Injuries Increase As Pitchers Throw Harder, Faster And Younger

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. Major League Baseball gets underway this weekend, and our guest, sports writer Jeff Passan, says before the season's over, about half the game's pitchers will be on the disabled list because of injuries. In his new book "The Arm: Inside The Billion-Dollar Mystery Of The Most Valuable Commodity In Sports," Passan says pitchers are throwing harder and faster and starting younger, and more and more are getting surgery to repair a torn elbow ligament. The operation is called Tommy John surgery, named after the Los Angeles Dodgers sinkerballer who got the first such surgery in 1974.

Passan writes that major league teams spend a billion and a half dollars a year on pitchers but know relatively little about what's causing arm injuries or how to prevent them. And, he says, there's plenty of evidence that the competitive pressure on kids to throw harder and longer is making them more vulnerable to injuries. Jeff Passan is a baseball columnist at Yahoo Sports and the co-author of a previous book about college football. He spoke with FRESH AIR contributor, Dave Davies.

DAVE DAVIES, BYLINE: Well, Jeff Passan, welcome to FRESH AIR. When this elbow ligament goes - the ulnar collateral ligament - what does a pitcher experience?

JEFF PASSAN: You know, it's different depending on the pitcher. Some pitchers, it is abject pain. They know that they have heard something sounding like a pop, that they felt something. It could be shooting down their arm toward the wrist, shooting up their arm toward the shoulder. It can be excruciating at times. You see guys jump off the mound not just because it physically hurts, but because psychologically they understand that their arm is done and that they're going to need surgery of some kind. It's almost a preternatural feeling.

On the other hand, there are some pitchers who say, well, I felt something in there, but I'm going to keep trying to pitch through it. And you can almost always tell when there's a significant drop in their velocity on their fastball. You know, a pitcher that normally throws 93 or 94 is sitting there at 88 or 89.

DAVIES: Well, the surgery to fix this is named for Tommy John, the Los Angeles pitcher of the '70s. Tell us about his injury. What happened?

PASSAN: Tommy John was a sinkerballer, and he never threw particularly hard, you know - normally around 82 or 83 miles per hour. But the wear and tear on his arm was significant enough that one day he just could not throw anymore without there being pain. And so he went to visit Dr. Frank Jobe, who was baseball's legendary orthopedist. Now, Dr. Jobe had gotten the sense that this surgery might work - taking a tendon from the wrist, drilling holes into the elbow, and essentially making a new ligament there.

The body turns tendons into ligaments within an 18-month process. The surgery had been done before in the ankle area, but this was the first time that it was done ever on the elbow. And Tommy John took 18 months but came back and had every bit as good of a career after his surgery as he had had before it.

DAVIES: It's remarkable - something like 300 starts after getting his elbow reconstructed.

PASSAN: Yeah. You know, back then, this was such a novel thing. Frank Jobe - when he opened up Tommy John's elbow - did not know what it was going to look like, did not know what was going to be in there, did not know how it was going to take. And Tommy John for the first six months was miserable because he actually - his hand was formed into a claw. You know, they had hit a nerve there, and his left hand was not working. So not only was he concerned that he wasn't going to pitch again, he was concerned that the rest of his life he was going to have a disabled hand.

And so they went back in, they fixed the nerve issue, and over the next 12 months, Tommy John went out and did his own thing. He really set the protocol for how to rehabilitate an ulnar collateral ligament transplant surgery, and he was back on the mound and almost every bit as good as he was before the surgery.

DAVIES: You've spent a lot of time learning about the arm and studying pitching motion, and there's - I don't know if we can do this without pictures - but there's a point in the book where you describe the motion of the shoulder and its relationship to the elbow in delivering an effective fastball. Can you describe that?

PASSAN: The way that throwing anything not just the ball but any overhand throwing works is through something called the kinetic chain. And the kinetic chain is essentially the building up of energy because every part of your body is intertwined and all of that energy loading into a particular place. And when you're throwing something overhand, it starts down at your feet, your ankles up through your backside, all the way up your back, and the energy goes into the shoulder. And when the energy is in the shoulder, imagine a rubber band being pulled back as far as it possibly can and as tight as it actually can. That's what happens when your foot lands and when your hips start to turn. Your arm almost lays back flat and parallel to the ground. And at that point, once it reaches as far as it can go, the motion going forward is the fastest movement the human body can make. It is 8,000 degrees per second. It's faster than an eye blink, and that's called the internal rotation of the shoulder.

