“Embrace the tragedy.” An interview with Larry Cripe

Posted on October 12, 2012 by

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Larry Cripe is a leukemia specialist who researches physician-patient communication and medical decision-making. He also writes for Grace Notes, a radio essay series. His essays have appeared in JAMA.

In his essay, “The General,” Cripe remembers the difficulties he’s faced and the relationships he formed during his career as an oncologist. Interview conducted by Jasmine Turner.

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 In your essay, you say that medical workers aren’t trained to talk to patients about death. Why do you think that is, and what is the best way to discuss this topic with patients and their families?

Well, that is a huge question! I think the fundamental issue is that biomedical research and the practice of medicine are heavily (and appropriately) invested in restoration of health. The amount of energy and time it takes to competently practice the nuts and bolts of medicine is almost all consuming. Death catches most physicians by surprise, and they are not prepared for it in general. This silence is mutually agreeable to everyone. I personally believe the best way to discuss the topic is to acknowledge first that it is a relevant topic for many patients and then seek how the patient feels comfortable discussing the topic.

Do you think that most people you encounter in your line of work are in denial about death?

I really do not like the concept of denial; I think most people are acutely aware of their mortality, but they are trying to find something that will delay the inevitable. Perhaps we compartmentalize as one coping strategy: “I have a life-threatening illness but a) there are treatments that could prolong life or even cure the disease; b) I need to stay positive just in case attitude affects the fates or the willingness of my medical team to help me; and c) I need to remain engaged in life, and it is a bummer to think all the time about being pulled away.”

You work in oncology, so you must encounter death on a pretty frequent basis. How do you deal with and process this on a personal level?

I find caring for people who almost certainly will die to be the most rewarding part of my job. I do not deny the tragedy of a life ending prematurely (and most deaths are premature) or the grief. However, I find it more useful to embrace the tragedy, grieve briefly and then move on. I feel more connected to life through my work in caring for the dying. On a more practical level, I try to take good care of myself physically and mentally. I suspect I write to process what is happening around me.

Even though your essay explores painful and emotional topics, there are still moments of humor in your interactions with patients and coworkers. What role does humor play in your work as an oncologist?

I never deliberately try to use humor. I am not very funny and worry about the risk of offending someone. On occasion there are humorous moments and I laugh with my patients, but only at their invitation.

Most people don’t like hospitals and don’t want to spend their final days there. You describe them as “sterile and impersonal” places. Do you think that will ever change, especially in terms of end-of-life care?

Not from my perspective. I think “personal” implies a sense of belonging to a space or that the space has been shaped by a person’s personality. Hospitals are meant to care for many people at once.

 A really interesting moment in this essay is when you write that what you do is similar to “loving someone, especially as life is ending.” Could you talk a bit more about what you mean by that?

Basically, what is love? I think love, in part, is working really hard to care for someone, and there are moments when I invest all of my resources in trying to connect with or treat or comfort a patient. That feels like love to me—though it’s not a perfect analogy.

You write that patients often rely heavily on you and trust that you will be able to help their disease. Seems like a lot of pressure. How do you handle this?

I carefully delineate the limits of what I have to offer in terms of interventions that will change their prognosis. I then distinguish between the limits that are due to me personally—and consequently may be solved by referral to someone more expert than I am—and the limits of the science of medicine, which are not easily circumvented. People commonly grow to appreciate my honesty (for some, it is jarring to the point that they seek other doctors) and eventually thank me. To me, no matter how hard this job is, it would be harder if I thought I were misleading people to protect them or myself.

You write that your priorities as a physician have shifted over the years away from the belief that clinical expertise is enough to care for the seriously ill. Where are your priorities now?

I thought all I had to do was learn medicine and I could help people; that clearly is not true. So my priority is helping people understand when life will end, to formulate their goals, and make sure I do not recommend treatments that will interfere with their achieving their goals. If I had an incurable illness, I’d make darn sure my doctor was ready to care for me when my life was ending.

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Jasmine Turner, an editorial assistant for Creative Nonfiction, is a junior at the University of Pittsburgh studying English nonfiction writing, political science and French.

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