional hockey rink, and a landmark study of colonoscopy patients. So have a listen; we promise, it won't hurt a bit.

One or two mornings a week, I take the subway from the Upper West Side of Manhattan, where I live, down to Soho, to the radio station where we make this program. I take the C train. It's about a half-hour ride. I wear headphones, those ridiculous, big, earmuff-type, noise-canceling headphones. Now, I don't wear them because I'm listening to music. Usually I read. I don't wear them because I'm listening to music. Usually I read. I don't wear them because the train noise bothers me. I kind of like that old clackety-clack of steel wheels on steel tracks. I wear them because when I get off the train at the Spring Street station,

this is what happens. Wait a minute, wait a minute. I'm not going to do to you what they do to me. So whatever device you're listening on right now, turn your volume down. Okay? Okay. Now, this is what happens. That's the alarm on the emergency door at the subway exit. All right, you can go ahead and turn your volume back up. But this is no emergency. This is what happens every morning during rush hour. And again, during the evening rush, every time a train arrives at hundreds of subway stations across

the city, you're supposed to exit through the turnstiles. Now, these days, a lot of those turnstiles are called HEATs. That is, high entrance and exit turnstiles. They look kind of like a cross between a floor-to-ceiling revolving door and a jail cell. It's a turnstile you cannot jump over or squeeze under, and they don't turn very fast, certainly not fast enough for New Yorkers on their commute. So, inevitably, someone bangs open that emergency door, and boom. This got me to wondering, is it really worth it, withstanding the pain of that alarm, just to get above ground a little bit faster? Who are these people? From WNYC and American Public Media, this is Freakonomics Radio.

Today, bring on the pain, because we know you can handle it. Here's your host, Stephen Dubner. On a snowy Tuesday morning in January, I met Pete Foley down at the Spring Street station. For more than 20 years, Pete has worked for the Metropolitan Transportation Authority, which runs the subways. He's the senior most revenue equipment maintainer in the city. That means he's in charge of keeping those turnstiles and emergency doors and everything else in working order. It was rush hour. Let's go in here. Watch this one for a minute. Okay. Everybody get off first. You got to stand back now. Yeah. What I always think about is the fact that the first guy through, he actually suffers less than anybody because he's out the door, he's up the stairs it's kind of a

backward incentive right that the guy who you want to pay the most is actually paying the least did you think about that in the design i don't think they did that person's gone up the stairs usually they have their headphones on full blast anyway so they couldn't care less it's the people that got to stand here waiting for the next train that have got to listen to it. All right, we've got an incoming C train. This is my train. We'll try to blend in here. You don't have an MTA hat on, do you? No.

All right. Do you think we'll get one here? There's a lot of people coming out. Maybe we'll have somebody hit it. Oh, there we go. She didn't look like a lawbreaker at all, did she? No, she didn't. Usually it's not the women.

Usually it's the young guy that pushes the gate open. But once it's open... It'll keep going. And the people keep going. Right. And then if there's somebody on the other side, a lot of people come in for free then. The other thing on the station, there's no cameras here either. So they couldn't even record the fare beaters coming in to catch them.

You have to catch them in the act. And unless the police is here and they see the person coming in, they can't do anything about it. Now, it says right on it, emergency exit, push bar for emergency exit, alarm will sound. Is it illegal to go through an emergency exit if it's not an emergency? It's actually supposed to be, but they haven't enforced that at all. You see signs that say do not go through the emergency gate unless it's an emergency, but I don't know what the penalty is for it, and I haven't seen any real enforcement of it at all. So the only real disincentive to banging open that door is the painful

shriek of the alarm. And like I said, the first guy through gets out of the station faster than anyone. And then 30 or 40 people follow him through the open door and another 30 or 40 patient schmucks, that's me, we wait our

turn at the turnstile, wallowing in the noise. I decided to follow some of these first people through out of the station. Ask them what they're thinking. I just want to talk about why you popped the emergency door to come to instead of going through the turnstile. Because it's always blocked. A lot of people, a lot of traffic on the station. Does the alarm bother you when you come through or not really? A little bit, yes.

But it's worth it? Absolutely. How much time do you think you save coming through that door? Four or five minutes. Four or five minutes? Seriously? I asked Foley how much time she really saves. 45 seconds or so.

