A Real-Life ER Doctor Examines The Pitt

Watching The Pitt often feels like navigating an anxiety attack: You’re overwhelmed with a wave of doom, you work through it, then you deal with however things shake out … just as the next wave hits again. Max’s spiritual successor to ER — though it’s legally complicated to call it that — follows a shift in the life of a busy emergency room in Pittsburgh. Noah Wyle anchors the show as Dr. Michael “Robby” Robinovich, the attending physician who leads the department’s efforts to treat the endless swirl of patients barreling through the door.

Visceral, grisly, and exceedingly stressful, The Pitt draws a lot of its stickiness from its real-time structure: Taking a page out of 24, the 15-episode season tracks the goings-on of one entire 15-hour shift. That format lends a greater sense of realism to the show, which has apparently been so effective that it’s driven some chatter online (and in the Vulture comments), often from voices within the medical community praising the series’ verisimilitude.

To kick the tires on these plaudits, Vulture reached out to a medical professional who is a fan of the show: Dr. Lukas Ramcharran of the Johns Hopkins University School of Medicine. A physician who holds an M.D. and an M.B.A. from New York University, Ramcharran serves as an attending physician and assistant professor in the Department of Emergency Medicine at Johns Hopkins. In other words, he’s a real-life comp for Dr. Robby. We spoke earlier this week ahead of The Pitt’s eighth episode, as he was enjoying an off day doing administrative tasks on his computer.

I’ve heard some people say that The Pitt is the most realistic depiction of emergency medicine on television, perhaps ever. Does that ring true to you?
Oh, absolutely.

How did you get into the show? 
My wife and I are not huge consumers of television, because we have a 10-month-old at home and we have another due in a month. She’s working full-time, and I’ve got ER shifts. Years ago, I watched ER, and I loved that show at the start when it was really about the medicine, but less so as the show understandably had to create more plotlines and become more dramatized. I don’t think I even finished the series.

We had seen the ads for The Pitt on HBO. But what really turned me on to it was seeing social-media chatter from the educational side of things. EM:RAP endorsed it, which is a national education platform for emergency medicine that creates a lot of content we use for learning about the specialty. It’s a wonderful resource outside of the more traditional lectures and things we do in the formal residency-training program. I believe it also consulted on the show. Then I saw some promotional clips with Noah Wyle and physicians who were consulting on the show talking about the medical boot camp they had put the actors through to get them to portray this as accurately as they could, and that really got me interested.

But surely you still went into the show with some skepticism.
Of course. A lot of us in the field, regardless of speciality, like to poke fun at how inaccurate things are depicted on television. And we understand why. The purpose of these scenes is to best serve the plot, right? But The Pitt is great. My wife, who’s not in medicine, and I have been together since college, and she’s seen me go through the entire educational pipeline to become an attending physician. I’ve always told her I would love for our family to see what we do on a daily basis — to see the specialty that I love and have dedicated my life to. Of course, because of HIPAA and patient-privacy needs, we can’t ever have family members stop by on a workday, so my primary motivation was seeing if this show could show her that. It’s been such a joy. I’m constantly pausing and saying, “That’s what we do! That’s the thing I told you about!” Obviously, I edit too. “This would actually be more bloody” and so on. And she is constantly saying, “Hey, can you quit pausing?”

What stands out to you about the show?
I really like the format. The idea of one shift is good at showing what a day in the life is like and different push-and-pulls in the role. You have the medicine, but you also have all these other non-medicine things that pull at your attention: your team members, your hospital, the trials and tribulations of working with people who come to you on their worst day.

Unlike other shows, it doesn’t linger in long dramatic plotlines. There’s no time for that, because it’s one shift and everything they’re doing has to revolve around what’s actually happening between people in the ER. It’s a lot less Grey’s Anatomy in that sense. There’s a lot more computer work. There’s a lot more phone calls. There’s a lot more interruptions, right? All of that is very accurate.

Dr. Robby is constantly jumping around, and that’s really close to what being an attending physician is like. You’re trying to do the medicine, but you’re also there for the education of your medical residents. He’s constantly dropping into things, seeing where he can help out a learner, giving them a little bit of autonomy, giving them some leash, trusting his senior residents and empowering them to take on the next stage of their career. That’s really wonderful to watch, but you also see aspects where he’s human. You see the full system: the support staff, the people up front being triaged in the waiting room, the people handling the waiting room. You have the social worker, who’s probably one of my favorite characters; they are the unsung heroes in many ways.

And you’ve got administrators, who I think are a bit dramatized and more vilified than usual. Everyone, including administrators, is working to be aligned in trying to take care of everybody and moving care forward. They are the ones who are trying to look at systematic and operational issues, asking, “How can we take care of more patients?”

