This is a lightly edited transcript of Apollo on Call 

00:19 

Welcome to Apollo on call, the podcast of medhumb.org 

00:23 

I’m your host. Dr, David Hsu, hope you enjoy the show. 

DAVID HSU 00:33 

All right, we are back here for Apollo on Call. I have been rejoined by the guru of pop culture, Dr Stuart Harman, the pediatric emergency medicine physician and director of the pediatrics residency training program at the University of Ottawa, and most importantly, our expert on all things The Pitt. Because we are here to have our follow up discussion about possibly the greatest medical television drama ever made, and this time, we’re gonna do it with spoilers. Stu, welcome back to Apollo. 

STUART HARMAN 01:09 

Thanks for having me back. I get invited to do a fair number of things, but I don’t always get invited back after I showed up once. 

DAVID HSU 01:17 

Well, the first episode was so fun, and we managed to make it fun, even though we didn’t spoil anything, right? So anyone who’s listening to this show, if you haven’t seen The Pitt yet, and you haven’t heard the first episode of our discussion on The Pitt, go back and listen to that one. This one is only for people who have seen the show or who have decided for some reason they don’t want to watch the show. They just want to listen to hear us talk about it. Spoiler alert. Either way, you’ve been warned. 

STUART HARMAN 01:39 

Spoiler alert. You’ve been warned. 

DAVID HSU 01:42 

All right. Now we have both finished season one of The Pitt. Where it stands is, apparently there is going to be Season Two, but we’ve finished Season One, and we’re willing to talk about every detail of the show, whatever comes up. We won’t hold back today. But the first question, the question that everyone asks, is, how realistic is the show? We dealt with this issue in the first discussion, and we came away from it saying The Pitt is very realistic. Not in the sense so much that everything is perfectly representative of a regular day in the life of an emergency room doctor, but the way they cram everything together makes it feel realistic to the audience. So even for us as physicians, watching it, the show brings out the feeling of what it would be like to be in the hospital after one of these long shifts or during these difficult cases.  

STUART HARMAN 02:39 

I think that’s what I said last time, that there are a lot of scenes where you’re saying no, objectively speaking, that doesn’t really happen, but that sure feels like what’s happening.  

DAVID HSU 02:49 

Correct. Now, having said that, I think we should talk about the same issue, because this issue comes up all the time when people talk about The Pitt is, how realistic is it? And this time, we can actually go into some of the details. What did you think the show did really well in terms of depicting that it was real? 

STUART HARMAN 03:11 

On a very superficial level, a lot of the procedures that they show them demonstrating, I’ve got to give credit to the special effects and makeup people, a lot of that stuff looked fairly real, not all of it, but some of it. 

DAVID HSU 03:26 

Right. And the actual medical sequence, you know, like a patient comes in, they have a pneumothorax, what’s the next thing to do? They really got their money’s worth with whichever medical experts they paid. Because it seemed to be very, very accurate, right? 

STUART HARMAN 03:42 

Yes, 

DAVID HSU 03:44 

And I know this, because I was watching the show with my wife, and she’d be calling out, “they need a Blakemore. Get the Blakemore”. Meanwhile, I’m sitting in the background, like, what’s a Blakemore? I don’t really know. And I’m not asking my wife, because I can’t admit to her that I don’t even know what the next thing in the sequence is. But she had trained as an internist, so she had seen a lot of these things in real life. It was really astounding to see that the show was being very, very realistic. And even the things that I did understand, like a lot of the psychosocial Family Medicine stuff, okay, this is pretty accurate. Pretty close to how we’d be handling things in real life, with a few little exceptions. 

STUART HARMAN 04:17 

Yeah, I found it fun, perhaps, when I was watching some of the pediatric cases to guess what the answer was going to be. And in none of them did I feel like, Oh, that’s a cheat. That’s not right. It’s like, oh, you know what, for what you presented beforehand, that diagnosis makes sense. Although I think I mentioned before that there are a few diagnoses that I guess were less based on the medicine, and more based on what would be an interesting case to put on a TV show.  

DAVID HSU 04:48 

Now, since you’re the pediatrics guy, I’m gonna ask you about this. There’s a big case in the show where a girl drowns, right? And I have never actually seen a small child die in the emergency room or on the wards. As a family medicine trainee, you only get so much exposure. And fortunately, these things don’t happen every day in an emergency room. But I have heard people talk about it, and my wife has also talked about it a few times. They saw some younger patients, although she didn’t work with actual children, but in her case, it would be maybe young adults, the 20 year old, 21 year old. 

Even those cases, as a physician, you just feel gutted, because these people have their whole life ahead of them. So for these things to happen, it’s such a tragedy, and The Pitt drags you through this with a young girl who drowns and drowns saving her sister because in a swimming pool accident. Now, you’ve dealt with this kind of thing in real life. How accurate was the representation of this case? 

