Ezra Klein

So tell me the story of the two nails.

埃兹拉·克莱因

那，告诉我“两个钉子的故事”。

Rachel Zoffness

Great. So 2007 “Journal of Psychosomatic Medicine” reported on two gentlemen. They were both construction workers, because apparently that’s the most dangerous job anyone can ever have. So one was a 29-year-old construction worker, and he was on a job site, and he jumped off a platform straight onto a seven-inch nail.

雷切尔·佐夫内斯

好的。

【关于“两个钉子的故事”的翻译，请看：

https://blog.sciencenet.cn/home.php?mod=space&uid=306792&do=blog&id=1377410】

And that nail went straight through his boot, clear through to the other side. And he was in terrible, excruciating pain. And his colleagues were all horrified, and they rushed him to the emergency room. And he was screaming with pain and they gave him an I.V. of intravenous fentanyl, which is a very powerful opioid, as we all know.

And the good doctors removed his boot, and they discovered that a miracle had occurred. The nail had passed between the space between his toes. There was no blood. There was no wound. There was no tissue damage, but his pain was real. How is that possible?

His brain, a.k.a. his danger detector, used all available information — memories of past pain experiences, knowledge of the dangerous work environment, the panic that he saw on his friends faces, this visual, of course his five senses, this visual of a nail sticking out of his boot. I also would freak out, and because —

Ezra Klein

I feel pain just hearing this story.

Rachel Zoffness

Yeah, and because his brain decided that his body was in danger, it made to protect him. So second tail of nails, and by the way, of course I like stories that rhyme. I call it a tale of two nails. The second story, another construction worker was on a job site. He was somewhere in Colorado. And he was using a nail gun.

And the nail gun accidentally discharged, and ricocheted backwards, and it clocked him in the jaw. And he had a mild headache and a mild toothache, but he continued on with work and life for about six days. And at the end of six days, he turned to his wife and said, you know, I’m going to get this toothache checked out.

And he went to a dentist, and the dentist did a scan of his patient’s jaw. And much to both men’s surprise, they discovered a four-inch nail embedded in his face. Right, and what had happened was, when the nail gun discharged, he saw a nail shoot across the room and bury in the wall across from him.

So again, his brain, our danger detector, used all available information to determine whether or not to make pain and how much. So it used this visual of this nail shooting across the room, and information also of this experience of having this nail gun clock him in the jaw, and decided that not much pain was needed because his body ultimately was safe.

And I read this, like I went down this rabbit hole with these stories so far you have no idea. I have a collection of every interview, everything. And one of the doctors who finally did the surgery to remove the nail said something like, he’s the luckiest man I’ve ever met. Ezra’s shuttering, everybody.

So again, to me what I really love about these stories is that they illustrate the point, pun intended, that I’m trying to make, which is your brain is always using all information, not just some information. Pain and tissue damage are not the same thing.

The conclusion of the tale of two nails is, you can have damage to your body and not a lot of pain, like a four-inch nail embedded in your face. And you can have no tissue damage and have a lot of pain, like our friend who had the nail in his boot.

And we all know that this is true. If you’ve ever gotten into the shower and you’re like, whoa, I have a black and blue mark. How did that get there? That’s evidence of damage to your body without accompanying pain. Or if you’re someone who’s an athlete — I am not. I am a bookworm.

But if you’re someone who grew up playing sports, and you ever had a great soccer game or a great football game, and at the end of the game, you discover that you were covered in blood and you had no idea what happened, and it was only then that the pain started, you also have had that experience. All factors matter when it comes to pain production and pain reduction.

[MUSIC]

Ezra Klein

So I think this gets at what is often, in addition to painful about pain, scary about having pain, which is an assumption many of us have, that it is signaling some kind of harm to the body. And you make this distinction, it’s very central to the book, between hurt and harm. Tell me about that.

埃兹拉·克莱恩

因此，我认为这涉及到通常情况下，除了因疼痛而痛苦之外，因疼痛而令人恐惧，这是我们许多人的假设，它表明对身体有某种伤害。你在受伤害（hurt）和会伤害（harm）之间做了这个区分，这是这本书的核心。请解释一下。

Rachel Zoffness

It’s a critical distinction for patients to get better from pain. And by the way, I include myself in that category. We have this other myth in medicine that it’s us versus them. It’s us as providers on the right and patients on the left.

雷切尔·佐夫内斯

这是让患者从疼痛中恢复过来的关键区别。顺便说一句，我将自己归入该类别。我们在医学上还有另一个“误传”，那就是“我们和他们”。右边是我们作为治疗提供者，左边是患者。

And I want to say clearly, none of us are going to escape pain. It’s coming for everybody. Whether you’ve had it in the past, or you have it now, you’re going to have it in the future, or someone you love will. Pain is everybody’s problem. There’s no such thing as a, quote unquote, “pain patient.” We are all pain patients.

