Health Economics and 'The Pitt'

A misallocation of resources

Dr. Carter is back! Well, kind of. Twenty years after leaving “ER”, actor Noah Wyle has returned to the emergency room in “The Pitt”. Wyle plays Dr. Michael "Robby" Robinavitch, an attending physician of a fictional Pittsburgh hospital. “The Pitt” is basically what would happen if “ER” and “24” had a baby. Rather than each episode following the course of a shift or every shift, the entire first season of “The Pitt” is one shift. Each of the 15 episodes covers one hour in real time. Episode 1 starts at 7am, as Dr. Robby reports for work. Episode 15 finishes at 10pm, with the same, albeit worse for the wear, doctor clocking out.

Parts of the show are paint-by-numbers medical drama. The doctors engage in constant repartee. A few have a romantic history. There are the grizzled veterans and first-year interns. Some patients are “case of the week” type. They appear in one episode only. Some patients present with minor health issues and die and other patients arrive in desperate straits but are discharged by the end of the episode. There are a few humorous melodramas throughout to lighten the overall heavy subject matter.

Other aspects of the show are novel. The premise allows for some unique plot lines to develop. Some patients appear in several episodes. Like in a real hospital, lab results take time. So if a patient needs to wait for a test result in episode three at 9:15am, they might not reappear until 10:30am in episode four. The show does an excellent job including distinct characters that still seem like real people, allowing the audience to remember who is who without resorting to ridiculous caricatures. The show also does a marvelous job throwing the viewer into the setting. There isn’t a lot of wooden exposition. Many, many medical terms are not explained at all. These are doctors dealing with emergencies, so they don’t have time to spell out to one another what’s going on. No medical training is needed to enjoy, however, as any necessary technical terms are realistically explained, usually with a doctor telling a patient or family member what’s going on.

The show is excellent. My only complaint is it gets a bit preachy at times - there is a truly cringy moment where the nurses suddenly discuss the physical threats healthcare workers increasingly face as if they were in an infomercial. That, however, is my only complaint. The acting is top notch and the drama is engrossing. The 6:00 P.M. episode is one of my favorite TV episodes of all time. The show is also medically accurate. Doctors and nurses have praised how the show is sound from both a technical perspective as well as how the show depicts the overall atmosphere, feel, and tension of an urban ER.

And therein lies the problem.

“The Pitt” makes clear that ER staff wear a lot of hats. Not only must they know a great deal about medicine and anatomy, but they also play the role of detective, psychologist, counselor, comforter, and spiritual advisor. It’s up to ER doctors and nurses to determine when patients are seeking drugs or are withholding information. It’s up to doctors to work through the ethics of organ donation and comfort families after a loved one passes. This is, to be frank, a terrible use of resources.

I’m not blaming the doctors. They are doing an incredibly difficult job and in most cases, they are expected to provide many services that go beyond traditional medical care. The problem is that they should not be doing much of this work. Becoming an ER doctor requires an incredible amount of training. After high school, a would-be doctor needs to spend four years getting an undergraduate degree, then four years in med school, and then at least three years as a resident. That’s the bare minimum and doesn’t include any sub-specialty training. It takes an astonishing 11 years to become an ER attending physician. The whole process is insanely competitive. Only the best and brightest get into medical school in the US. It’s also highly remunerative. A typical ER attending can easily pull in $300,000 a year.

Someone with this much training should not be spending much time comforting patients or trying to convince family members to allow for treatment. That might sound callous. But the reality is there are other people in the hospital for that. Nurses can make patients more comfortable. Social workers can talk through ethical issues. Chaplains can discuss end-of-life outcomes. Society spends a stupendous amount of resources on making ER doctors extremely good at their job. Having them spend a significant amount of time on anything other than emergency medicine prevents those same experts from saving lives elsewhere.

Compare a hospital to a restaurant. The maître d' seats diners. The server takes food orders and relays complaints. The busboy takes empty plates and refills water glasses. Would it be nice to have the head chef personally walk you through the menu and cook your food? Of course. It would also be nice to have the head waiter always take your order. But this clearly isn’t optimal. The chef needs to spend almost all of their time overseeing the kitchen. The head waiter can wait on a few tables but also needs to make sure front-of-house operations are running smoothly. Most people have an understanding that they should approach different staff members for different items.

In a hospital the stakes are exponentially higher. In “The Pitt” a great deal of attention is focused on making sure patients are satisfied with their treatment. That doctors appear to be caring, involved individuals who will spend as much time with their patients as possible. This feels better, but we would all be better off if the doctors were left to doctoring and the nurses were left to nursing. Patients should be examined, treated if necessary, and discharged. Patient satisfaction should never supersede patient outcome. As Jack Nicholson’s character says in “The Bucket List”, “I run hospitals, not health spas.” As our medical system becomes increasingly stretched, we need the adults in the room to put patient health above all else. Our incredibly talented and trained physicians should be spending time on what they do best, and leave the rest to others.