When the shoulder is internally rotating, all of that energy goes down the arm and into the elbow and onto this ulnar collateral ligament which is just a 2-inch triangular band of flesh. And unlike shoulder muscles which can be strengthened, ligaments cannot be. And so all of this pressure going onto the ligament time after time after time will wear you down. The harder you throw, the more force is going down there. The less conditioned you are, the likelier it is for your shoulder to go as well as your elbow. And the pitching motion - it is - to me, the fallacy is that it is an unnatural motion. It's far from that. It's the opposite of that. Humans evolved into overhand throwing just so they could go hunt and gather. So it, to me, is the epitome of something that is natural. What it isn't natural to do is throw a hundred pitches every five days.

DAVIES: Now, how common has this surgery become among ballplayers?

PASSAN: It's not just common among major league players; it's common among players, period. The estimates are about a quarter of pitchers at any given time on major league rosters have had Tommy John surgery. And I actually expect that number to grow in the coming years because of what's happening throughout baseball. And this is the thing that frankly compelled me to write this book. I have a son. He's 8 years old now. He's just starting pitching. And within the next five or six years, he will know kids who have undergone Tommy John surgery, and that's not an exaggeration.

This is a frightening thing because there are 13 and 14 and 15 and 16-year-old kids who are having this surgery that for a long time was just limited to major league and minor league and at the very least professional players. But the number of kids who have had surgery has spiked significantly in recent years to the point where more than half of Tommy John surgeries now happens with teenagers. And I'm hoping that this book is an alarm for parents and for coaches out there who don't quite understand that the amount of pitching you do as a child could significantly damage you for years to come. And maybe - just maybe - they will start listening because ultimately the responsibility is as much on parents and coaches as it is on Major League Baseball adjudicating this from the top down.

DAVIES: There's not a lot of hard data and hard science behind some rules like the 100-pitch limit, but you're saying it is clear that throwing too much when you're a kid makes you more susceptible to injury.

PASSAN: Unquestionably at this point, yes. There is hard data on that. The American Sports Medicine Institute has run multiple studies, you know, a 10-year long study on pitchers following them throughout their youth careers. And what this study showed is that pitching when you're young excessively is truly injurious. It's harmful, and the number of kids who end up pitching too much when they're younger and staying healthy is far outnumbered by the ones that just can't go anymore. And so the incentive is there for change. And Major League Baseball is helping in some respects.

Baseball turned a blind eye to this for a while, but within the past few years, they've really taken the right steps between establishing the Pitch Smart program which encourages pitch limits for certain ages - every age starting at 8 years old that says what is healthy for a kid to go out and do, how often he should pitch, how many pitches he should throw, how many days off, he should take. And beyond that for the major leaguers, they've been collecting injury data for about half a decade now that they're sending to epidemiologists at Johns Hopkins who are looking it over and trying to find some sort of correlation between injuries and something that we just don't know yet.

DAVIES: Jeff Passan's book is called "The Arm." We'll continue our conversation after a short break. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

DAVIES: This is FRESH AIR. And if you're just joining us we're speaking with Jeff Passan. He is a sports writer and a columnist for Yahoo Sports. His new book is called "The Arm: Inside The Billion-Dollar Mystery Of The Most Valuable Commodity In Sports." Decades ago major league pitchers threw a lot more innings than they do now. And you described talking to Sandy Koufax, the great Dodger, about his experience and his endurance and the toll it took. Tell us a little bit about that.

PASSAN: Sandy Koufax was a warrior. And he would go out there and pitch no matter how much his arm hurt. There were times when he woke up in the morning and he would look at his left arm and the entire upper arm would be black and blue. And I mean the entire thing. It was almost like it had been painted like a fatigue. And his arm was rebelling against what he was doing to it. The amount of pain pills that he took, the number of times he went in with Robert Kerlan and got a giant needle stuck into his elbow and the fluid drained from it - it's sad in hindsight and in retrospect.

DAVIES: You know, it's generally understood that once a pitcher gets to around a hundred pitches in a big league ballgame, it's time to think about getting him out of there. Sandy Koufax would drain his elbow and just go through this miserable pain and then go out and throw how many?