The funny thing is at the end of it, they all got to come up a narrow staircase, so everybody gets funneled at the staircase anyway. Here's another guy. Just as guilty, but at least he's got a more realistic sense of time. I just need to get out of that door as quickly as possible, so if I'm the first one there, getting stuck in that little cattle gate just makes it a really slow morning. How much time do you think you save?

Oh, come on, like 30 seconds? That's big. That's like one email. But to get to that email, you've got to endure some pain. Maybe even a little guilt, too, knowing you're leaving behind a big noise bomb for everybody else. Is it worth it? Obviously, it is. If not, people wouldn't be doing it every day. It all depends on how you experience the pain. And even more important than how you experience the pain, how you remember the experience. I'd like you to meet Donald Rettelmeyer. He's a doctor. Who better to talk about pain? I'm usually called to see people when there are many things going wrong at the same time. Rettelmeyer works at Sunnybrook Hospital in

Toronto, which is a busy trauma center. He's used to caring for people who've got pain layered on top of pain with more pain around the corner. So a person has been smashed into a roadway crash, and they've also had a heart attack. Or somebody else has fallen down a staircase, and they've also got AIDS. Or somebody else has been shot in the chest, and they also have got diabetes. Rettelmeyer is also a professor at the University of Toronto,

and he does a lot of research. But not your typical medical research. Ah, Stephen, it's a pretty eclectic portfolio, and some people would criticize me on that basis. So some of the most, the single most famous study I'm known for is on the association between cellular telephone calls and motor vehicle crashes, identifying about a four-fold increase in a risk when a driver is using a phone compared to when they are not using a phone. Other studies include the effect of rainy weather on medical school admission interviews. Another study was on the survival of Academy Award winning actors and actresses. Fourth study was on driving

fatalities during Super Bowl Sunday. And another one was on the risk of sudden death while running a marathon. So quite a broad swath of research, mostly on the non-biological aspects of medicine, with a particular focus on the determinants of health. About 15 years ago, Rettelmeyer became interested in pain. He started collaborating with Daniel Kahneman, the Princeton psychologist who would go on to win a Nobel Prize in economics for changing the way we think about decision making. Rettelmeyer and Kahneman wanted to know how a medical patient's experience of pain

during a procedure might differ from how they remembered that pain. Now, why is this important? Well, for one, a doctor wants to cause as little pain as possible. But also, if you want a patient to return for follow-up care, you want to know how their memory of the pain might influence whether they return.

They worked with patients who received a colonoscopy, a procedure to detect colon cancer. Yeah, colon cancer is very, very serious. It's about the number three leading cause of cancer deaths in North America, and with a case fatality rate of about 30%, i.e. of the people who are diagnosed with colon cancer, roughly about one-third will die from their colon cancer. Of those that don't die, they need to go through some pretty nasty operations and nasty chemotherapy.

So it's no joy at all. And many cases of colon cancer could be prevented from early detection, making it quite a different malignancy from, say, lung cancer or prostate cancer. Now, not everyone thinks a colonoscopy is the best way to address colon cancer. It's expensive, it's invasive, there's a potential for medical side effects, and it's not foolproof. That said, it's become pretty standard practice in many countries. But in the U.S., only about half of the people over 50 are getting any kind of colon cancer screening, including colonoscopy. Why? Well, a colonoscopy is not exactly a pleasant experience. A day or two beforehand, there's the bowel prep,

in which you have to purge all the solid waste from your body and then consume just clear liquids from then on out. At the hospital, you probably start with an anesthetic, which means that afterward, someone else will need to drive drive you home and there's not a lot going for the procedure itself a doctor inserts a long flexible scope into your anus guides it up through your rectum and then into your colon scope has a camera on the end which lets the doctor see what's going on inside via a television monitor. A colonoscopy can take up to an hour. It's not massively painful, especially with the anesthetic, but it's not a lot of fun either.

So how do you get people to sign up for that and then to come back for it again? What Rettelmeyer and Kahneman did was ask people having a colonoscopy to record their pain in real time using a handheld electronic device. And then afterward, these same patients were asked to record how much pain they remembered experiencing. There were three interesting results. Firstly, is that the worst single moment of the procedure correlates extremely heavily with their final impression of the procedure.

