21. Bring on the Pain!

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.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:01Stephen J. Dubner?

  Freakonomics Radio is sponsored by Southern New Hampshire University. The best investments are the ones you make in yourself, and no one knows that better than Southern New Hampshire University. With more than 200 online degree programs, no set class times, and low online tuition, Southern New Hampshire University is built to fit your life today and set you up for success tomorrow. Education is an investment. Why not make it a smart one? Apply for free at SNHU.edu/freakonomics. Freakonomics Radio is sponsored by PNC Bank. Boring. Great word, bad rep. Yet, time and time again, here at Freakonomics, we find that when something culture-changing

• 0:42Stephen J. Dubner?

  happens, boring things like calculations and careful planning are usually behind it, which begs the question, why not apply it to other aspects of life? Like banking, for example? Well, PNC Bank did since its inception, proving time and again that the best banking strategy isn't the exciting type, but the steady, reliable, definitely not YOLO type. PNC Bank: brilliantly boring since 1865. Brilliantly boring since 1865 is a registered mark of the PNC Financial Services Group, Inc. PNC Bank, National Association, Member FDIC. Freakonomics Radio is sponsored by Hotels.com. Hotels.com helps you find and book the right stay for work faster.

• 1:27Stephen J. Dubner?

  With business preferences, save your travel must haves, like gym access or breakfast, just once, then get tailored results whenever you search for work travel. Plus, with a free membership, you can save up to 20% on hotels and earn rewards on every stay for future travel. Book now at hotels.com. Visit hotels.com for details. Freakonomics Radio is sponsored by ChatGPT. ChatGPT Work is a new way to work in ChatGPT. ChatGPT Work can pull info from across your apps and connect to your tools to help you create finished work. You can even automate work in ChatGPT with the Scheduled Tasks feature, and the whole

• 2:12Stephen J. Dubner?

  time, you stay in control. Put ChatGPT to work on your most ambitious ideas and projects. Get started at chatgpt.com by selecting Work Mode, available on Plus and Pro plans.

• 2:31Stephen J. Dubner?

  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 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.

• 3:13Stephen J. Dubner?

  So whatever device you're listening on right now, turn your volume down, okay? Okay. Now, this is what happens.

• 3:27Stephen J. Dubner?

  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 HEETS, 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.

• 4:07Stephen J. Dubner?

  So inevitably, someone bangs open that emergency door and... BOOM!

• 4:16Stephen J. Dubner?

  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?

• 4:38Speaker 01

  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.

• 4:55Stephen J. 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.

• 5:18Speaker 02

  Let's go in here and watch this one for a minute.

• 5:21Stephen J. Dubner?

  Okay.

• 5:22Speaker 02

  Better get off first. You gotta stand back now.

• 5:25Stephen J. Dubner?

  Yep. 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?

• 5:42Speaker 02

  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 gotta stand here waiting for the next train that are gonna listen to it.

• 5:54Stephen J. Dubner?

  All right, we got an incoming C train. This is my train. Let's, uh, we'll try to blend in here. You don't have an MTA hat on, do you?

• 6:00Speaker 02

  No.

• 6:01Stephen J. Dubner?

  All right. You think we'll get one here?

• 6:05Speaker 02

  Uh, there's a lot of people coming out. Maybe we'll have somebody hit it. Yep, there we go.

• 6:12Stephen J. Dubner?

  She didn't look like a lawbreaker at all, did she?

• 6:16Speaker 02

  No, she didn't. Usually it's not the women. Usually it's a young guy that pushes the gate open.

• 6:21Stephen J. Dubner?

  But once it's open...

• 6:22Speaker 02

  It'll keep going.

• 6:24Stephen J. Dubner?

  And the people keep going.

• 6:26Speaker 02

  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 even if, they couldn't even record the fare beaters coming in, you know, to catch them. You have to catch them in the act. Unless the police is here, they see the person coming in, they can't do anything about it.

• 6:49Stephen J. Dubner?

  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?

• 6:57Speaker 02

  It's actually supposed to be, but they haven't enforced that at all. There's, you see signs that says, "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.

• 7:11Stephen J. Dubner?

  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 thirty or forty people follow him through the open door, and another thirty or forty patient schmucks, that's me, we wait our turn at the turnstile, wallowing in the noise.

• 7:40Stephen J. Dubner?

  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 through instead of go through the turnstile?

• 7:52Speaker 03

  Because it's always blocked. A lot of people, a lot of traffic on the station.