PASSAN: (Laughter) Two hundred sometimes. I mean, there - you know, there were outings where he would throw 130, 140, 150 pitches. And the number 100 that is standard these days I don't really think is based on a whole lot of science. I think that as time has gone on and as we've seen the number of arms get injured as do get injured - and as the salaries have gone up - the human instinct is to go into protective mode. It's that if we're doing a lot of something and that's bad, doing less of it is good. And that's not necessarily true with baseball players.

I think with younger pitchers, certainly keeping them on pitch counts is the right thing to do because they're still growing into their body. They still don't understand what the right type of soreness is versus something that could be harmful. But when you have an older pitcher, like Clayton Kershaw with the Los Angeles Dodgers or Madison Bumgarner with the San Francisco Giants, I firmly believe they could go out there, throw 120 pitches every time and stay healthy.

DAVIES: When we look at pictures in the past, where they threw a lot and were paid a whole lot less, I mean, I wonder if what you had was a herd of arms coming in and lots of them blew out, were injured, but the teams really didn't care because they weren't expensive and they could be easily replaced.

PASSAN: That's 100 percent correct. And you talk to any great pitcher and he has a teammate who was better than him in the minor leagues. With Sandy Koufax there was Karl Spooner, who struck out 27 in his first two outings for the Dodgers back in the mid-50s and barely ever pitched again - got hurt. And what's amazing is that we know so much more now and the players still are getting hurt. You talk to Jim Palmer, there was Steve Kariya - had much better stuff than Jim Palmer did. And Jim Palmer was pitching in World Series games at 20 years old. So you had this generation of players who went down and there were no fixes for it.

DAVIES: One of the most influential agents in the game is a guy named Scott Boras. And he's had some pitchers that he's really tried to limit the work of - Stephen Strasburg of the Washington Nationals. You want to tell us about what he was trying to do and how it worked out?

PASSAN: Well, Scott Boras has a think tank, really, at his agency. And they have done some significant analysis on what happens to pitchers who throw too much when they're young. And the result tends to be their careers don't last much past 30. And so he wants to limit not just the number of pitches that these players are making but the number of innings that they are throwing as well. And so whether it is Strasburg, whether it is Matt Harvey, whether it's Jose Fernandez - these are all players of his who have undergone Tommy John surgery. And when they've come back, Strasburg was under an innings cap where he ended up missing the playoffs and the Nationals lost. And many still look at Strasburg and say, well, maybe he should've pitched.

DAVIES: I just want to understand what you're saying. This is a team that gets into the playoffs and their best pitcher is on the bench - not performing - to preserve his arm?

PASSAN: That is correct - and controversially, I might add, because we don't know whether that's the right move. The - one thing that I've learned in studying this subject is that it is foolish to try and make assumptions. I would've assumed that the fewer innings you throw or the fewer pitches you throw, the less likelier you are to get injured. And history, frankly, has not proven that because pitchers now - starting pitchers - are throwing fewer innings than ever at the major league level and they're still getting hurt. And so with Stephen Strasburg, for all we know he might have gone out and pitched the Nationals to the World Series that year and might still be healthy these days. But we just don't know whether that would've happened and there simply aren't enough cases to test that and to say for certain whether there is any kind of a correlation there.

DAVIES: You say there's certain things we know. We know that kids pitching too long too young tends to increase injuries. But you say there's a lot we don't know. What do we need to learn about the relationship between what arms do and how they break down? And how do we find out?

PASSAN: I think there have been enough advances in recent years to give us a decent sense. For example, there is a product called Kinatrax. And Kinatrax can - what it does is with cameras positioned around a stadium or around a baseball diamond - whatever it may be - allows you to see the movements and the joint angles of every single millisecond a pitcher is throwing a ball. And so if we can take that data and put it into a massive database and allow people far smarter than I to try and find patterns, maybe we can get a sense of which people - because of how they throw - are at risk for injuries and identify those earlier and make changes. Now, changing a delivery is not an easy thing to do. But if you know you're at risk for injury long-term, the likelihood of you doing it is far greater than someone coming up to you and saying, hey, you should probably change your delivery. Another part is understanding that the elements surrounding the ulnar of collateral ligament. For example, Dr. James Buffi was a graduate student at Northwestern. And when he was younger he played baseball and was always fascinated at the ability of people to generate the same type of pitch, whether it's a 95-mile-per-hour fastball from a guy who stands 5-foot-9 or a guy who stands 6-foot-5. And Dr. Buffi did his research - his doctoral research - in the muscles of the forearm and their ability to stabilize the elbow joint. And what that means is he came to the conclusion, through musculoskeletal modeling, that strength in the forearm muscles has the ability to lessen the impact on the ulnar collateral ligament. All of which is to say there could be exercises that we could do to strengthen the forearm muscles that might prevent the ulnar collateral ligament from snapping eventually.