STUART HARMAN 05:50 

I think it’s fairly accurate in terms of just the medicine side of when someone’s drowned. You hear these stories about falling through the ice, freezing, cold water, drowning, where you warm them up and actually you bring them back. And I think the easy route to take on a TV show might have been to do that. Might have been to say, Oh, she’s cold. We warm her up and she’s back to normal. But that isn’t realistic in the case of somebody who’s drowning in not really freezing water. Really that person just wasn’t getting oxygen, and so if you don’t have oxygen, eventually everything shuts down, including your heart, and then you’re gone. And if I’m not mistaken, that is the case where the child — it goes to what you call asystole, right? They completely flatline, right? I think that’s the part of the show where the parent is saying, okay, well, you can shock her now, like do the thing with the paddles. And talking to a lot of my friends who’ve watched the show, when they talk about what sets this show apart from maybe some other less researched medical dramas, or even just TV shows in general, they really liked that part. They really liked how in real life, when you have a flat line like that, you can try to treat it by giving them epinephrine medication to make the heart beat. But that flat line represents that the heart is doing nothing, and the heart is not a battery that just runs out of electricity that you can shock it, put in more electricity, and it starts back up again. The electricity is to reset the rhythm of the heart when the rhythm is not compatible with life’s rhythm. But if there’s no rhythm at all, the heart’s not beating at all, and you’re flat lined like that, you can’t shock them back. And I’ve definitely seen movies and shows where they did shock somebody from a flat line and the heart comes back, or they did chest compressions, and it went from a heart not beating to the resumption of normal heart activity. So that part was realistic. And even that extra element of having the parent sort of saying, can’t you do this is a little over dramatized in my experience. But definitely, I’ve had parents who are sort of aware of something they’ve seen on TV, and they’re wondering, well, can’t you just try this? Can’t you just try it? So I thought they captured that well. 

DAVID HSU 08:06 

Now you and I have talked about medicine on the air on Medical Dads. We’ve talked about life in private for years, but I’ve never asked you this question. How often do these cases really happen where you see a case that you’re really gutted by because you are on the front lines of this in the peds ER. How often does it happen, is my first question, and then I’ll ask you my second question after you answer this. 

STUART HARMAN 08:32 

So, I mean, drowning, specifically, in my city, we have a couple of drownings a year, and most of them don’t actually make it to the emergency department, because the person’s found, you know, significantly after the time that they’ve drowned. So they happen. They happen enough that we still have —  

DAVID HSU 08:49 

How about, not necessarily a drowning, but like a tragic, senseless death of a child. 

STUART HARMAN 08:54 

Any child that died — well, are we just talking about, how often do we see children die in the emergency department, or die somewhat unexpectedly in the emergency department? 

DAVID HSU 09:03 

I think that’s what the show is trying to hit with this. That’s the note the show is trying to hit on this case. 

STUART HARMAN 09:08 

I would say those happen, those happen several times a year. It’s not every day, it’s not every week, even. Sometimes it’s not every month. And then you’ll have a month where it happens twice. 

DAVID HSU 09:23 

This is to you, or just to the department, because you’re not there every hour. 

STUART HARMAN 09:27 

I’m talking about the department on the whole. To me, it happens enough times, but not so many times that I can’t — I was going to say not so many times that I can’t remember the cases. But actually, that’s not — that’s not exactly true. It’s happened enough times that there are ones that I wouldn’t remember unless somebody reminded me. But I would say, well, once every couple of years, I’ll personally be the person there. For a case where we don’t bring them back, non-survival in the emergency department setting. 

DAVID HSU 10:06 

So this is my second question, and I’m very curious about this, going beyond The Pitt, because The Pitt is just focusing on what’s happening in the halls of the hospital for that shift. How do you handle this as a medical doctor, when you go home after you’ve had these things happen. They’re super emotional, draining. Are you able to process it in some way? Are you compartmentalizing it and not talking about it with your family or do you bring it up at dinner? What happens to you, Dr Harmon, when you go home after a case like this? 

STUART HARMAN 10:43 

I don’t think they addressed this on the show The Pitt, but there is this element of you see some of these terrible things, and it’s not always a death, right? Sometimes you see some things related to child abuse or just catastrophic injuries, where the person survives, but you know that their outcome afterwards, it’s not gonna be great. I’m a pediatric emergency doctor, so it’s all children. So there is definitely this real life aspect of not really being able to go home and just talk about that with your spouse. Just unload all that stuff all the time. Because, my wife, she definitely signed up for better or for worse. You know, sickness, health, richness, poorness, all that, but not specifically to be my therapist, where I can come and put so much stuff on her that now she is going to have her own trauma, right? So that people ask my wife, how do you deal with having to deal with hearing about all the horrible things? 

DAVID HSU 11:45 

Well, she’s also, she’s not a physician, right? So she would be, she’d be facing it with a different perspective. She’s a teacher, so it would give her a different perspective. And it might be, it’s not good or bad. It’s just, it would be different. 

STUART HARMAN 11:58 

That’s a good point. People listening to this podcast, as opposed to the one you and I usually do together, don’t know that my wife is a teacher. And you know, people choose their careers based on the type of things that they like to do, expect to do, what they handle well, what they don’t handle well. So you wouldn’t expect people who don’t go into medicine to necessarily be well equipped to hear about that type of death, those types of tragedies, all the time. So there is this element of when I go home, I can talk a bit to my wife, but I consciously try not to overdo it. So how else do we deal with it? How else does a physician — how else do I process these things? 

DAVID HSU 12:45 

I mean, you strike me as being a very jovial guy in general. I’m sure most of their regular listeners to medical dads would agree. And even the people who are going to hear us on Apollo on Call will agree. You’re pretty jovial. It’s hard to imagine you simmering or stewing, for lack of a better word about a case that happens, but I’m sure that this job is difficult, right, and your job in many ways is more intense than my job. As a family doctor, things do happen. A lot of times they’re not happening directly under my supervision. And even then, I’m sometimes just like — feels like a huge thing has hit me on the head, and I need a week or two to slowly, pace my way through it. But the stuff you’re seeing and the stuff The Pitt people are seeing is a whole different level. That’s why I’m curious. 

