Dan Weissmann
People who work in real-life emergency rooms have raved about how the brand new TV drama “The Pitt” precisely captures the complicated dynamics of their workplaces and the medical particulars of their instances.
Host Dan Weissmann talks with Alex Janke, an emergency medication physician and well being coverage researcher, about how the present stacks up in opposition to his experiences within the ER. They additionally talk about its depictions of the monetary forces that form day-to-day issues inside ERs.
Dan Weissmann
Host and producer of “An Arm and a Leg.” Previously, Dan was a employees reporter for Marketplace and Chicago’s WBEZ. His work additionally seems on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.
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Transcript: Why ‘The Pitt’ Is Our Fave New Drama
Note: “An Arm and a Leg” makes use of speech-recognition software program to generate transcripts, which can comprise errors. Please use the transcript as a instrument however verify the corresponding audio earlier than quoting the podcast.
Dan: Hey there. I’ve acquired a brand new favourite TV present: “The Pitt.” I signed up for HBO — Max, no matter –thats what my editor says I’m purported to name it. The present takes place in a Pittsburgh emergency room, and the primary season follows the employees by means of a single, jam-packed day, hour by hour. It’s riveting. Noah Wyle, who acquired well-known taking part in a younger physician on the present ER within the Nineteen Nineties, stars right here because the senior doc on responsibility. And individuals who work in emergency rooms say it will get a number of issues proper, together with medical particulars that fly previous most of us in scenes like this…
Doctor 1: Bring me up to the mark?
Doctor 2: Intubated for agonal respirations. GCS 5, in all probability anticoagulated. Doctor 1: With what?
Doctor 3: First time right here. There’s no medical information.
Doctor 1: Call for FFP.
Doctor 2: No, we acquired 4 components…
Dan: And yeah, I principally didn’t catch any of that. But after I performed it for an precise ER physician, Alex Janke, he saved smiling and nodding alongside. In any case, these weren’t the sorts of scenes I referred to as Alex Janke to speak about. Because what drew me to the Pitt — for skilled functions at the least — are scenes that present the bigger-picture forces — the monetary forces — that MAKE at the present time, and daily, so tough for the individuals who work in big-city ERs, and for the individuals who present up needing care. Forces that make ERs extra crowded, and extra chaotic. Less protected, and dearer. I referred to as Alex Janke as a result of on prime of working shifts at ERs, he does analysis on these forces as a professor on the University of Michigan.
Alex Janke: I care rather a lot about. Emergency medication. Like I feel that what we do is admittedly, actually particular. And I additionally suppose that if you wish to perceive the issues on this planet, you need to come to the emergency division,’trigger that’s the place individuals go once they have issues.
Dan: Problems like gun violence, homelessness, intercourse trafficking,drug habit, and a possible hate crime carry sufferers to The Pitt all through the season. The Pitt additionally seems at questions that Alex research: Why do individuals have to attend so lengthy to get seen at ERs? How badly can these lengthy wait-times have an effect on our well being? So, we watched some scenes that handle these questions collectively and Alex was like…
Alex Janke: I’ve gotta discover the people who made this present. This is so loopy. They, they’ve gotta have some docs working for them.
Dan: There’s a complete crew. There’s a complete crew.
Dan: Alex Janke thinks the producers picked the proper crew… as a result of, he says: This is just too actual. So right here comes a debrief. Basically freed from spoilers — by way of the MEDICAL drama. And I’ll let you know proper now: The monetary issues? Those storylines don’t get wrapped up on The Pitt, or in actual life. But the present does assist us perceive them, and what they value all of us– docs, sufferers, everyone– in cash, in our well being, and in our emotional well-being.
This is An Arm and a Leg, a present about why well being care prices so freaking a lot, and what we will perhaps do about it. I’m Dan Weissmann. I’m a reporter, and I like a problem. So the job we’ve chosen on this present is to take one of the crucial enraging, terrifying, miserable components of American life, and convey you one thing entertaining, empowering, and helpful.
The people who made “The Pitt” made a super-canny alternative: The present follows a single day on this ER — and it occurs to be the primary day for a crew of latest residents and interns. So whereas we watch them get proven round, we get a tour. First cease, the ready room. It’s PACKED. A second-year resident explains how sufferers register, get a fast evaluation…
Doctor: And then they arrive again to ready room until mattress opens up Doctor 2: For how lengthy?