DAVIES: You know, baseball is 30 teams that have - that are independently owned and have their own coaching staffs and their own priorities and their own medical records of their players, which they don't necessarily share. To what extent is major league baseball, overall, doing what it should be doing to give us useful data?

PASSAN: Major League Baseball as an organization itself, the commissioner's office, is doing good work. Major League Baseball teams, on the other hand, are doing everything they can to figure out the arm and not tell anyone about it. And that's where the inherent conflict is here because teams understand that the first one to find out what is causing arm injuries is going to win a World Series because of it. The idea that you can bring up pitchers who are healthy and keep them healthy and know that these pitchers aren't going to be drags on your payroll or that you can take these raw arms coming out of high school and college and turn them into major league commodities who you know will be there - there is such great power in that. And so Dr. James Buffi, who I was just talking about, got hired by the Los Angeles Dodgers. And any breakthroughs that Dr. Buffi has from now on will be property of the Los Angeles Dodgers. The Dodgers have an eight-billion-dollar television contract. And their not just using that TV money to go out and buy players. They started a think tank full of quantitative analysts, like Dr. Buffi, who are trying to figure out the mysteries of this game that we just don't know even 150 years after its beginning.

DAVIES: So the arms race goes on.

PASSAN: That's good, Dave. That's good (Laughter).

DAVIES: Sorry, sorry, sorry. Jeff Passan, thanks so much for speaking with us.

PASSAN: Dave, the pleasure was mine. Thank you for having me.

GROSS: Jeff Passan is the author of "The Arm" and writes a baseball column for Yahoo Sports.

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross.

(SOUNDBITE OF FILM, "WHEN HARRY MET SALLY")

MEG RYAN: (As Sally) I'd like the chef salad, please, with the oil and vinegar on the side and the apple pie a la mode.

KIMBERLY LAMARQUE: (As waitress) Apple a la mode.

RYAN: (As Sally) But I'd like the pie heated. And I don't want the ice cream on top. I want it on the side. And I'd like strawberry instead of vanilla if you have it. If not, then no ice cream, just whipped cream, but only if it's real - if it's out of a can, then nothing.

LAMARQUE: (As waitress) Not even the pie?

RYAN: (As Sally) No, just the pie, but then not heated.

LAMARQUE: (As waitress) Uh-huh.

GROSS: That's Meg Ryan in a scene from the 1989 film "When Harry Met Sally," which was written by the late Nora Ephron. A new HBO documentary about Nora Ephron called "Everything Is Copy" was directed by her son, my guest Jacob Bernstein. Bernstein is the child of two famous parents. His father is Carl Bernstein who, with Bob Woodward, broke the Watergate story. One of Nora Ephron's best-selling works was her novel "Heartburn," a fictionalized version of the breakup of their marriage, which she adapted into a film. Nora had a successful career in Hollywood and publishing.

She co-wrote the movie "Silkwood" and wrote and directed "Sleepless In Seattle" and "Julie & Julia." Nora's best-selling book "I Feel Bad About My Neck" was considered a candid and funny series of very personal essays about getting older. But there was something fundamental she didn't reveal in that book. She had a serious blood disease that developed into leukemia. She died in 2012 at the age of 71.

Jacob Bernstein writes for The New York Times. His documentary, "Everything Is Copy," which debuted on HBO earlier this month and is available on demand, features interviews with family, friends, and people Nora worked with, including her sister Delia Ephron, Carl Bernstein, Mike Nichols, Meryl Streep and Tom Hanks. Let's start with a clip of Nora Ephron being interviewed and then reading from one of her essays. She's telling the story that gave Jacob Bernstein the title of his documentary. It's a phrase that was used by her mother who was also a screenwriter.