STUART HARMAN 13:33 

You know what I think, what aspect of this is for a lot of people, when something, when a tragedy, just happens, simply being aware of it or witnessing it doesn’t necessarily affect you in an unshakable way, compared to if you feel that there’s some element of that that’s your fault, right? Some element of that, well, it’s your responsibility, and you could have done more. So it’s not every time I have a bad case that I have a long process that I have to go through to get through it and move on. But from time to time, there are going to be those cases where there is some sense of what could have been done differently. What more could I have done that day? Or if only this thing had happened or lined up just right? Those can sort of rob you of sleep a little bit. Plus, there’s a whole other element that you’re accountable for some of these things, right? So you never know if somebody is going to launch a complaint or a lawsuit or something along those lines. And I think actually for a lot of physicians, that sometimes robs them of more sleep than the actual case itself. Sometimes even a case that went well and you did everything right can rob you of a lot of sleep if other people don’t think you did it right. But so, yeah, that’s a little bit of a peek behind the curtain for old Dr Harmon here. Sometimes there are some of those that you have a sense of responsibility about it, that affects you a bit. But I do feel like I have a fairly good outlook on all of that. You know, I think I’ve come to grips with the limitations of being a human being and just the fact that, for me, if I often look at it, okay, some terrible thing happened, somebody was in a car accident, or someone had something really horrible happened to them, and if I wasn’t there, that thing would have happened anyway. So me being there, I’m exposed, I’m aware of something, but it’s not like being aware changed anything. And at least I could try to help in some kind of a way. I think that that outlook has helped me manage quite a bit of this. 

DAVID HSU 15:59 

Not a bad way to think your way through it. I think I hear what you’re saying. A lot of times these bad things happen. And sure, sometimes it’s like, you know, as a physician, we made a mistake. And so you’re kind of thinking, okay, could I have done better? A lot of times there’s nothing obviously that you did wrong, but it’s just, could I have done things a little bit differently? Maybe we could have achieved an even better outcome than whatever outcome we had, right? And so that kind of thing, it’s hard to let that go as human beings, if we care at all about our patients, right? And a lot of times these things are out of our control, but we kind of wish that it was still within our control. And you do see elements of this playing out on the show, right? Like the older doctor, Dr Robby, he’s seen all this stuff before. So for him, he’s seen good and the bad, and he has to balance it. And these younger people who are coming through and training and seeing things for the first time, they’re getting caught up in stuff like, oh, I had a patient die, right? Like, this happens to Whitaker a lot on the show at the beginning, it’s almost like a comedy at the beginning, right? Everything he touches goes bad for a while. He’s like, maybe I’m just not cut out for this kind of thing. But you realize that’s also part of being a doctor, right? That you have to learn that you can’t save everybody. A lot of it’s out of your control. You do your best, and then you move on to the next one, because the system needs you to keep functioning. 

STUART HARMAN 17:19 

 In the show, I noticed that they did try to do some debriefs. You saw that with some of the cases where they get everybody together and try to do what we call a debrief. We do that. We do that at my hospital, if somebody dies, certainly. 

DAVID HSU 17:32 

And you have, like, a moment of silence and stuff. I’ve never actually seen that in real life. 

STUART HARMAN 17:36 

The moment of silence, I would say that is not routine. We don’t always do a moment of silence, but what we do is something where we get everybody who is involved in the case together after the case is over, you give people five to ten minutes to go and sort of clear their head, try to get everybody back together, not in the same room where the case happened, where everybody’s looking at it, but in a different room. And you go through this debrief, where you try to find out from people, first of all, does everybody understand what happened? You go through the medicine of the case, describe what happened. Then you give people an opportunity to ask questions, or to say, well, how come we didn’t do this? Or should we have done that? And then you get a chance to talk through that. And then there’s an emotional part to it too, where you just like, give people a chance to express what they’re feeling and acknowledge that and talk through that. And like what you were saying, after you’ve been around for a while, you see certain things. It’s very different than when you first start out. So often with these debriefs for children who’ve died by time they’ve got to the emergency department or in the emergency department, I’ll start off by setting that stage for everybody, since some of the people in the room this is the first time they’ve lost a patient, and explaining that on TV, or what we are often led to expect is that when someone needs to be resuscitated where their heart stops, or something like that, that 80% of the time, if we do everything right, we’re going to bring them back. Whereas that, that’s not the expectation of the statistics, right? For some of these cases, they’re coming in with less than a 30% expectation, 30% chance, that you could actually bring them back from that, sometimes less, right? Sometimes the patients come in and they’re gone. And so I’m often explaining that to the group, that there was no real, real hope. It would have been a bit of a miracle. And sometimes we do pull off miracles, but just so that they understand that. 

DAVID HSU 19:26 

So you’re telling me that when you do the debrief, you actually reference television. 

STUART HARMAN 19:31 

No, no, I won’t say, I won’t say, oh, you know, if you’ve been watching a lot of television, you think we’d bring this back. But I’ll say it more along the lines of, what we have to keep in mind here is that although it can feel like or people may come into this with the expectation that we’re going be able to reverse this, most of the time, that’s not what it is for this case, this patient actually came in asystole. 

DAVID HSU 19:53 

This was actually a known thing on the original ER. When ER came out, people would watch the show and track how often they got out the paddles and charged it, and people survived, right? And, wow, 80% of the people on the show survive, right, and it would create this false expectation for patients. You’re just like, oh, beep, okay, get out the paddles. We can bring them back, right? And, and it makes for great television drama, but it’s not realistic, right? I think in this show we have a bit more of a realistic view of it. A lot of the patients are dying, and it’s gut wrenching to watch, but I think they did a pretty good job of balancing that. The doctors on this show are — they’re heroic, right? And we can talk a bit about this, but they’re tempered by the reality of their limitations as physicians. 