我想明确地说，我们没有人能逃避疼痛。它是大家都会有的。无论你过去有过，还是现在有，你将来还会有，或者你爱的人会有。痛是每个人的问题。没有什么所谓的“有痛的病人”之类的东西。我们都是疼痛患者。

So there’s a really important distinction between hurt and harm. And the tale of two nail stories in my mind really brings that to the fore. So hurt is the subjective experience of pain that you have, for example, when you stub your toe. And harm is the actual damage that occurs to your body.

所以受伤害和会伤害之间（between hurt and harm）有一个非常重要的区别。我脑海中的两个钉子的故事，确实使这一点脱颖而出。所以伤害是你对疼痛的主观体验，例如，当你踩到脚趾时。会伤害（harm）是对你的身体造成的实际伤害。

So if you look at that stubbed toe and it turns purple and it’s swollen, that’s inflammation and evidence of crushed capillaries. But it turns out that hurt and harm are not the same. You can have damage to your body without accompanying pain. You can have pain without accompanying tissue damage.

所以，如果你看那个被扎破的脚趾，它变成紫色并且肿胀，那就是炎症和毛细血管破裂的证据。但事实证明，受伤害和会伤害（hurt and harm）不是一回事。你可以在不伴有疼痛的情况下对身体造成伤害。你可以在不伴有组织损伤的情况下感到疼痛。

And what has happened, understandably, is that our brain conflates the two. And that is adaptive, and it’s not necessarily a bad thing because it saves our life, right? Because one of pain’s most important jobs is to grab your attention and get you to change your behavior.

可以这样理解，我们的大脑将两者混为一谈。那是适应性的，这不一定是坏事，因为它可以挽救我们的生命，对吗？因为痛最重要的目的之一，就是吸引你的注意力并让你改变你的行为。

So if you go for a run and you break your leg and you don’t stop running, your body is going to be in danger. And it’s pain’s job to stop you in your tracks, make you go seek medical help, and then rest for however long is required to heal.

因此，如果你去跑步时摔断了腿，而且你还不停地跑步，那么你的身体就会处于危险之中。阻止你继续跑步是痛的目的，让你去寻求医疗帮助，然后休息多久才能痊愈。

But the problem is because we’re so used to — acute pain is the more common type, and I want to define my terms. Acute pain is pain lasting three months or fewer. That’s how it’s generally defined. And chronic pain is pain that’s three months or longer, or quote unquote, “beyond expected healing time.” So it’s a bit nebulous in its definition.

但问题是因为我们太习惯了——急性疼痛是更常见的类型，我想定义我的术语。急性疼痛是持续三个月或更短时间的疼痛。一般是这样定义的。慢性疼痛是三个月或更长时间的疼痛，或者引用不引号，“超出预期的愈合时间。”所以它的定义有点模糊。

But acute pain is more common. It’s the pain of childbirth, or the pain of an illness, or breaking a bone. And chronic pain is a little bit more rare. But with acute pain, it’s adaptive and useful to pay attention to the pain message, which again is a danger message. Because there’s a high chance that it is warning you of potential danger or damage to your body.

但急性疼痛更为常见。这是分娩的痛，或者是疾病的痛，或者是骨折的痛。慢性疼痛更为罕见。但是对于急性疼痛，注意疼痛信息是适应性的和有用的，这也是一个危险信息。因为它很有可能会警告你潜在的危险或对你身体的损害。

So if you’re going for a run and your body is hurting, it’s good to pay attention. It’s good to stop. But the message here is that hurt, which is pain, the subjective experience of pain, which is your brain’s opinion of how much danger your body is in, is uncoupled, actually, from damage or harm.

所以，如果你要去跑步，而你的身体正受伤，那么注意一下是件好事。停下来就好。但这里的信息是伤害，也就是疼痛，疼痛的主观体验，也就是你的大脑对你的身体所处危险程度的看法，实际上与受伤害或会伤害（damage or harm）无关。

And I want to say, I’m not saying that when you have pain it doesn’t mean there’s tissue damage. It most surely could mean that, but it doesn’t always mean that.

我想说，我并不是说当你感到疼痛时，并不意味着有组织损伤。它很可能意味着组织损伤，但它并不总是意味着组织损伤。

Ezra Klein

Well, let me use an example for this, because I think it’s easy to hear, say, the story of two nails and say, well, a freak situation. But one thing in addition to when we are harmed, expecting hurt, is when we hurt, we go looking for harm.

埃兹拉·克莱恩

好吧，让我为此举个例子，因为我认为很容易听到，比如说，两个钉子的故事，然后说，嗯，一个极其反常的情况。但是，除了我们受到伤害（harmed）、期待受到伤害（expecting hurt）之外，还有一件事是当我们受到伤害时（hurt），我们会去寻找伤害（harm）。

Rachel Zoffness

Oh, so true.