• 7:58Stephen J. Dubner?

  Does this, does the alarm bother you when you come through, or not really?

• 8:01Speaker 03

  A little bit, yes.

• 8:02Stephen J. Dubner?

  But it's worth it?

• 8:03Speaker 03

  Uh, absolutely.

• 8:04Stephen J. Dubner?

  How much time do you think you save coming through that door?

• 8:07Speaker 03

  Four or five minutes.

• 8:09Stephen J. Dubner?

  Four or five minutes? Seriously? I asked Foley how much time she really saves.

• 8:14Speaker 02

  Forty-five seconds or so, I don't, you know. 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.

• 8:22Stephen J. Dubner?

  Here's another guy, just as guilty, but at least he's got a more realistic sense of time.

• 8:28Speaker 04

  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.

• 8:37Stephen J. Dubner?

  How much time do you think you save?

• 8:38Speaker 04

  Oh, come on, like thirty seconds? That's big. That's like one email.

• 8:45Stephen J. Dubner?

  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 Redelmeier. He's a doctor. Who better to talk about pain?

• 9:14Speaker 05

  I'm usually called to see people when there are many things going wrong at the same time.

• 9:20Stephen J. Dubner?

  Redelmeier 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.

• 9:31Speaker 05

  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.

• 9:48Stephen J. Dubner?

  Redelmeier is also a professor at the University of Toronto, and he does a lot of research. But not your typical medical research.

• 9:55Speaker 05

  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 fourfold 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.

• 10:36Speaker 05

  A 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.

• 10:58Stephen J. Dubner?

  About 15 years ago, Rettelmeier 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. Rettelmeier 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.

• 11:39Stephen J. Dubner?

  They worked with patients who received a colonoscopy, a procedure to detect colon cancer.

• 11:44Speaker 05

  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

• 12:27Speaker 05

  malignancy from, say, lung cancer or prostate cancer.

• 12:31Stephen J. Dubner?

  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 US, only about half of the people over 50 are getting any kind of colon cancer screening, including colonoscopy. Why?

• 12:56Stephen J. Dubner?

  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 afterwards, someone else will need to 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. The 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.

• 13:37Stephen J. Dubner?

  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 Redelmeier 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.

• 14:09Speaker 05

  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 their overall impression of the experience, regardless of whether that moment occurred once or several times.

• 14:44Stephen J. Dubner?

  So if I have a pain level of, let's say, 6, for a solid hour, versus a pain level of 4, for 58 minutes, but a pain level of 10, for those other 2 minutes, I'm going to remember the entire procedure as worse, yes?

• 14:59Speaker 05

  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...

• 15:14Speaker 05

  Patient's 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.

• 15:31Stephen J. Dubner?

  Interesting. And then the third factor?

• 15:33Speaker 05

  Was the, and this was the largest phenomenon, that we termed 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.

• 15:53Stephen J. Dubner?

  So, not only does a longer procedure not necessarily generate a worse memory, but as Rettelmeier puts it, "The last impression is the lasting impression." These findings led Rettelmeier 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.

• 16:20Speaker 05

  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.

• 16:39Stephen J. Dubner?

  So you literally would leave the scope inside the patient for an extra few minutes to change the final impression of the colonoscopy?

• 16:50Speaker 05

  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, but looking at rates of return.

• 17:30Speaker 05

  And we found a small improvement in subsequent adherence rates with return visits for colonoscopy. For those individuals who had had the somewhat extended experience.

• 17:45Stephen J. Dubner?

  So if I understand correctly, you're telling me, Dr. Redlmeyer, that when people have a longer colonoscopy versus a shorter 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?

• 18:08Speaker 05

  You've described it accurately, except the effect isn't enormous here, right? I mean, we'll 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%. And it does improve their subsequent adherence rates by from about, maybe about 45% to about 55%, all right? 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.

• 18:48Stephen J. Dubner?

  An increase from 45% to 55%. Those 10 percentage points represent a gain of 22%. That's a 22% improvement in people coming back for a potentially life-saving procedure. A 22% gain achieved by simply doing nothing for a couple of minutes.

• 19:11Stephen J. Dubner?

  Redelmeier 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.

• 19:21Speaker 05

  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. 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.

• 19:54Stephen J. Dubner?

  Coming up. If you think a colonoscopy is painful, you're probably not a professional hockey player.

• 20:00Speaker 06

  I broke my bottom five teeth, got knocked out. They were like sitting in my throat, I could feel them.