STUART HARMAN 20:43 

One thing that I worry about what this show might do that’s going to create a false impression. There were so many times over the course of this one season where one character is doing some kind of medical procedure and other characters are telling them, Don’t. Stop. That’s dangerous. You’re going to kill the patient. And the person will be saying something along the lines of, this is unconventional, I read a case report once. They’re treating it like it’s fine to do these Maverick moves, right? And it always works out, even if it’s the Junior trainee trying something that’s way out there. It never fails, and that, I think in real life, that’s not how that goes. Not to say that people can’t do — I do feel a little bit like the emergency department in particular could — that type of work in the field of medicine can potentially attract a certain type of personality, right? Because people have different ways of how they react under stress. I don’t just mean when you’re stressed, but when you have something critical happen. There are people who, their natural instinct is to sort of slow down, stop, go inward and think through things, which sometimes is the right approach, but sometimes you miss the opportunity to make a quick decision that you should be doing. But then there are the other people who are faced with any kind of pressure situation, their thing is to act, and they don’t necessarily slow down to think. That’s their instinct, is to act. And they have to fight that instinct to slow down and think. And if I was going to generalize the stereotype, I would say for some the quick acting is what can be attract them to emergency medicine, and I would hate for people to watch this show and get the impression that, like, yes, that’s the way I should behave when I get into medicine. And there’s going to be lots of opportunities for me to do that and be rewarded for it. 

DAVID HSU 22:32 

Right. This is something that the show is spinning a little bit, and because they’re making the pace of the show so fast that you have to be problem solving that way. And emergency medicine is faster than most other forms of medicine that are practiced. But this is a really, really extreme way of portraying it. 

STUART HARMAN 22:49 

Yeah, and it would be more collaborative in my hospital, at least. Even if you do need to do this crazy procedure that’s a Hail Mary toss, it wouldn’t be with your supervisor or with somebody from some other service, because apparently the surgeons in this show like to come down to the emergency department and tell you what not to do. But it wouldn’t be with some other service on the sidelines saying, don’t do that. I’m going to bring that patient to the operating room instead but you do it anyway. And then they say, oh —  

DAVID HSU 23:15 

All’s well that ends well, that’s repeatedly on the show. 

STUART HARMAN 23:20 

That’s the theme of the show, all’s well that ends well. 

DAVID HSU 23:23 

Now, here’s a case that a lot of people have talked about and written about. It’s the case of the Advanced Directives. There’s an old man right in the middle part of the season. He gets brought in. He’s having difficulty breathing. He’s already got pretty advanced dementia. There’s a son and a daughter. They’re arguing about what they should do, because dad has already said he doesn’t want to be hooked up to a ventilator. He doesn’t want any heroic measures taken. And then the son says he’s in agreement with dad’s plans. The daughter says, we want to keep him alive. I haven’t spent enough time with dad yet, right? And they’re having an argument about this, this specific case, did you feel this was realistic or not from what you’ve seen? 

STUART HARMAN 24:10 

I was going to ask you the question, because in pediatrics, these advanced directives are something that are made with the parents. I’ve had cases where we didn’t have an Advanced Directive, and the parents had to make the children — adult children of grown up parents — had to make a decision. So I remember distinctly one of these cases when I was in medical school, we’re really not sure. So are we starting chest compressions and resuscitation, or are we not? And the family, we were waiting for the family to make that decision. And in pediatrics, we’ve had cases certainly where the parents were not in the head space, where anybody was able to get them to agree to an Advanced Directive, and so we’ve had to make this decision on the spot. But I was going to ask you, is that actually legal in Canada that you could be an elderly person who has written an Advanced Directive stating what your wishes are, and that goes out the window? 

DAVID HSU 25:06 

To the best of my knowledge, what happens in real life is not so cut and dry. So just because you have an Advanced Directive and you’ve indicated what your wishes are, when you actually get into the hospital in that moment, my experience of it is, the family can still go against the advanced directives. There was a case that was a family that I knew pretty well. I had looked after the elderly parents, both of them for many years, and unfortunately, it was a very strange case, because the lady had developed Creutzfeldt–Jakob dementia, like mad cow disease, which is a really, really severe form of dementia. Actually, backtrack. The lady had just developed really, really severe dementia over a couple years, and she got admitted to hospital with some other sort of, like must have been a broken leg or something, and there was this whole dilemma about, should they do any measures to prolong this lady’s life? Her quality of life was already very, very, very poor. It was very severe dementia. The children, the children that were living in Canada, were all on board with, you know, no heroic measures. Do Not Resuscitate, right? And then suddenly there was another child who wasn’t even in Canada. It was a long-lost son or someone from China, calls long distance to the hospital and says absolutely not. We must do everything for mom and dad, right? And in this case, the family had already agreed there was a plan, and I think the husband was on board with the plan, and he would have been the substantive decision maker. The children were in agreement with the plan, but they couldn’t get 100% consensus, right? There was this other voice, and as soon as the hospital heard that there’s this other voice, they’re like, whoa, we’re gonna back off. We can’t execute this because there could be legal ramifications later. So it was almost to the point of whether legally that written document or the substantive decision maker document held water or not, didn’t matter anymore. It was we need to get everyone on board. And I’m not even sure that’s the right thing to do, but that was actually what ended up happening in real life. So they ended up prolonging this lady’s life for x more months/years and it was very interesting to me to watch this happen. A lot of times, we’ve seen these things happening in real time. You and I can debrief about the show in detail and break down, what’s the law, what’s the ethics? Right? We can teach a whole course on it, ask all our students to write an essay about what they saw. But in real life, you have five minutes, right? The person’s about to code, do we do this or not? And you get this phone call from China, and it’s like, okay, everyone, we can’t decide now, right? We’re in a log jam. 