Doctor: Eight hours in the event that they’re fortunate. Loads of instances 12.
Doctor 3: Ah, is it all the time this busy?
Doctor: Uh, no. It will get rather a lot busier.
Dan: Here’s Alex’s tackle that snapshot.
Alex Janke: I feel that is totally actual. And we will actually anticipate this to be true going into the long run that, uh, you realize, eight hour waits, 12 hour waits, very excessive charges of left with out being seen are simply gonna maintain taking place all around the nation. And it’s not gonna be daily that you simply stroll within the door. nevertheless it’s gonna maintain taking place.
Dan: Why?
Alex Janke: That’s an incredible query.
Dan: Alex has a few solutions. One is about demographics: We’ve acquired extra people now who’re outdated, with complicated medical points than ever earlier than, and that’s solely gonna get extra true for a very long time to return. The different principally will get dramatized within the subsequent couple scenes we watch. First, Noah Wyle’s character, the senior MD on this shift, Dr. Michael Rabinovich — everyone calls him Doctor Robby – provides the newbies his briefing. Here’s the very first thing he tells them.
Robby: As you possibly can see, our home is all the time packed and our division is generally clogged up with borders. Those are admitted sufferers ready for a room upstairs typically for days.
Dan: OK, that glided by fast, however Dr Robby principally simply described WHY individuals wait eight hours, twelve hours, why this ER and its ready room is so full. I’ll let Alex clarify.
Alex Janke: The emergency division shouldn’t be full as a result of people with the sniffles got here in once they may have gone to an pressing care. That shouldn’t be the explanation that the ER is crowded. Those sufferers are really easy, we see ’em out in triage. I really like seeing these sufferers ’trigger that’s any individual that I can
get out and in. I can take actually excellent care of that affected person typically simply from the ready room. The ER is full as a result of there are people that should be within the hospital or people that should be in expert nursing services or in rehab and we will’t get them to that subsequent step.
Dan: So these sufferers turn out to be “boarders” — get caught: they’ll’t get moved to the following step, however after all they’ll’t go residence both.
Alex Janke: And so that they wait within the ER and that creates crowding throughout all the opposite sufferers.
Dan: The “boarders” replenish the ER beds. So everyone else piles up within the ready room. Things get super-crowded. That sucks for these of us who present up as sufferers — a number of us wait a super-long time. And that crowding — and the chaos that comes with it — creates burnout for individuals who work in ERs.
Alex Janke: The factor that burns you out is feeling such as you’re not capable of do a great job otherwise you’re not accountable for your working setting. And that is the explanation. It is as a result of it’s crowded. Like an outdated girl is available in with stomach ache. I can’t care for that affected person within the ready room that I would like that girl again within the division. I wanna get a CAT scan on that girl. I would like a while along with her. And it’s simply, it’s, it’s harmful and unsightly throughout.
Dan: Because you, since you don’t have area to see her. You don’t have a mattress, you don’t have capability to see her. And so she’s in peril.
Alex Janke: Absolutely. Without a doubt. And, you realize, there’s a deep, there’s a deep literature on this, crowding impacts the standard of care alongside each attainable dimension. It makes you extra more likely to screw up. I’m an ER physician. My complete job is to not screw up. I’m like taking part in this recreation and the sport is to not miss one thing actually unhealthy. And the sooner you make me go along with fewer assets, your ER physician’s just a bit extra more likely to screw up and never deal with that appropriately. I’ve grey hairs from a few instances.
Dan: He tells me about considered one of them. A girl who got here in with a rash. When he lastly examined her, twelve hours later, it turned out that rash was from flesh-eating micro organism. Those twelve hours meant that micro organism did a number of injury. Alex says that girl spent a very long time within the ICU, and took months to totally get well.
Alex Janke: I imply, these are the, you realize, that’s one of many instances I find out about, like what number of sufferers have I been on shift and I don’t even know what occurred,’trigger there’s a lot chaos occurring that I don’t have perception into what might need missed or what we’d not have carried out very effectively?