I.e., that because these extended episodes are just so long, people do not keep a full record of what the experience was like. Instead, the worst single moment is often what they return to, is often apparently the basis of 10 for those other two minutes, I'm going to remember the entire procedure as worse. Yes. Right. Okay. Second observation was that the last few minutes of the procedure were far more important than the first few minutes of the procedure in terms of influencing patients' subsequent memories of the experience, i.e. the single most important thing was the worst moment of the procedure. The second most important thing was the final moments of the procedure, i.e. whether it ended on a good note

or a bad note. Interesting. And then the third factor? And this was the largest phenomenon that we term duration neglect, i.e. procedures that were distinctly prolonged were not remembered as distinctly unpleasant. Procedures that were distinctly brief were not remembered as distinctly mild. So, not only does a longer procedure not necessarily generate a worse memory, but as Rettelmeyer puts it, the last impression is the lasting impression. These findings led Rettelmeyer and Kahneman, along with a third researcher, Joel Katz, to perform a follow-up experiment. Again, working with colonoscopy patients, they randomized the people in their sample, and with half of them, actually made the procedure last longer.

Probably the single most practical thing is to slow down towards the end of the procedure when all of the technically difficult things are over with, so that you give them a real mild, a sense of mildness during the last one or two minutes. So you literally would leave the scope inside the patient for an extra few minutes to change the final impression of the colonoscopy? You got it. About half underwent randomization so that the procedure was prolonged by a few minutes by making sure that the last couple of minutes of the procedure were sort of,

were relatively mild and we were meticulous about comfort and pain control so that their experience ended on a positive note. And then we tracked them forward about what their memory of the procedure was like. And sure enough, they rated the entire experience as more favorable. And we also tracked them forward for another five years. We're looking at rates of return. And we found a small improvement in subsequent adherence rates with return visits for colonoscopy for those individuals, and that part of what makes it longer is just leaving that scope in for a few extra minutes without pain, that those people remember the whole experience as being more pleasant than a shorter colonoscopy, as long as there's that brief period at the end without pain. That's a pretty neat magic trick, yeah? You've described it accurately, except the effect isn't enormous here, right? I i mean we will not turn a frog into

a prince for example all right so what it does is it does improve their final impressions by about 10 or 15 percent and it does improve their subsequent adherence rates by from about maybe about 45 percent to about 55 percent all%. So it doesn't completely reverse the situation, but does lead to a small improvement at no financial cost to the healthcare system and no medical risk to the patient. An increase from 45% to 55. Those 10 percentage points represent a gain of 22 percent. That's a 22 percent improvement in people coming back for a potentially life-saving procedure. A 22 percent gain achieved by simply doing nothing for a couple of minutes. Rettelmeyer is 50 years old. I asked him if he'd had a colonoscopy, and if so, how he experienced the pain.

Turns out, I was asking the wrong guy. I've had one colonoscopy, and I enjoyed it. I actually enjoyed watching myself on television. I did not find it all that undignified. The prep was not so horrible, and I thought it was a great way to sort of rule out colon cancer. And I got a bit of anesthesia. I kind of enjoyed that too. And then I got to watch myself on television.

And it's really kind of beautiful. Coming up, if you think a colonoscopy is painful, you're probably not a professional hockey player. I broke my bottom five teeth, got knocked out. They're, like, sitting in my throat. I can feel them. Well, I want to drive the Zamboni. Hey, I want to drive the Zamboni Yes, I do

From WNYC and American Public Media, this is Freakonomics Radio. Here's your host, Stephen Dubner. Hockey hurts. Hard checks up against the boards. In the first period, you might get slashed across the face, and then you get some stitches in the locker room, and you're back on the ice for the second period. If you're a professional hockey player, you've got the ability to withstand a lot of pain,

and then do it again the next day. Now, colonoscopy patients have to be tricked into returning for their next procedure. So how do hockey players keep coming back for more? We sent producer Chris Neary to find out. One of the most painful parts of a hockey game is blocking shots. I'm not talking about a heavily padded goalie stopping a shot from going into the net. I'm talking about defensemen and forwards, players with much less padding and nothing at all to protect their necks and half their faces,