STUART HARMAN 27:57 

 I had looked it up at one point after that show, because I was so curious as to what the law is in Canada. It seems it’s not exactly the same in every province. So province to province, there’s differences, but the general consensus seems to be that if you have an advanced directive that’s written at the time, when you, as the person writing it, are competent, then that’s legally binding, and other people can’t overturn that unless they are petitioning to say that you weren’t in your right mind when you wrote it, or that you’re you know, they would otherwise say it’s invalid. But that situation of two adult children coming in and saying, oh, we’re not following dad’s advance, I don’t, I don’t think that that’s the way that’s supposed to work here. 

DAVID HSU 28:35 

Right. But in real life, I think what’s happening is the doctors want the family to feel like they’re getting heard, right? So they’re giving the daughter the option, which I guess is what’s happening in my patient’s case, right? They’re allowing this child who isn’t even present to be heard and let them sort it out as a family. Because otherwise, if we just let, you know, the brother decide, and then the sister doesn’t get any say in it, this is going to become a huge issue for them afterwards. So it’s almost better to let them work work through this thing as a family, which is the approach of the show. I think that probably is the best option, honestly. We’ve gotten into discussions about things like advance directives, and it gets really complicated. It’s an Advance Directive. It was written. It was scribbled on a piece of paper, right, and the date is wrong. Is it still valid? Like, these issues appear all the time, right? If you look up, what do you need to indicate your will? All you need is a piece of paper that you wrote down what you want done, and you sign it right? And that can be a will. But will it hold up in court? Will it hold up after you die, when people examine it under a microscope? No one really knows, right? So it’s very, very complicated. 

STUART HARMAN 29:47 

But if anything good came out of that episode of the show, or if something good could come out of people listening to the podcast and listeners talk about it, hopefully it would be that someone listening or someone watching would be motivated to say, okay, let’s actually set up advanced directives for our family members and talk about it now, instead of at the time, this analogy that’s often made of, you know, if you’re on an airplane and the plane is crashing, that’s not the best time to be going over instructions for what you’re going to do with an oxygen mask, and that is tough, right? Better to do that before it happens, when everything is safe and when everyone’s thinking clearly 

DAVID HSU 30:26 

Except before it happens, you don’t really know what it would actually feel like to be in that situation, right? Today, if you ask me about advanced directives, I have a certain opinion about it, but when I’m actually facing life and death, right? I might have a slightly different answer at that point. 

STUART HARMAN 30:45 

I think what Dr Hsu is saying is that, before the plane takes off, put the child’s oxygen mask on, after you put your oxygen mask on. I agree with that concept, but when that plane is crashing, in that moment, he might change his mind to be like, You know what? Both oxygen masks. I want them all. 

DAVID HSU 31:01 

Save yourself. Man, physician, you cannot heal other people if you cannot heal thyself first. Now, here’s the question about that case, though, so the brother and the sister have this long, emotional conversation guided by the doctors, where they eventually explain why it is that the sister isn’t ready to let Dad go, and it’s because she didn’t have a great relationship with dad, and they have this long, teary, emotional conversation, and this type of conversation I’ve had with my patients in the family doctor office, because these patients, because I know these people so well. I’ve known them for years. So then when something happens to their family, they come in and it’s also not happening at the moment. So then they come in later, and then we have a talk, and it’s kind of like a debrief and they can explain why their marriage is struggling, or why their relationship with their son isn’t what it should be, and so forth. And that’s the coolest part of family medicine for me, but I’m wondering, because as I was watching the show, I don’t know, I’ve never been in your shoes, or not much, right, in an emergency room setting, and I feel like there, this is a bit forced. If I was in the emergency room, I don’t think I’d blab out all this stuff to the doctor who I just met, right? I’d probably be more inclined to go back and talk about it with my GP or my buddies, right? But with this in the emergency room, in the moment of, just like unloading all the stuff about my childhood, Is that realistic? 

STUART HARMAN 32:35 

That’s exaggerated, but not completely unrealistic. 

DAVID HSU 32:37 

Okay, so it does happen. 

STUART HARMAN 32:39 

Yeah, you’d be surprised in the emergency department, how often we find ourselves using up a fair amount of time on some of these things that are more probably appropriately addressed elsewhere. But this is just where they’re coming up. So this is where we’re going to talk about it, where sometimes you’re trying to get somebody on board with what to do, or what the next step is to take, and you find yourself spending a lot of time doing that, and some physicians are more willing to do that than others, and some physicians are more naturally inclined to that than others. I think in peds emerge people are maybe more inclined to do that just by nature of being drawn to working with families and children in that way, but it does touch on this character of Slow Mo that they have on the show. 

DAVID HSU 33:24 

Right. So this character is the trainee who spends too much time with her patients, so everything is getting backlogged because she’s not seeing patients quickly enough. 

STUART HARMAN 33:37 

There definitely are trainees and sometimes even staff physicians who can be a bit like that. And the show makes it seem very noble that they all are the same. Well, I guess the show isn’t saying that they’re all the same, but this show presents a very noble version of that, where it’s just because I care so much about these patients and giving them the positive experience that I get drawn into doing these things. But it is true that by the time you’re now having just chit chat and conversation with the families, that actually is becoming a bit of a detriment to the other patients in the department that you need to be spending time with. But I feel there are also sometimes situations where people are spending too much time with the patient, maybe because they enjoy that part more than they enjoy going to see the next patient whose problem might be more challenging, or sometimes the easiest part is the part that’s just building rapport. And actually, I’ve certainly met patients who it doesn’t matter how much rapport you build with them, if you can’t also nail the medicine part, then none of that rapport is going to mean a thing. 