Dan: So the ER doesn’t work as a result of it’s too crowded. And it’s crowded due to “boarders” — sufferers ready for beds elsewhere. And within the subsequent scene, we get Dr. Robbie’s perspective on WHY that’s taking place. That’s when a hospital administrator, Gloria, exhibits as much as give him a tough time. She says, WE NEED TO TALK ABOUT YOUR NUMBERS. Meaning, affected person satisfaction numbers.
Gloria: Do you know the way doubtless sufferers are to suggest this hospital? Robby: Um, that is an emergency division, not a Taco Bell. Gloria: 11%.
Robby: Well, if you’d like individuals to be happier, don’t make ’em anticipate 12 hours.
Gloria: There’s a nursing scarcity throughout the nation.
Robby: Most of our sufferers are boarders who’re ready for a mattress upstairs.
Gloria: We don’t have the beds.
Robby: That’s bullshit. The beds are up there. You simply don’t wish to rent the employees. You must look after ‘em.
Dan: Alex has one little downside with this scene. He’s like, these conversations positively occur, however not on shift, on the ER flooring. But you realize, OK it’s a TV present, and the entire premise is that we’re on the ground the entire time. And Alex has a second downside. Dr. Robby perhaps does too good a job conserving his cool.
Alex Janke: You know, Dr. Robby is dashing from one dying affected person to a different, and somebody exhibits up in a go well with and says, you realize, your sufferers aren’t very glad together with your care. I feel he handles it like an angel. If it had been me, I feel I’d lose my job that day.
Dan: Otherwise, Alex is like: This is lifeless on.
Alex Janke: There’s a lot occurring right here. This is wild. It’s so wild.
Dan: And he unpacks it. Yes, there’s a nursing scarcity. Yes, there’s an precise scarcity of hospital beds. And to a level, these shortages are … enterprise choices.
Alex Janke: There’s some actual fact, there’s an actual hook to the concept the emergency division ready room and the emergency division beds as a spot to maintain people ready for a mattress upstairs within the hospital — it’s an optimization downside.
Dan: An optimization downside. That’s what Alex says individuals who research hospital administration have referred to as this case. The query is, what are you optimizing for? If you’re a hospital administrator, Alex says, you’re making an attempt to optimize … your price range. You’re asking your self: How do you get probably the most return for what you spend? You don’t do it by paying nurses to employees beds with no sufferers in them. Nobody’s paying you for empty beds.
Alex Janke: I imply, we wish our hospital beds full. we’ve gotta pay these monumental prices for inputs, like, uh, nurses and, each single hour of nursing care that you simply pay for, you wanna make it possible for, uh, it’s getting used. Every hospital mattress day that you’ve got staffed, you higher replenish that mattress.
Dan: So, now you’ve acquired a brand new equation to stability. Here’s how Alex describes the query:
Alex Janke: How do you maximize your affected person mattress days —that’s the way you receives a commission — with out ever having to show away enterprise?
Dan: OK, let’s unpack that: You wish to maximize affected person mattress days. The variety of beds that really have sufferers in them, beds you’re getting paid for, on any given day. But you’ve restricted the availability of beds upstairs. You don’t wish to pay for one thing you won’t have the ability to promote. And but: You don’t wish to flip away enterprise.You’ve acquired a affected person who wants a hospital room — a possible paying buyer –you don’t wanna inform ‘em, hey we don’t have room for you on our cardiac ward. You gotta go some place else. So, how do you make room for sufferers — for patrons — when there’s extra demand?
Alex Janke: Well, a method to do this is to queue these sufferers, put them in a in a slot in order that they’re able to replenish that mattress as quickly as that mattress turns into accessible. Where does that occur? The emergency division.
Dan: So this is the reason Alex is so captivated with this scene: It dramatizes this complete evaluation — and Dr. Robby’s perspective– the boarders who crowd up the ER and the ready room: They’re the outcomes of the hospital’s monetary technique. No marvel Dr. Robby’s mad.
Coming up: How docs get caught within the processes that find yourself with terrible payments for sufferers.
This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom overlaying well being points in America. Their reporters win every kind of awards yearly. We are honored to work with them.