(SOUNDBITE OF DOCUMENTARY, "EVERYTHING IS COPY")

NORA EPHRON: We all grew up with this thing that my mother said to us over and over and over and over again, which was everything is copy. You know, you'd come home with some thing that you thought was the tragedy of your life - someone hadn't asked you to dance or your - the hem had fallen out of your dress or whatever you thought was the worst thing that could ever happen to a human being. And my mother would say everything is copy. I now believe that what my mother meant is this - when you slip on a banana peel, people laugh at you. But when you tell people you slipped on a banana peel, it's your laugh. So you become the hero rather than the victim of the joke.

GROSS: Jacob Bernstein, welcome to FRESH AIR. Why did want to make...

JACOB BERNSTEIN: Well, thank you for having me.

GROSS: ...This movie about your mother?

BERNSTEIN: I think that I was interested in what the life of a writer is and how the personal becomes public and what all of that is, you know. I write for The New York Times, but I write much less personally, generally, or less autobiographically at least, I think. I certainly had not written about, you know, my family or my own life explicitly. And so, I was curious about what that had been like for her.

And I had been - you know, my parents had gotten divorced when I was very young. And it had inspired this book that she had written. And I wanted to know a little bit more about what that was like. And I wondered whether she had been ambivalent about sort of spilling all of these secrets, I wondered what the experience of that was like. I didn't get an enormous sense of my mother's vulnerability growing up. And I always sort of wondered if that was there. I would not say that, during the course of this documentary, I found a huge amount of vulnerability. I think my mother was fundamentally different than the rest of us were in some way in the family. She was relatively unencumbered by the kind of ambivalence that often fells people and keeps them awake at night.

GROSS: Your mother was Nora Ephron. Your father is Carl Bernstein. It took you a long time to convince your father to participate in your documentary about your mother. And the book that you referred that was about her divorce was a novel called "Heartburn" that she adapted - she wrote the screenplay adapted from her book. And in the movie version of "Heartburn," Meryl Streep played the character that Nora Ephron is based on. Jack Nicholson played the character that your father, Carl Bernstein, is based on. The book and the movie were great things for your mother, not so much for your father. He was really angry about it, he didn't come off really well on it. And so it took a long time for you to convince your father to be part of your movie. Why was he reluctant to participate?

BERNSTEIN: Well, you know, my father is in a very happy marriage at this point. It's been 30 years. And so, you know, when my mother died, I think there was a part of him that thought - maybe the kids will now spend Thanksgiving with me. I don't think he was thinking my son is going to be going through my divorce records from 30 years ago. There was no script for him to look at. You know, I wasn't showing him the footage. We hadn't edited anything. I mean, there was a lot of sort of - please do this movie without saying exactly what it was. He didn't know if he was being put on trial. He didn't know what it would become. And we're in a very exhibitionist era. So I think it was tricky, even among people who one love one another.

GROSS: But you convinced him?

BERNSTEIN: I did. A lot of arm-twisting and no, I'm not coming over for dinner, you know. I mean, there was just...

GROSS: Seriously (laughter)?

BERNSTEIN: Yeah. I mean, there was a lot of psychological manipulation. And in fact, a lot of that stuff that reporters do with subjects whom they have no relationship with - where you say it's going to be better for you if you cooperate. I mean, you do what you have to do because I didn't know how badly we needed him. And I needed him psychologically, too. I mean, I did - I was tremendously worried about what would happen to our relationship if he wasn't in it. And I was very worried about what the movie would look like without him. And I didn't think it could be complete.

GROSS: It sounds a little bit like you developed some of these skills about writing about family (laughter) or doing a film about family from your mother because she...

BERNSTEIN: Yes.

GROSS: ...That. She disguised it in fiction, but not always. She wrote a lot of essay, too. And she wrote a lot newspaper columns. And she hurt a lot of feelings along the way. So do you feel like you picked up this sense from your mother that feelings might be hurt if you're a writer? And that's kind of unavoidable, and you deal with it.

BERNSTEIN: Yes. My mother wrote about her parents' alcoholism. You know, she wrote about her mother right after she died. Her father was still around. She wrote about the first husband. She wrote about the second husband. She wrote about Dorothy Schiff at the New York Post after she left there. And then she went to New York Magazine and - she went to Esquire and then New York Magazine. But she wrote about each of those at various points and not flatteringly.