DAVID HSU 34:48 

Well, ideally you should do both. But that gets into this whole art of medicine. I thought it was interesting that the show actually addressed this, right? That the doctors can work at different speeds and the different speeds do affect how the system runs on a whole. It also affects the quality of the medical care, right? So there are patients who are getting brushed by, right, like they’re coming in with issues, and the doctors don’t even have time to deal with it, that if they spent a little more time, they might unearth something. And so we see both sides of this on the show. It’s quite interesting, because it gets into the whole business of medicine being a human-being endeavor, and that means it comes with a lot of variability, right? You have the slow doctor, the thoughtful doctor, you have the fast-thinking doctor, you have the doctor who’s not so good with patients. And there’s always two people in the room, right? It’s not just the Doctor, the patient is also part of this interaction and affecting it. So I liked how the show presented this issue to us. 

STUART HARMAN 35:46 

I also liked that the show didn’t give us an answer or didn’t tell us what’s right and what’s wrong. They had that character slow mo, and they did show that actually sometimes that being slow is causing an issue, and the element of the staff physician actually trying to teach that you can’t just be slow because you’re not confident enough to make a final decision, or that you’re always afraid you’re going to miss something, because that is not a good type of slow to be, that you’re doing unnecessary tests, spending unnecessary time because you’re afraid of what you’re going to miss. But then, on the flip side, they also had it where that character realizes the patient has mercury poisoning because she took the extra time to connect with the patient and to look into it. 

DAVID HSU 36:27 

There is also a scene, if you remember, Collins comes up to her and is like you’re doing a good job, so don’t listen to all the doubters, and you keep on doing you, which I think is a really good message too. There’s no right answer the way that the show presents it, which I thought was quite true. That really is the thing. I feel like I’ve experienced this as a teacher in family medicine, where sometimes these students come through and they’re a little bit slower, and it’s like, wow, a lot of the people in the department are really piling on this person. They feel like they should be faster, and they’re missing the point that actually this person is really honest, and they’re very good with the patients, and maybe the level of expectation for what we have for each individual person doesn’t need to be exactly the same. It certainly isn’t, when they’re actually working. 

STUART HARMAN 37:14 

I feel though the reality of what should be done is quite nuanced, or is in between this, because definitely you’ll have trainees who can be slow enough. People just keep telling them, you do you. And if people sell the narrative that this is actually the best possible care, right? Because that patient is going to be so satisfied the more time you spend with them, you could spend an entire shift with one family, right? That could definitely happen. So — 

DAVID HSU 37:41 

That would not be good medicine. Basically, is what you’re saying. 

STUART HARMAN 37:43 

That would not be good medicine. But then you also do reach a certain point where you do actually have to say, I gotta do me. I gotta be comfortable with what my approach is. And there are some doctors who I’ve known, who’ve been great doctors, who get great patient feedback, who do spend more time — are a bit slower, but I wouldn’t tell them to change. I don’t think I could make them change, and I don’t think they would be better by trying to be faster. 

DAVID HSU 38:13 

I mean, it gets into this question where, what do you think is a good doctor for you. If you were the patient and you walked into the Pitt because you had some injury, which doctor would you want to treat you? And everyone might have a different answer. So maybe you tell me which out of all those people, who would you want to treat you? 

STUART HARMAN 38:38 

Honestly, what you want is the doctor who is the best at getting the diagnosis. 

DAVID HSU 38:41 

You think so? 

STUART HARMAN 38:42 

Yeah. I mean, I think pretty much universally, if the person at the end of the day gave you the right answer and treated you and you got better, then that’s the doctor you would want, even if their bedside manner was slop, even if they were terrible. 

DAVID HSU 39:03 

I don’t think that’s true.  

STUART HARMAN 39:06 

I think it’s true if you actually do get better.  

DAVID HSU 39:10 

That’s only if you think of medicine as a purely zero sum or a binary thing, where there’s a right answer and a wrong answer, right? Which it’s not. It’s a human being thing. 

STUART HARMAN 39:19 

Well, I mean, everybody wants it all, right? Everybody wants the doctor that’s got great bedside manner and the right diagnosis. But if we posed it as a question of you can get a doctor who’s super nice to you, but you don’t get the right diagnosis, would you rather have that or a doctor who’s terrible bedside manner, but definitely you’ll get better? 

DAVID HSU 39:37 

Okay, but let’s talk about The Pitt, all right? You’re not allowed to pick Dr Robby, because I think we would all pick Dr Robby. He seems to have it all at the beginning of the shift, but clearly he’s a flawed character as the shift goes on. But okay, maybe you can include Dr Robby out of all these people you walk into the emergency room during that 15 hour shift, which of the doctors would you be glad to see the most? 

STUART HARMAN 39:58 

Yeah? You know that doctor, Dr Robby, he does have that kind of thing where all his flaws are the things that are self-destructive. He burns himself up for the job. So most patients would definitely like the doctor who’s got all these great qualities and yeah, but at the end of the day, the doctor himself is — 

DAVID HSU 40:15 

All right. I feel like you and I could talk about The Pitt endlessly, yeah, but we must. move forward a little bit here. 

STUART HARMAN 40:22 

We should just have a whole other podcast series on the show. We’ll call it the Bottomless Pitt, where we come up with endless things to say about this show. 