We’re gonna skip forward to episode six of The Pitt. No spoilers right here. This scene stands alone, and it’s all enterprise. Robby stops by a pc terminal the place one of many newbies is charting– writing up her notes after seeing a affected person. Listen for a key time period proper up prime: Medical Decision Making. Slightly later we’ll hear Robby use its initials: MDM.
Dr. Robby: Four-year-old with a fever. Your medical resolution making says otitis media.
Dr. Javadi: Yeah, she had an ear an infection.
Robby: Did you additionally think about and rule out meningitis, mastoiditis, malignant otitis exterior?
Dr. Javadi: I did.
Dr. Robby: Then you need to doc your cognitive work within the MDM. Dr. Javadi: You need me to pad my chart?
Dr. Robby: No. I need you to point out your work. Billing is the aspect impact of that.
Dan: “Billing is a ‘side effect’ of adding details” to the chart. When I watched that scene with Alex, he was like, Yup: charting is the place our work turns into medical payments.
Alex Janke: So once we invoice for care, we invoice an insurer for care, we invoice the chart, proper?
Dan: The billing division interprets the work described within the chart into 5-digit codes, and each has a price ticket. MDM, medical decision-making, contributes to codes for “evaluation and management” like 99281 or 99285.
Alex Janke: And in case you invoice for 99285, you get a complete bunch of cash. And in case you invoice for, uh, 99281, then you definately get a bit of bit of cash.
Dan: The solely distinction is that final quantity. It displays a scale — 1 to five — how a lot work went into this go to. Was this easy? That’s a one. Was it high-level? Really complicated? That might be a 5. Researchers have discovered that “upcoding” — like billing a stage 4 for one thing that’s actually in all probability a two — is one purpose why, as a rustic, we spend extra on ER payments yearly. I inform Alex: In one of many very first episodes of this podcast, we heard from a listener who had introduced his son to the native ER — solely place open at night time — for what turned out to be …and ear an infection. The hospital coded the go to a “4” out of
5. Pretty costly. Our listener stated, if that’s a 4, what’s it whenever you carry your leg in a bag? Alex was like, Yeah.
Alex Janke: There’s this battle between like doctor teams on the one hand, and insurers alternatively about like how onerous our job is and the way a lot they need to pay us, and the one one who persistently loses in that battle is the affected person.
Dan: Yeah. Well stated. Well stated.
Alex Janke: You’re completely proper. It’s positively true in emergency medication. And you realize, like I, I’ve written on this matter our sufferers are extra medically complicated than they’ve ever been. The complexity of the analysis administration that occurs within the emergency division is greater than it has ever been. But that’s no excuse for, you realize, leaving the affected person with an absurd invoice that’s out of proportion to what she did for them. This is without doubt one of the methods during which you’re like, put in all of those like little conditions the place such as you’re in a lose-lose state of affairs.
Dan: Lose-lose state of affairs. Alex tells me a narrative. He was working in triage someday, and a man got here in with a bug chunk.
Alex Janke: …and his buddy had satisfied him that he might need like a very unhealthy downside. He was like, this can be a black widow spider chunk. And it was a loopy day and I’m identical to floating round at triage, slinging orders. And, he like stopped me within the hallway as he was like fascinated by leaving. And he was like, do I actually should be seen for this? Do I actually should be seen for this? And I’m like, effectively, you’ve got been seen. I’m a health care provider. And, and he walked out the door and I had this second the place I used to be like, do I’m going write a word on this man? If I write a word, then we’ll invoice him.
Dan: And Alex says he knew: That man didn’t have insurance coverage. Whatever that invoice was, he may get caught paying for it.
Alex Janke: I don’t know what that invoice seems like. I don’t have perception into that. I don’t know the way the place that I work at operates on that finish. I’m virtually by no means concerned in it in any respect.
Dan: What’d you do?
Alex Janke: Nah, I didn’t write a word.
Dan: I stated to Alex: Geez, some hospitals have people who assist individuals in these conditions, who go: “Hey, let’s see if we can sign you up for Medicaid. Or a super-subsidized Obamacare plan. Or maybe you qualify for charity care here.” But after all not each hospital has these people. Alex was like, oh yeah, for certain.
Alex Janke: One of the locations the place I at the moment work, our registration employees know like a ton of stuff about insurance coverage and sufferers will like ask me, and I’m like, oh, no, no, no. This is the individual you gotta speak to. They truly know tips on how to enroll whether or not it’s Medicaid or one thing else. Yeah.
