Bring on the Pain!

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. 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, 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 HEETs — that is, High Entrance and Exit Turnstiles, they look like a cross between a floor-to-ceiling revolving door and a jail cell. It’s a turnstile you can’t 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 aboveground a little bit faster? Who are these people?

*      *      *

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.

Pete FOLEY: Let’s go in here and watch this one for a minute.

DUBNER: OK.

FOLEY: Let them off first. You gotta stand back now.

DUBNER: 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? The guy who you want to pay the most is actually paying the least.  Did you think about that in the design?

FOLEY: I don’t think they did. That person’s gone and up the stairs. Usually they have their headphones on full blast anyway so they couldn’t care less. It’s the people who got to stand here waiting for the next train that got to listen it.

DUBNER: All right, we 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? Do you think we’ll get one here?

FOLEY: Uh, there’s a lot of people coming out.  Maybe we’ll have somebody hit it. There we go.

DUBNER: She didn’t look like a lawbreaker at all, did she?

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

DUBNER: But once it’s open…

FOLEY: It will keep going.

DUBNER: And the people keep going.

FOLEY: Right, and if there’s somebody on the other side, a lot of people come in for free, then. The other thing on this station is there’s no cameras here either. So they couldn’t even record the fare beaters coming in. You have to catch them in the act. Plus, if the police is here, if they see the person coming in, they can’t do anything about it.

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?

FOLEY: 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:

DUBNER: Just wanted to talk about why you popped the emergency door to come through instead of going through the turnstile?

WOMAN: Because it’s always blocked, and a lot of people are…a lot of traffic on this station.

DUBNER: Does the alarm bother you when you come through or not really?

WOMAN: A little bit, yes.

DUBNER: But it’s worth it?

WOMAN: Absolutely.

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

WOMAN: A good four or five minutes.

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

FOLEY: Forty-five seconds or so, you know. The funny thing is at the end of it they all have to come up a narrow staircase so everyone 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.

MAN: I just need to get out of that door as quickly as possible. So if I’m the first one there and getting stuck in that little cattle gate just makes it a really slow morning.

DUBNER: How much time do you think you save?

MAN: Oh, come on, like 30 seconds. That’s big! That’s like one e-mail.

But to get to that e-mail, you’ve got to endure some pain. Maybe even a little guilt, too, knowing you’re leaving behind a big noise bomb for everyone 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?

Donald REDELMEIER: I’m usually called to see people when there are many things going wrong at the same time.

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.

REDELMEIER: 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.

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

REDELMEIER: Ah, Stephen it’s a pretty eclectic portfolio, and some people would criticize me on that basis. The single most famous study I’m know 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. 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 particular focus on the determinants of health.

About 15 years ago, Redelmeier 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. Redelmeier and Kahneman wanted to know how a medical patient’s experience of pain during a procedure might differ from how they remembered the 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.

REDELMEIER: 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 percent, i.e., of the people who are diagnosed with colon cancer, roughly about one third will die of their colon cancer. Of the people who 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 detections, making it quite a different malignancy from let’s 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 before hand, 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 there on out. At the hospital, you probably start with an anesthetic — which means that afterward, 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. 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.

REDELMEIER: 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.

DUBNER: So if I have a pain level of let’s say six for a solid hour versus a pain level of four for 58  minutes but a pain level of 10 for those other two minutes, I’m going to remember the entire procedure as worse, yes?

REDELMEIER: Right. 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 bad note.

DUBNER: Interesting, and then the third factor?

REDELMEIER: 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.

So: not only does a longer procedure not necessarily generate a worse memory; but, as Redelemeier puts it, “the last impression is the lasting impression.” These findings led Redelmeier 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.

REDELMEIER: 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 sense of mildness during the last one or two minutes.

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

REDELMEIER: You got it. About half underwent randomization so that the procedure was prolonged by a few minutes by making sure that the last couple minutes of the procedure 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 looking at rates of return. 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.

DUBNER: So if I understand correctly, you’re telling me Dr. Redelmeier, 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 is that brief period at the end without pain. That’s a pretty neat magic trick, yeah?

REDELMEIER: Yeah, you’ve described it accurately, except that the effect isn’t enormous. It 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 45 percent to about 55 percent, all right? So it doesn’t completely reverse the situation. But  does lead to a small improvement at no financial cost to the health care system, and no medical risk to the patient.

An increase from 45 percent to 55 percent — 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. 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.

REDELMEIER: 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 sort of a great way to rule out colon cancer. I got a bit of anesthesia; I kinda 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.

[TAPE] My bottom five teeth got knocked out. They were like sitting in my throat; I could feel them.

*      *      *

Hockey hurts. Hard checks up against the boards. In the first period, you 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.

Chris NEARY: 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 per 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 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. Here’s how he described it recently in the locker room, after practice:

Jack HILLEN: My jaw has a big crack right here, and they put two plates and twelve screws. It shattered. My bottom five teeth got knocked out. They were like sitting in my throat; I could feel them. The oral surgeon said that it looked like a gunshot wound.

NEARY: 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?

HILLEN: I don’t remember.

NEARY: Why don’t you remember?

HILLEN: Because you play thousands of games in a career. I mean, I remember the play that broke my jaw, but I don’t remember most of the games in my career. You don’t remember specific plays that well. I think you think more about what you need to do to get through it.  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?” Do I need to ice it, do I need to stretch it, do I need to, you know, get a message?  What do you need to do?  And that’s what you remember about injuries in sports, I guess, not necessarily so much the pain.

NEARY: 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 MacDonald.

Andrew MacDONALD: What’s the word I’m looking for? There’s a lot of parity between, you know, players. So, you know, there’s a lot of players in the minors that are good enough to play in the NHL but they just might not get their chance. I think guys are realizing that now more than ever and they’re doing whatever they have to do to stay here. I mean I think putting your body in front of a hundred-mile-an-hour shot sometimes, I think guys pick up on that, like you know coaches and general managers, and they realize that you’re trying to do whatever it takes to stay.

DUBNER: So what Chris found out is that men like MacDonald 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 memories as fast as they can, so they can move on to the next assault on their bodies. Subway riders in New York — well, they’re driven by the temptation of getting to dash off one more e-mail. And Donald Redelmeier 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.

DUBNER: So what you’re talking about now is a, if I understood correctly, a 10 percent budget cut essentially, 1.4 billion on 14, correct?

Governor Martin O’MALLEY: That’s correct.

DUBNER: 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?

O’MALLEY: Ah. 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 is the, and the better frame that people are willing to accept is this, these are the tough choices we need to make in order to give our kids a better future than the one we’ve enjoyed.

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 suggest to people that it’s going to hurt, they will hurt. So there are, you know, euphemisms or tough choices and sacrifice and streamlining and downsizing. Is there a kind of a governor’s handbook of euphemisms for budget pain?

O’MALLEY: Nah, I wish there were. It would make all of this a lot a lot simpler, wouldn’t it?

ANNOUNCER: 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 Collin Campbell, Suzie Lechtenberg, Nora Benavidez and Bourree 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.