DAVID HSU 40:30 

Now, just thinking broadly from a medical humanities standpoint, because this is Apollo on Call. What do you think about the show overall? Like a meta thing in terms of medical humanities? 

STUART HARMAN 40:43 

I think the show is actually not a bad thing for physicians and even for non-physicians to watch and take home talking points from some of the various scenarios that they put in the show. The scenario of sickle cell disease patients, the scenario of the end-of-life discussions, even the scenario where it’s just a throwaway thing, I kind of wondered why they put it in there, because they didn’t follow up on the plot thread. But there’s a character who misses a urinary tract infection and a patient who comes back, and another character who makes a suggestion, are you sure it’s not because she’s obese that you just biased against obese people, that you fat shamed her and so somehow missed the diagnosis. And the character who otherwise seems very understanding of people, is sort of saying, oh, I don’t think so, but I will reflect on that. I thought it was weird in the show, but for people watching from a medical humanities point of view, it’s a good talking point, a good starting point. Hey, do we think that we have unconscious bias against the obese that maybe affects the way we treat them medically. 

DAVID HSU 41:46 

I thought overall, that the show does a really good job of championing medicine and portraying doctors as heroes, and I don’t think we get enough of that anymore in a way that really hits home. Maybe I’m just jaded from working as a physician. I feel like in this day and age, and I’m talking about doctors themselves — this show doesn’t talk about this — but I think maybe we should talk about it a bit. There’s a lot of this talk in medicine about how doctors are not paid enough. There’s not enough money in medicine. There isn’t a single character in this show that is portrayed as being in it for the money. But you and I went to med school, we did our training. There are many people around us that are in it for the money. Right? That character is missing on the show, and I think they deliberately omitted it, yeah, because they want us to see the heroism part of being a doctor again, which I think is actually a cool thing, because we don’t hear this enough anymore. 

STUART HARMAN 42:51 

It’s true. I mean, I will reflect that this show is taking place in an American hospital. So maybe nobody’s saying anything about money, because they’re being paid so much more than we are here in Canada. 

DAVID HSU 43:01 

Well, they’re all residents and trainees. So they actually are not. One of the students, Whitaker, has nowhere to live. He’s slumming it in an empty ward in the hospital. 

STUART HARMAN 43:12 

That’s true. All the all the doctors and residents complaining about their salary on this show are all hiding out together with all the other sub specialists and specialists that should be showing up to the ER to see patients apparently don’t on the show, since the only characters we see outside of the emergency are surgeons and the odd other person that wanders through when, in real life, there are other people in hospital coming to the emergency departments besides the emergency docs. 

DAVID HSU 43:36 

Right. So it does seem like we’re painting a picture of people who ultimately, for better or worse, no matter what personality type they have, they are in the job because it is their calling. And that’s not completely accurate in real life, but it does reflect well. I think people need to see this. And I think you talked about this in the first episode we did. This is not a bad show to watch for doctors to remind you of why you got into medicine. You know, because we lose sight of that during the day-to-day grind of a long career. For sure, we lose that.  

STUART HARMAN 44:09 

Yeah, this wasn’t lost on me either watching the show. I reflect on how lots of physicians I’ve talked to about the show have told me that they didn’t make it through the first couple episodes, that they just saw it and it’s too overwhelming, or it’s just too intense. And the show does have a bit of a weird intensity, where at the beginning, people are having scalpels dropped in their foot. I kept expecting some main character to have some weird death in the show, but that said, I watched the show to completion because you told me to, because we were going to talk about this podcast. So I knew from the beginning, I’m pushing through. And one thing I thought the show had some serious value in that the characters don’t quit, right? They’re going through all this crazy stuff, and they have this thing of I’m doing this. And I felt a bit inspired by that, or at least I felt a little bit like, yeah, like in every other area of my life that I’m trying to use television to emulate what I should be, this too. I should try to be more like Dr Robby. 

DAVID HSU 45:09 

I definitely got that feeling. Like at the end of the season, I was like, Screw it. We should just all go back and do our jobs. I got to stop podcasting all the time and get back to the core thing that I do, right? And then I went back to work, and I was like, yeah, I could kind of see why I need to do more podcasts. Now. Season Two of The Pitt is coming. It is going to be a real thing, right? And I’m not sure how they’re going to structure it. What does Apollo on Call want to see out of Season Two of The Pitt, if we had any say in it at all? 

STUART HARMAN 45:43 

I think I said on the previous podcast my spiel about how I thought it actually exists perfectly as a singular entity, but aside from the fact that maybe there shouldn’t be a Season Two at all, what do I want to see? Well, there’s a few plot threads that we’re all dying to see how it plays out, right? So what does happen with this doctor who’s using drugs because the show — that aspect is a bit unrealistic — like the way the staff person just exploded on him, the actual medical system treats those doctors as patients. A doctor with a drug addiction is treated as a person with an illness, and the medical system is actually quite supportive of those doctors and helps them to get recovery if they’re willing to admit they have a problem. So now that he’s been forced into that situation, will we see him come back? Will he be allowed to work in an emergency department, or will he come back as a family doctor with a thriving practice, but who’s not allowed to have access to drugs. 

DAVID HSU 46:44 

Will Dr Robby even call him out for it officially, it seemed kind of ambiguous, right? Because he took Langdon’s pills, it looked like he was about to flush them down the toilet. So maybe he wasn’t going to mention the thing to anyone. He deliberately didn’t tell any other people about what was actually going on. So it’s possible that he even buries this issue and allows his prodigy student to continue. But I’m not sure where they’re going to go with it. There’s a lot of ways this thing could play out. 