Dan: It’s nice that there’s any individual , and you realize, who the any individual is, for them to speak to,’trigger that isn’t everyone’s expertise.
Alex Janke: Yeah. And additionally, I’ve labored at different locations the place you go searching within the division and nobody is aware of. And like, that’s all the time a bummer. Like there was a short while the place I used to be handing out a telephone quantity ’trigger I didn’t like actually know what I used to be purported to be doing. And so I’d, I’d give individuals this telephone quantity. I’d be like, what you’re telling me makes it sound such as you qualify for Medicaid. But like, I don’t actually know something about Medicaid. This is the web site, that is the telephone quantity. It’s so unhealthy.
Dan: Alex says he hopes individuals who don’t work in ER’s watch The Pitt.
Alex Janke: This present is sweet for individuals like me as a result of it like humanizes us in a number of methods and the present positively makes us out —at the least the primary two episodes — they make us out in plenty of heroic methods, and I feel that’s nice. And I feel plenty of emergency physicians are heroes. Lots of us should not heroes. You know, we’re simply individuals.
Dan: He thinks it’ll assist individuals like him — in his function as a researcher and advocates — make a case for insurance policies that’ll assist ERs. And he’s not mad about seeing the enterprise questions get dramatized.
Alex Janke: We must have these conversations means out within the open with vivid lights and that’s the one means that they received’t finally have the affected person be the one one who loses within the change. So, yeah.
Dan: As if we all know a bit of bit extra about the entire, in regards to the recreation that we’re in the course of. Yeah.
Alex Janke: Exactly. Yeah.
Dan: But as blissful as he’s that The Pitt is on the market — having watched the primary two episodes so we may have this dialog– he’s not inclined to look at extra of it.
Alex Janke: I feel lots of people, a number of, like my associates, we don’t, we don’t have to look at it. I simply go to work. It’s so spot on, so typically, it feels such as you’re at work. I’m like, effectively, I do that. I’ll let you know, I’m watching Abbott Elementary.
Dan: The community sitcom a few Philadelphia grade college.
Alex Janke: It’s fairly good. It’s fairly good. There’s some robust dialogue, there’s some actually robust characters.
Dan: Teacher associates of mine love that present. And it’s one other, I imply, it’s fascinating ’trigger that’s one other present about individuals who, a part of their job is it like they’re within the path of struggling that different persons are headed for and doing their greatest.
Alex Janke: I typically say this to residents, however like you possibly can go give as a lot as you need within the job of emergency medication. You can provide every thing to the individuals who come within the door. It’s the identical factor with lecturers, proper? If you’re a instructor, you possibly can simply maintain giving. They’ll by no means cease asking for extra, and a number of ’em do. It looks as if a tough gig to me and significantly much less remunerative than my job, so…
Dan: I’ll let my instructor associates know Alex stated that. Meanwhile, about fifteen hours after we launch this episode, HBO — I imply, Max — will launch the final episode of The Pitt. For now. The present has been renewed for a second season, beginning January 2026. Producers stated lately that season two is gonna happen over a Fourth of July weekend… which, a research from Pew Research exhibits, means the busiest days of the 12 months, by far, for emergency rooms.
We’ll be again with a brand new episode in just a few weeks. Till then, care for your self.
This episode of An Arm and a Leg was produced by me, Dan Weissmann, with assist from Emily Pisacreta and Claire Davenport, edited by Ellen Weiss. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting director of operations. Lynne Johnson is our operations supervisor. An Arm and a Leg is produced in partnership with KFF Health News. That’s a nationwide newsroom producing in-depth journalism about well being points in America – and a core program at KFF: an unbiased supply of well being coverage analysis, polling, and journalism. Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this present. An Arm and a Leg is Distributed by KUOW– Seattle’s NPR station. And due to the Institute for Nonprofit News for serving as our fiscal sponsor. They enable us to just accept tax-exempt donations. You can study extra about INN at INN.org. Finally, thanks to everyone who helps this present financially. You can take part any time at arm and a leg present, dot com, slash: help. Thanks! And thanks for listening.
“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.
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