雷切尔·佐夫内斯

哦，真的如此。

Ezra Klein

And to quote something you say that is very striking, and as somebody used to cover healthcare policy, I ran into a lot, studies on back pain reveal there’s little to no correlation between back scan abnormalities and pain. In one study, disk degeneration and bulges were found in 80 percent of elderly patients who had no symptoms or pain. In another, M.R.I. abnormalities were found to be completely unrelated to the degree of disability or pain intensity reported by patients.

埃兹拉·克莱因

引用你曾经说过的非常惊人的话，作为一个曾经报道医疗保健政策的人，我遇到了很多关于背痛的研究表明，背部扫描异常和疼痛之间几乎没有相关性。在一项研究中，在 80% 没有症状或疼痛的老年患者中发现椎间盘退化和凸起。在另一项研究中，发现 MRI 异常与患者报告的残疾程度或疼痛强度完全无关。

But what often happens to people is they’re having a lot of, say, back pain. And you go in and you get a scan, and they say, well, it’s got to be that. I mean, look, it’s bulging out in seven places. So there’s also this question of — I don’t want to always call it overtreatment, but the assumption that hurt and harm are the same leads us to assume to go looking, and then possibly go solving things that aren’t always relevant.

但是经常发生的事情是，人们有很多疼痛，比如说，背痛。然后你进去接受扫描，他们说，好吧，一定是这样。我的意思是，你看，它有七个地方鼓起来了。所以还有这个问题——我不想总是称之为过度治疗，但受伤害和会伤害（hurt and harm）是相同的假设，导致我们应该去寻找（疼痛的原因），然后可能去解决并不总是相关的事情。

Rachel Zoffness

I love that you read those studies, because I’m a statistics person and I try — but those studies are so important in the science of pain. And those of us who are down this rabbit hole with pain science quote them all the time, and I would not have remembered the numbers if you hadn’t said them. So thank you for that.

雷切尔·佐夫内斯

你阅读这些研究，太好了；因为我是一名统计学家，我也尝试过——尽管这些研究在疼痛科学中非常重要。我们当中那些钻研疼痛科学的人一直在引用它们，如果不是你说的话，我不会记住这些数字。非常感谢你的帮忙。

So what happens is, and the reason we all run to the doctor when we have back pain, understandably, is because for decades, we’ve been told that pain means, to your point, tissue damage and harm, and that’s not actually the case. And pain is this complex experience that involves our emotional health, and contextual health, and environmental health, and social health as well. But that’s why we all run to the doctor.

所以，发生的事情是，当我们有背痛时我们都跑去看医生的原因是可以理解的，因为几十年来，我们一直被告知疼痛意味着，组织损伤和伤害，而这实际上并不是真的。痛是一种复杂的体验，涉及我们的情绪健康、情境健康、环境健康、和社会健康。但这就是为什么我们都跑去看医生。

And there’s a diagnosis that makes me crazy. It’s called failed back surgery syndrome. Failed back surgery syndrome is when a poor patient with chronic back pain has done the thing they’ve been told by all their doctors and surgeons to do, which is to just go after the tissue damage, just go after the herniations and the bulges.

有一个诊断让我发疯。它被称为“背部手术失败综合症”。背部手术失败综合症是指患有慢性背痛的可怜患者做了他们所有的医生和外科医生告诉他们要做的事情，那就是只处理组织损伤，只处理疝气和隆起（the herniations and the bulges）。

And seven back surgeries later, they still have pain. And now there’s a name for it, which I find very patient blamey. Like, you failed the treatment. And it’s like, no, our healthcare providers are unwittingly, most of the time, failing patients. Because at no point do my patients — like my patients come to my office, and I’m the last stop on the train because no one wants to see a pain psychologist. Nobody trusts me.

七次背部手术后，他们仍然感到疼痛。现在它有了一个名字，我觉得非常不对，这是怪别人。就像，你治疗失败了。其实，不，我们的医疗保健提供者，在大多数时候都不知不觉地让病人失望了。因为我的病人——就像我的病人一样，来我的办公室，而我是火车的最后一站，因为没有人想去看疼痛心理学家。没有人信任我。

Back to the stigma, and psychosomatic medicine, and it’s all in your head. And at no point have my patients been told, by the way, pain is your body’s warning system. It’s subjective. It’s tied up in your emotional health. It’s tied up in your social and environmental health. And if we really want to treat your pain, we have to treat you like a whole person and not just a body part. So this failed back surgery syndrome just really kills me.

回到耻辱感和心身医学，这一切都在你的脑子里。顺便说一下，我的病人从来没有被告知，疼痛是你身体的警告系统。这是主观的。它与你的情绪健康息息相关。它与你的社会和环境健康息息相关。如果我们真的想治疗你的疼痛，我们就必须像对待一个完整的人一样对待你，而不仅仅是身体的一部分。所以这种“失败的背部手术综合症”真的要了我的命。

（待续）