So I certainly was aware that one's experiences - if you're not writing about your experiences at some point, you're wasting them. And with her death, I was deeply aware of the finality of it. And I was aware as well that my Aunt Delia is a very good writer. I knew that she was going to approach this subject. I didn't want to lose the opportunity to reach people about it at a point when they were still interested in it. I mean, I know that that sounds a little bit cannibalistic. But of course, my mother often said writers are cannibals. And I think we are.

GROSS: So my understanding from what you said before is that your mother didn't write much about you. Am I right about that?

BERNSTEIN: Yeah. That's correct.

GROSS: But in writing about herself, she was writing about you indirectly in the sense that she's your mother. So everything that she does reflects in some way on your life and on what friends and their parents and the public project onto you. Can you reflect a little bit about how her public presence and her opening up of her life and using the stories of other people's lives affected your sense of self?

BERNSTEIN: Well, I think that comedy exists in this thin line between bravery and ruthlessness. And part of what I was after with the film...

GROSS: That's good (laughter).

BERNSTEIN: ...Was the belief that it's both. And that it's possible for the kind of cannibalism that writing is to be both a tremendous source of self-actualization and something that's also a little unseemly and, you know, unfair to other people. F. Scott Fitzgerald wrote about Zelda and her descent into madness in "Tender Is The Night," which was, you know, a book I read actually shortly before making this film. All sorts of people have kind of stumbled across this question at one point or another, you know. I mean, Philip Roth's mother did not have an easy go of it when her son became a writer, right? But that's what it is.

GROSS: If you're just joining us, my guest is Jacob Bernstein. And he's directed a new documentary about his mother Nora Ephron. And it's called "Everything Is Copy." It's playing on HBO and is also available for viewing on demand. Let's take a short break then we'll talk some more. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR, and if you're just joining us, my guest is Jacob Bernstein. He's a journalist who writes for The New York Times. And he has directed a documentary about his mother, the late Nora Ephron. The documentary includes his father, Carl Bernstein. It's called "Everything Is Copy." It's an HBO film. It's playing on HBO and is also on demand. How old were you when you read your first book or saw your first film by your mother and what was it?

LAUGHTER

BERNSTEIN: We saw "Silkwood" when it came out, you know...

GROSS: The movie based on Karen Silkwood's life?

BERNSTEIN: Yeah, and I do remember being in Los Angeles when she drove herself to the Oscars 'cause she had been nominated with Alice Arlen for the screenplay that she wrote. And in fact, it was a sort of interesting memory. There was something very casual about the way that she did that. It was not made into a big event. She just got in a rental car - not a particularly glamorous one. She had on what I believe was an Armani suit with too much shoulder padding...

GROSS: (Laughter).

BERNSTEIN: ...And off she went. And that was that. And it was a great window into her, you know, that for somebody who made so much of her life material, she was very undramatic in certain ways.

GROSS: So "Silkwood" is one of the things that is not based on her life. It's about somebody who was a whistleblower. So when did you start reading things that were based on your mother's life that offered insights about things that maybe she didn't talk to you about as her child? There's plenty of things parents don't share with children that would end up in a memoir or in a novel.

BERNSTEIN: Well, I read a number of her essays as a kid, you know, from Esquire or New York Magazine. And I guess when I was 14 or 15, probably, I read the breasts essay. I didn't stumble upon her essay about getting crabs until doing this movie (laughter). And...

GROSS: Let's back up a second - the breasts essay you're talking about is her talking about what she doesn't like about her breasts and how that's affected her. And it's funny.

BERNSTEIN: Yes.

GROSS: It's a humorous essay.

BERNSTEIN: Yes it is. And...

GROSS: But that's kind of awkward right there, right? A son (laughter) reading an essay about his mother's breasts. I mean, it's the kind of thing you run into when you're a writer. You want to write about certain things and then, you know, it can be awkward.

BERNSTEIN: But I knew it was good.

GROSS: Yes.