flinging their bodies in front of a frozen rubber puck traveling 80 to 100 miles an hour, just to save one shot on goal. The New York Islanders are pretty good at blocking shots. Over the past five seasons, they've been in the top ten in the league. But that doesn't mean they're very good. During that same period, they haven't finished in the top ten in points. That's how wins and losses and ties are measured in hockey, and they haven't won a playoff series since the 1992-93 season. So maybe blocking shots isn't a good strategy,

but whatever the case, the Islanders do it a lot. Jack Hillen is a defenseman with the Islanders. Last season, he took the full brunt of a blocked shot. He stopped the puck with, well, with his face. Here's how he described it recently in the locker room after practice. My jaw has a big crack right here, and they put two plates and 12 screws, and it shattered. My bottom five teeth got knocked out.

They were, like, sitting in my throat. I could feel them. And the oral surgeon said that it looked like a gunshot wound. So tell me if you can just kind of help me see what that game looked like. Where were you playing? What was happening in the game before that happened? Yeah, I don't remember so um why why don't you remember because you play played a thousand games in my career i don't i mean i remember the play that broke my jaw but i don't i mean i don't remember

most games in my career you know you don't, I mean, I don't remember most games in my career, you know, you don't remember specific, you know, specific plays that well. I think you think more about what you need to do to get through it. Like, as a hockey player, you have an injury and your mind immediately turns to, what do I need to do to take care of my body to get better, you know, do I need to ice it, do I need to stretch it? Do I need to, you know, get a massage? What do you need to do? And that's what you remember about injuries in sports, I guess, not necessarily so much the pain.

Who wouldn't remember the circumstances around having their jaw shattered by a hockey puck? As these guys told me, pain is an almost forgettable step in the process of doing something important for your team. And to keep your job. Here's Hillen's fellow defenseman on the Islanders, Andrew McDonald. That's the word I'm looking for.

There's a lot of parity between players. So there's a lot of players in the minors that are good enough to play in the NHL, but, you know, they just might not get their chance. And I think guys now are realizing that more than ever. And, you know, they're doing whatever they have to do to stay here. And, I mean, I think putting your body in front of a 100-mile-an-hour shot, sometimes guys pick up on that, like, you know, coaches and general managers,

and they realize that, you know, you're trying to do whatever it takes to stay. So what Chris found out is that men like McDonald and Hillen have taught themselves a lesson that, to most of us, makes no sense. Put yourself directly in the path of a painful puck in order to stop it from becoming a threat to your team and to your own future. Everyone has his own pain threshold and his own way of remembering the pain. Hockey players, they just throw out the memory as fast as they can so they can move on to the next assault on their bodies. Subway riders in New York? They're driven by the temptation of getting to dash off one more email. And Donald Rettelmeyer

has maybe the most valuable lesson for easing the pain. Last impressions are lasting impressions. Now, you know who really needs some pain advice, don't you? Politicians. Budgets across the country are in horrible shape. Federal budgets, state budgets, municipal budgets, they're all getting slashed. And it's the politicians who have to stand up there and dish out the pain. The other day, I talked to Martin O'Malley, the governor of Maryland. Things are pretty grim there. So what you're talking about now is, if I understood correctly, a 10% budget cut, essentially, $1.4 billion on 14, correct? That's correct.

All right. And your state of the state address is coming up tomorrow. Can you give us a little bit of a preview? How many times, for instance, will the word pain or painful be featured in your address? You know what? I've been well advised not to use the word pain and not to use the word painful. Those words cause pain, and those words are painful. So I think the better context and the better frame that people are willing to accept is these are the tough choices we need to make in order to give our kids a better future than the one that we've enjoyed. So it's interesting.

You said that you literally don't want to say the words pain or painful because they produce pain. I guess if you suggest to people that it's going to hurt, they will hurt. So there are euphemisms or tough choices and sacrifice and streamlining and downsizing. Is there a kind of governor's handbook of euphemisms for budget pain? No, I wish there were. It would make all of this a lot simpler, wouldn't it? and Dubner Productions. This episode was produced by Chris Neary and mixed by David Herman. Our staff includes Colin Campbell, Susie Lechtenberg, Nora Benavidez, and Beret Lam.

Subscribe to this podcast on iTunes and you'll get the next episode in your sleep. You can find more audio at Freakonomicsradio.com. And as always, if you want to read more about the hidden side of everything, go to Freakonomics.com.