How many times per day do administrators actually visit an emergency department?
Very, very few. When you’re an attending on shift, your job is to care for patients and train your learners. The medical director, the associate medical director, and our admin staff who are not on shift that day — those are the ones who field those kinds of requests. The idea of an administrator coming down in the actual shift and engaging with you in real time … that’s not realistic. You can imagine how that would be an incredible disruption to patient care.

That back-and-forth between the administrator and Dr. Robby recurs throughout the season, and The Pitt seems to use it to explore the tension between patient satisfaction, hospital incentives, and delivering care. How do you feel about that portrayal?
Those sentiments are true, but it isn’t necessarily felt on an individual-to-individual level. We all feel the stresses of a strained hospital system: congested waiting rooms, the patients who are admitted but not yet upstairs. It isn’t typically expressed as interpersonal conflict. I understand why they do that for the show, but in real life, it tends to be more collaborative. There’s a lot of us saying, “How do we get better?”

But the issues are real. It’s certainly not an excuse for prolonged wait times, but my hope is that if a patient sees a show like this, there’s exposure to an issue we’re trying to remedy. Clinicians and nurses are not sitting around and choosing who they want to see. There’s just so much going on. It’s almost an explanation of how we want to get to everybody in time but sometimes can’t. People are constantly busy.

Do a quick performance evaluation for me: Is Dr. Robby a good head of emergency? 
I think so. He’s not Superman. He certainly has these ghosts that haunt him related to what appears to be the death of his mentor during the height of the pandemic. But he is very skilled in terms of his clinical ability. Can he do better? Sure. But we’ve all had those days, right? I’ve had days where I’ve done well clinically, if that’s the measuring stick, but I needed to do a better job of leading the hearts and minds of my support staff who I’m entrusted with.

As an attending, one of the hardest things we do isn’t the cardiac arrest or the complicated procedures. We’re all trained to feel comfortable to handle those. It’s the family members who you’re trying to help understand the poor prognosis, or intubating someone whose family is revoking those goals of care in real time. It’s the end-of-life care, the abuse cases — those things stand out to you in a shift.

It’s the ethics, too. There’s a case in the show where a mom intentionally gets herself into the hospital to draw attention to her son who may be having thoughts of hurting people in school. You see that Dr. Robby wants to help that kid, even though he’s not actually a registered patient. You see other residents say, “Did you do the right thing?” I love all that stuff, because equally important to the more technical aspects of medicine is the portrayal of all the things that affect us emotionally.

That scenario is part of a trend on the show, where we see the physicians struggling with the role of being mandated reporters. There’s the kid with the troubling thoughts, but also the young woman seeking an abortion and that patient who’s suggested to be sexually assaulting his daughter.
Those cases really illustrate how complex things can get. We are mandated reporters, and as physicians, we’re constantly partnering with child-protective services and law enforcement to ask, “What are we obligated to report? Do we have enough here?” There are clear-cut cases, but there’s a lot of gray too. Sometimes we see female patients who are victims of domestic violence, and the decision to report is ultimately theirs. As a clinician, you might want to say: “You have resources, you have the ability to talk to a social worker, you have the ability to talk to a police officer should you want to.” But they can come in and say, “No, I just want to make sure my arm is not broken.” So there are situations where you want to help but you just can’t.

There’s that case on the show where a mother has been giving her husband medication to curb his libido, but giving that medication is illegal and highly dangerous and may result in death. So there’s the mission of needing to report that, but then the show layers on the question of whether there’s inappropriate harassment going on with the patient — though there’s nothing concrete. In real life, we would partner with the mom and the social worker, we would have a discussion, we would ask permission to engage with the daughter and find out if there’s probable cause where we can start involving the authorities. But that’s gonna have to come at the permission of the guardian. Would we ever go behind a guardian? There are things that can medically and legally emancipate a minor from their parents’ care, but this is one where you have no reason to believe the mother is also abusing the child.

Then, the series shows a doctor overstepping ethical bounds and taking justice into her own hands. What’s interesting, of course, is how they’re indicating that this character (Dr. Trinity Santos, played by Isa Briones), who’s already a bit of a loose cannon, has a troubled past that somehow overlaps with the situation. So she threatens the patient, who’s in a vulnerable state. I thought that one was a little dramatized. I’ve never met a physician who’d do that.

There are so many of these moral conundrums in this one shift. Have you had shifts like that?
Not that often, actually. If things were like this every day, the burnout would be hard to overcome. With a show like this, you have to pack a lot into the shift to make good TV. It’s not that it’s unrealistic — I’ve had shifts as busy as this, and I’ve had shifts not as busy as this.