BERNSTEIN: You know, the humor of her made all of it less awkward. And the fact that it really didn't feel solely exhibitionistic the way that so much for what passes for self-examination today does. You know, she had this comedic voice where she wasn't writing about sex in a pornographic way, she was writing about it as comedy. So it's a little different. And I think it was easier to process from that angle. But going back to one of your earlier questions about how, you know, we were affected by her writing about us, there's no question that as a teenager, when I reached my time to get angry at my mother place, that her having written "Heartburn" was a little thing and her being off directing movies was a little thing.

And it wasn't until I was sort of about 17 or 18 that I kind of went, well, you know, other people's mothers that I know were sort of professional bar mitzvah planners. I mean, they kind of lived on Park Avenue and were just about consumption in some way, and she wasn't. And she did really interesting things. And it was interesting too to go from being a family that had an OK amount of money to being one that there was a tremendous amount of pride in what she did because she earned it. I think my mother was pretty cool.

GROSS: You say in the film that for decades, your mother put her personal life front and center, including writing about aging, but she stayed silent about the blood ailment that killed her. And she had Myelodysplastic syndrome, which destroys the body's ability to make healthy blood cells and ward off infections, and that became leukemia. One of the riddles that kind of stays a riddle through the movie is why did she stay silent about this illness that became a terminal illness when she wrote so openly about her life and about aging and she wrote memoirs, she wrote fiction? And I suspect that one of the reasons why you made the film was trying to answer that question. But when did she tell you that she was sick?

BERNSTEIN: She told me in 2006, which was shortly after she had been diagnosed - a few months.

GROSS: A few months, OK.

BERNSTEIN: A few months - she certainly waited. And, you know, at the beginning, they told her that she had 6 months to live, you know, and she went to Seattle hoping for a bone marrow transplant. And the guy said that not only was she not a good candidate but that basically she was going to be dead no matter what he did. She didn't tell me until she thought that she had a shot. I think that obviously had she wound up in the hospital dying, she would've told me. But I think she hit pause. I think she didn't want to come to me while she was feeling vulnerable or hysterical about it, you know? I know that they got back - she and my stepfather got back from Seattle, where she had seen this doctor, and she really broke down from what Nick (ph) said.

But I never saw her breakdown over her illness, just as I never really saw her breakdown over anything. And I think that probably was one of the things that I was interested in with this movie was how often did that happen? Not so often as, you know, I came to find or not find.

GROSS: There were a lot of people who she did not tell that she was sick, including a lot of people in the movie world that she worked with. Were you expected to keep a secret for several years before she told people?

BERNSTEIN: Yes, and I did. We were all aware that her life would change completely if everyone knew. I mean, some of the considerations for why she didn't tell people were pragmatic. You know, I don't think that she could've gotten ensured on a movie if people had known what she had. Her agent, Bryan Lourd, knew that there was a thing with her blood, and I think he did a little bit of willful blindness on her behalf, you know, as he sort of got her one project after another. But basically people didn't know.

And so there was this pragmatic component. The other component was philosophical, you know, that for her, this everything is copy philosophy was really a means out of victimhood. It really was the belief in being the heroine of your life and not the victim. And how do you not become the victim if people are walking up to you and saying how are you? Are you OK? She didn't want that. So it was a secret that allowed her to move throughout the world in control.

GROSS: My guest is Jacob Bernstein. His HBO documentary about his late mother, Nora Ephron, is called "Everything Is Copy." We'll talk more after a break. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. My guest is Jacob Bernstein. His HBO documentary about his late mother, writer and director Nora Ephron, is called "Everything Is Copy." In your film it's discussed how therapy was very important to your mother and that she learned in therapy that one doesn't have to become one's parents, which was important to your mother because her parents who were both screenwriters were also both alcoholics. Her mother died of cirrhosis. What were your mother's fears about becoming her parents? Was she afraid that she'd become literally an alcoholic or that she would - like, what was she concerned about?

BERNSTEIN: Well, I'm not my mother's therapist, so I'm not sure exactly what she said to Mildred Newman...

GROSS: Sure.

BERNSTEIN: ...Who, you know, was her guru in the 1970s and '80s. But I do think that my grandfather was having a number of affairs. And my grandmother, contrary to her assertions about "Everything Is Copy," kept those secrets ultimately. And I think that my mom was very aware that there was a cost to keeping secrets for other people. You know, if you look at some of what she wrote about Hillary Clinton over the years, I think that part of the reason that my mom thought Bill Clinton's affairs were so distasteful was not because of sex per se or the betrayal of the romantic relationship, it was because she believed that it forced Hillary to lie on his behalf, to sublimate herself, to become a diplomat for her husband and to fight a battle for him that he ought to have been fighting himself. You know, she was I think aware that having to lie for your husband is almost never a feminist position.