STUART HARMAN 47:11 

Especially because they have that other character who knows, I forget what her name is, Santos. So Santos knows, and I don’t think her character would let it drop if they had Season Two, so maybe there’d be that. Also, we need to find out what happens with Gloria, the charge nurse. After getting punched in the face and her saying that she’s not coming back, they really kind of left it a little bit like Robby thinks she’s coming back. 

DAVID HSU 47:40 

In real life, that character definitely comes back. In real life, that’s just a bad day. She might need a month off. You know she’ll be back. This job is in her blood and also, the actress that gives that performance, this character is actually one of the best characters on the show. There’s no way she’s not coming back. 

STUART HARMAN 47:58 

Maybe that character doesn’t need the paycheck, but that actress definitely needs the paycheck and won’t walk away from that money. 

DAVID HSU 48:05 

Now, if you were doing this Season Two, and one thing about Season One is they did this whole one hour, is a one hour of real time — 

STUART HARMAN 48:15 

 which I think only partly worked. After a while, they were a bit constrained by that gimmick 

DAVID HSU 48:22 

Right. Now, most likely they would continue that gimmick. I don’t see them changing that because it’s such an important part of the show’s description, right? So how do they top this? Like, how do they do a Season Two? The reason a regular eight hour shift, or a 12 hour shift stretches in the 15 hours is right at the 12 hour mark, this mass casualty event happens. So are we going to jump forward a year in Pittsburgh when another crazy mass casualty event happens? What plot line could they possibly put into this thing for next season? 

STUART HARMAN 48:58 

I would imagine it’s just a regular 12 hour shift, and then they extend it with three hours of them doing the paperwork that piles up so you have a 12 hour shift. 

DAVID HSU 49:06 

This is why you’re not writing television, right? You would want to go for uber realism, like we want the medicine to be totally true to life. 

STUART HARMAN 49:17 

Well, I mean, you haven’t read my exciting fan fiction that I wrote about that other doctor coming to grips with her bias against fat people. 

DAVID HSU 49:26 

Hour 15, Dr Harmon goes home, but is unable to talk to his family about all the crazy things he sees, and just goes and takes a nap. In this show, we don’t really see that. We see these people — they are soldiers, right? Literally, right? The mass casualty event happens, and these people are drawing their own blood and pouring it back into the patients. 

STUART HARMAN 49:47 

Never done that, I’ll tell people. I’ve never done that. 

DAVID HSU 49:51 

So this show tells us that people are thinking of medicine as their whole life. This is a calling beyond the calling, which, on the one hand, earlier, I said it’s kind of nice that we get this heroic portrayal. On the other hand, it’s kind of unrealistic, and maybe we need a bit of a reality check also. 

STUART HARMAN 50:08 

Yeah, that’s an insightful answer. Too bad listeners will never be able to hear it, because we’re going to have to edit that in such a way that none of your patients think they’re going to lose their family doctor in the next 10 years. 

DAVID HSU 50:17 

I don’t know. If I was in charge of Season Two, I feel they don’t necessarily need a mass casualty event, but I actually wanted to see more of some of the night shift doctors, so I thought maybe they could start the season with a little bit of an overlap the first couple hours with the doctors from the night shift, like the Asian doctor, because I definitely felt like I could have used a little bit more Asian representation on the show, and that guy that was sipping on the cappuccinos, he was the man. 

STUART HARMAN 50:43 

What about Santos? I thought she was the Asian represented by that show. 

DAVID HSU 50:47 

Well, that’s true. Santos is also there, but her character is a bit of a train wreck. So you were saying, like, which doctor would you want as your physician?  

STUART HARMAN 50:55 

Not her. 

DAVID HSU 50:57 

Definitely not her. But I could imagine season eight of The Pitt, by then, she’s going to be an attending, and this whole place is going to fall apart. 

STUART HARMAN 51:04 

Actually, you know maybe the doctor I would want is Dr Abbott. He seemed to have his act together. You know, when he’s not at the edge of the roof. 

DAVID HSU 51:12 

He’s a nut job. Also, he knows his medicine the most. So I guess that makes sense, because that’s what you’re looking for. But this guy, if you recall, he had threatened to jump off the building at the beginning of season one, right? The show opens with him about to jump off the building. 12 hours later, he comes in. I heard about the mass casualty event on the police scanner. Like, he goes home, he’s listening on his shortwave radio for the next time he’s going to get called in. Like, yeah, this is definitely the guy you want as a doctor. 

STUART HARMAN 51:44 

As long as he could treat me before his shift is over. Then, all right. 

DAVID HSU 51:49 

All right. Well, at the very least, we both really enjoyed watching The Pitt, but moreover, we really enjoyed talking about The Pitt, which is why we have these two very long episodes about this show. We hope that our audience has caught some of our love for the show, our passion for The Pitt. And you have plenty of time. You’ve got maybe half a year to catch up on this thing, and then Dr Harmon and I will see you when it’s time to roll out The Pitt Season Two discussion on Apollo on Call. 

STUART HARMAN 52:22 

Do you have some kind of way for people to discuss back their insights or things that they’ve learned from listening to the podcast or watching the show?  

DAVID HSU 52:29 

Yeah, you can put comments on MedHum, feel free. You can send us little notes about our discussion if you want. 

STUART HARMAN 52:43 

I’d love to hear what people thought of our take on the show and what their take on the show was. 

DAVID HSU 52:49 

Until then, until the next time we discover some medical humanities, pop culture thing that we need, Dr Harmon, we will bid adios. 

STUART HARMAN 52:59 

See you in Season Two, folks.