I have a technical question: In the hub area, the physicians choose their next patients off what appears to be a Google doc. Is that a Google doc?
That’s the track board of electronic medical records. We use Epic, which is the main electronic-medical-record system used around the country that shows you patient information: vital signs, age, sex, different color codes telling you different levels of acuity. It might look like a Google doc from afar.

What The Pitt demonstrates is a very common model, where physicians are constantly looking at a central screen figuring out what’s next, and the charge nurse is calling out what emergencies are coming through next. It’s not first come, first serve; it’s the sickest patient first, so there’s constant triaging. Here at Hopkins, we have a similar setup, but we have individual private rooms in a 60-bed ER. We don’t have a central screen, and our charge nurses are managing who goes into what rooms. We just keep moving from room to room, and your next room is your next patient. 

 How many times, if any, have you seen a new doctor pass out in front of a patient?
Once, but it was not in front of a patient. In this case, it was a mix of hours of training and dehydration, and it all caught up to them. They just needed a moment, and they ended up being completely fine. It absolutely can happen. You might have a medical student who’s not going into emergency medicine, for whom this is their first emergency-medicine experience, and it’s quite overwhelming. I’ve had observers in the ER from our medical school and from our undergraduate campus get lightheaded and have to sit down or exit the room. But in terms of fully passing out, just one.

How do you feel about the scrub machine?
 That is highly accurate and quite hilarious. The two compartment bins, the wrong sizes, the “does not detect” — absolutely. What happens to Dr. Whitaker (Gerran Howell) is deeply accurate. We all have changed scrubs multiple times. We’ve all gotten multiple types of body fluids on us. We all carry backup scrubs. I carry my own personal backup scrubs in my work bag.

The Pitt touches on this a bit, but there doesn’t seem to be much eating going on. 
Absolutely. We certainly don’t eat in the clinical area. It’s what we call a JCAHO violation, which is a violation in terms of patient safety and hospital operations. We also don’t eat in front of patients, because a lot of patients are not allowed to eat if they’re awaiting surgery. We see it as kind of cruel if we eat in front of them.

A lot of emergency-medical clinicians just don’t eat. They will do their whole shift with either a granola bar in their pocket or lots of coffee. I personally do a lot of protein shakes and liquid calories, so I don’t ever have to sit down to eat on a shift and I can walk around with them. You don’t really get a mandated break for meals. When I was a resident, I abandoned many meals that I was heating in the microwave because an overhead call came in and I forgot all about it. We all have our different tricks on how to take care of ourselves. We’re eating before and after shift and things like that.

And the bio breaks — bathroom breaks — look, we’ve all been there where you walk toward the bathroom and a gunshot victim comes in and you just have to hold it.

What’s your favorite procedure depicted on the show so far? 
In the last episode, the scene that I thought was really wonderful was where they did what we call the refractory ventricular fibrillation arrest that gets crashed on the ECMO. We have that protocol here at Hopkins. We also do dual defibrillation, which is what you see the two residents use: Two defibrillation pads are used to try to overwhelm the electrical system and get that heart out of rhythm. It’s much more complicated in real life, but seeing the cardiothoracic surgeons come down, seeing them cannulate, putting those large lines to the patient, seeing a resident explaining to a medical student but almost explaining it to the audience — I got really excited about that.

I also like how they use something called the LUCAS machine, which is the auto CPR device. That’s the device we use. It’s funny that I get to show my wife that, because my first name is Lukas, and that’s the LUCAS machine everybody always pokes fun at me for.

How common is it to have a super-young resident?
 I’ve certainly never had a child prodigy. We’ve had international trainees from Europe and Canada where they might be a year or maybe two years younger than the average. But I’ve never had somebody that young. I imagine it’s not impossible, but they still would need all these years of premed training in college and then medical school. But never say never.

Which character do you relate to personally?
I think every attending will probably say Dr. Robby. While I don’t see a lot of myself in him, I sympathize with the plight and what he’s grappling with. As I said, there are things he could do better, and we’ll see what happens as the show goes on, but I appreciate that he gives his colleagues and his support staff his best.

Last question. Why would you spend your days off watching a show that so effectively re-creates the stresses of your job?
[Laughs] I think if you talk to any spouse of a clinician, who themselves are not in medicine, they’ll wholeheartedly agree with the fact that when they get around their friends, all they do is talk medicine. For a lot of us, it’s a huge part of our identity. It’s a huge part of our purpose in life. I love medicine. I love my specialty. I would not be in an academic setting if I did not believe in buying into the mission of training the next generation. So this kind of stuff doesn’t stress me. It excites me.