GROSS: That so interesting because your mother did the opposite in writing "Heartburn..."

BERNSTEIN: Exactly.

GROSS: ...After she divorced her father, Carl Bernstein. So she just went - she just put it out there in fictional form. But getting back to the idea that her therapist told her, you don't have to become your parents. Did you have any fears like that yourself? I think, like, so many people do.

BERNSTEIN: I think that I feared more not being like her. I think that...

GROSS: Not being as smart and funny and...

BERNSTEIN: Not being as smart and funny and not being as productive as her. I mean, she was, you know, - she could've run Foxcon or something. I mean, she was formidable and productive. And she just didn't get waylaid by the kind of emotional baggage that frequently accompanies artists and writers. And I think that the most difficult thing in some way about being around her was both that she could be unsparing about other people but also that she was just a tremendously powerful example of propelling oneself forward. And so sometimes that was hugely inspiring. And sometimes it was kind of stupefying and just difficult to keep up with, both in principle and in practice.

GROSS: So you describe your mother as having been unsparing. Ken Auletta, the media writer in your movie, describes her as having a razor in her back pocket (Laughter). So when you started writing, did you want her to see what you were writing? Or did you want to kind of protect yourself from her unsparing gaze?

BERNSTEIN: Every now and then I allowed my mother to kind of look at a longer piece that I had written. And she could be very helpful with suggestions, though she was - she not only had a razor back pocket, she had - she sort of had one in her mouth, as well. You know, it was like - you know, and she - it was almost always a version of cut - you know. It was almost always, you've written more than you need to here, although sometimes it was, you ought to have done more reporting on this. I heard that, too. But, you know, she was a tough crowd.

I think I also had a bit of a razor in my back pocket as a writer. And I don't know whether that was because that was sort of impressed upon me by her or that was genetic - I don't know. But certainly I would say that in my 20s at least I shared a little bit of her desire to occasionally have fun at other peoples' expense.

GROSS: Did you get the opportunity or feel that it was even necessary to have the kind of final conversation in which you both, you know, like, declare your love and say the things that have been unsaid and, you know, say goodbye and all that stuff that sometimes people get a chance to do and sometimes they don't and sometimes there's no need for it because it's already been said?

BERNSTEIN: We had a version of that conversation. But I don't believe in closure in any fundamental way. I think that closure is a very overrated American concept. I think that doing the movie in a certain way rather than being closure was continuance. It was getting to stay with her in some way from looking at her on a monitor and reading her old essays and reading "Heartburn" again. And even, you know, the Johnny Carson book and the old New York Post pieces - there was her voice, you know, loud and clear.

GROSS: So if you don't believe in closure, how does that apply to how you're processing your mother's life and death and your relationship with her?

BERNSTEIN: I think that I looked for a way to make it continue. You know, now I'm sort of done with that. And it's sort of time to...

GROSS: You mean through making the movie?

BERNSTEIN: Yeah, I mean, now - I think the hardest thing in some way was the moment when it was done. And we went to New York Film Festival in the fall, where it sort of screened for the first time, and the reviews were good. We were as lucky really as you can be. And about 24 hours later I just felt this kind of piercing quiet - you know? The joke I kind of make of it sometimes is that it was a little bit like - you know that scene in "The Hurt Locker" where Jeremy Renner goes to the supermarket and he's standing in front of the breakfast cereal and he doesn't quite know what to do with himself because...

GROSS: It's so fluorescent and there's so many choices about so many trivial things.

BERNSTEIN: Yeah, exactly. And, you know, obviously I didn't go to Iraq. I just made a movie and a small one in terms of scale. But it felt like the biggest possible thing that I could do to process her death and to look at where I came from. And now it's time to find another thing.

GROSS: I want to thank you so much for talking with us. Congratulations on the film.

BERNSTEIN: Well, thank you.

GROSS: Jacob Bernstein's documentary about his late mother, Nora Ephron, is called "Everything Is Copy." It will be shown again on HBO next Wednesday and is available on-demand.

Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.