• 20:29Stephen J. Dubner?

  Freakonomics Radio is sponsored by Southern New Hampshire University. There's no hiding how convenient Southern New Hampshire University makes college. They offer over 80 career-focused graduate programs online. Classes have no set meeting times, so you can balance life and learning, and online tuition rates are some of the lowest in the country, making it all a little more manageable. A school this willing to work with you is worth the investment. Visit SNHU.edu/freakonomics to learn more. Freakonomics Radio is sponsored by PNC Bank. Boring. Great word, bad rep. Yet, time and time again, here at Freakonomics, we find that when something culture-changing happens, boring things like calculations and careful planning are usually behind it.

• 21:14Stephen J. Dubner?

  Which begs the question, why not apply it to other aspects of life? Like banking, for example? Well, PNC Bank did since its inception, proving time and again that the best banking strategy isn't the exciting type, but the steady, reliable, definitely not YOLO type. PNC Bank, brilliantly boring since 1865. Brilliantly boring since 1865 is a registered mark of the PNC Financial Services Group, Inc. PNC Bank, National Association, Member FDIC. Freakonomics Radio is sponsored by Amica. You know what they say, if you want to go fast, go alone. If you want to go far, go together.

• 21:54Stephen J. Dubner?

  So go with Amica and get coverage from a mutual insurer that's built for their customers, one that looks after what's important to you together. Auto, home, life, and more, coverage that fits your unique needs. Amica helps you protect what matters most. Visit amica.com and get a quote today.

• 22:13Speaker 01

  From WNYC and American Public Media, this is Freakonomics Radio. Here's your host, Stephen Dubner.

• 22:29Stephen J. 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.

• 23:02Speaker 07

  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.

• 23:31Speaker 07

  The New York Islanders are pretty good at blocking shots. Over the past five seasons, they've been in the top 10 in the league. But that doesn't mean they're very good. During that same period, they haven't finished in the top 10 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.

• 24:13Speaker 07

  Here's how he described it recently in the locker room after practice.

• 24:17Speaker 06

  My jaw has a big crack right here, and they put two plates and 12 screws, and it shattered. Like, 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.

• 24:33Speaker 07

  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?

• 24:44Speaker 06

  Yeah, I don't remember.

• 24:49Speaker 07

  Why don't you remember?

• 24:51Speaker 06

  Because you've played thousands of 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 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.

• 25:36Speaker 07

  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.

• 25:58Speaker 08

  There's a lot of parity between, you know, players. So, there's, you know, 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 just stay.

• 26:34Stephen J. Dubner?

  So what Chris found out is that men like McDonald and Hill 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 Redelmeyer has maybe the most valuable lesson for easing the pain. Last impressions are lasting impressions.

• 27:21Stephen J. Dubner?

  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?

• 27:51Speaker 09

  That's correct.

• 27:52Stephen J. Dubner?

  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?

• 28:02Speaker 09

  You know what, I've been well advised not to use the word "pain." To use the word painful, those words cause pain and those words are painful. So I think the the better context is the and the better frame that people are willing to accept is this is the this, these are the tough choices we need to make in order to give our our kids a better future than the one that we've enjoyed.

• 28:26Stephen J. Dubner?

  So it's interesting, you said that you literally don't want to say the words pain or painful because they produce pain. If you if you, I guess if you suggest to people that it's going to hurt, they will hurt. So so there are, you know, euphemisms, there are tough choices and sacrifice and streamlining and downsizing. Is there a kind of governor's handbook of euphemisms for budget pain?

• 28:46Speaker 09

  No, I wish there were. It would make all of this a lot, a lot simpler, wouldn't it?

• 28:55Speaker 01

  Freakonomics Radio is a co-production of WNYC, American Public Media, and Dubner Productions. This episode was produced by Chris Neary and mixed by David Herman. Our staff includes Colin Campbell, Susie Lechtenberg, Nora Benavides, and Borey 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.

• 29:36Stephen J. Dubner?

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• 30:09Stephen J. Dubner?

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• 30:39Speaker 10

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• 31:02Speaker 11

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• 31:06Speaker 10

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• 31:18Speaker 05

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• 31:21Speaker 10

  Stop the press mess. I would like to volunteer to administer any and all DNA tests. Maybe that should be part of the show? Let's talk off-camera with me, Kelly Ripa. You just put that in the universe. Listen and follow wherever you get your podcasts.

• 31:38Speaker 11

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