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Behind the Scenes of The Pitt: Depicting the Hard Truths
This discussion was recorded on May 7, 2025. This transcript has been edited for clarity. Robert D. Glatter, MD: Hi, and welcome. I'm Dr Robert Glatter, a member of the Medscape Emergency Medicine editorial board. Joining me today to discuss the new MAX docuseries, The Pitt , a depiction of daily struggles and realities of life in a busy level-one trauma center, are Dr Amy Ho, an emergency physician and member of the Medscape Emergency Medicine editorial board; Dr Nicholas Cozzi, an emergency physician and medical director of EMS and disaster medicine at Rush University Medical Center in Chicago; and finally, Dr Mel Herbert, an emergency physician and founder of a popular educational podcast known as EM:RAP (Emergency Medicine: Reviews and Perspectives) , a lifelong educator, and medical consultant for The Pitt as well as ER from the early 1990s. Welcome everyone. Amy Faith Ho, MD, MPH: Thanks for having us. Mel E. Herbert, MD: Nice to be here. Nicholas P. Cozzi, MD, MBA: Thank you. Making The Pitt Real: Accuracy in Every Hour Glatter: It's great to have everyone here. The Pitt , in my opinion, is one of the most influential and powerful series. It's so unique in that each episode is represented by 1 hour of an emergency department (ED) shift. That differentiates it from other past medical docudramas that you may have seen, such as ER . In reality, we know that an hour really passes quite quickly in any given shift. The show encapsulates the stressful clinical scenarios and interpersonal relationships that occur in any given ED shift, and it resonated with me and my colleagues. Mel, I wanted to get your feedback on how you chose to proceed with advising directors and producers on the show to provide real-world scenarios that could inform the audience, as well as emergency physicians, on how we manage complex situations, specifically families and bystanders, but also accurately depict how residents interact with other residents and attending physicians. Herbert: First of all, thanks for having me on the show. The Pitt has obviously become this huge hit, more than anybody — even we — expected. I have to give credit where credit is due. Scott Gemmill is the show creator and the show runner, and it was his idea to come up with this hourly format. He met with John Wells, the producer who did ER , and John was very clear and was like, 'We don't want to do just another medical TV show. We want to do the best one. How do we make it the best? How do we make it different? How do we make it real, but also entertaining?' That's when Scott came up with this idea that 1 hour of the show would be 1 hour of a shift. It was an incredibly insightful idea. The next person is Joe Sachs, MD, an emergency physician who has been practicing for 35 years. He was the main medical writer on ER , and he brought me in for the last six seasons of ER as a consultant. About 2 years ago, Joe said, 'Mel, we're going to do this new show. I think it's going be fantastic. Do you want to be a consultant again?' I'm like, absolutely. On that first season, I was consultant, and that basically meant that Joe would contact me multiple times a week, sometimes multiple times a day. We would go over cases and talk about how this case would really work out and what would be the dialogue between physicians, and he'd run stuff by me. For the second season, he said, 'That's great, but now I need you in the writers' room.' For season 2, I'm actually a staff writer and consultant with Joe, and that's been an incredibly fun experience. I've never really done it at this level — to be sitting there with the writers and actually, from day one, going through all of the cases. The key thing is to make it accurate. That's what we want to do. You can never be 100% accurate because it is still television, but we're making it as accurate as possible and the doctors, nurses, and everybody loves it. Many of them say, 'I can't watch it. It's too accurate.' Not Just Watching, Feeling It: The Catharsis of The Pitt Glatter: Many people are triggered by it, and my colleagues have talked about this. When they watch it, they feel like they're in it. Nick, let me bring you into this. Your article in Time was an excellent summary of the experience of so many of us, and you explain it as cathartic. I was hoping you could explain the catharsis and your thesis of your Time magazine article to the audience. Cozzi: Thank you very much for the opportunity to be here. Mel, congratulations, and great job on everything you've done, along with Joe Sachs, on The Pitt . Time magazine approached us with that thesis: 'We hear it's too triggering for emergency physicians to watch The Pitt . They feel as though they are back at work in the department, and they don't want to watch it.' It's not just emergency physicians, but anybody who works in the ER. They asked, 'Dr Cozzi, do you agree with that?' I said, 'No.' Just because it's stressful and depicts what is happening, we should not avert our gaze. We shouldn't shield our eyes. We need the entire healthcare system and the entire country's eyes on what is actually happening — the brokenness of our healthcare system and how emergency physicians and those who work in the ER each and every day are dealing with this struggle. That's where Time really understood what we were trying to do. More than anything, Mel, more than being accurate on a medical diagnosis, you pulled the curtain back and showed what's happening with hospital boarding. You pulled the curtain back to show what's happening with patients in the waiting room, with patients in the hallway, and with loved ones and members of their family. What we tried to do with the Time article was provide a way for the lay public to understand hospital boarding, to understand that it's not indifference from emergency teams, but it's the healthcare system pushing down on too few shoulders. Thank you, Mel, and it's a pleasure to be with you. Tugging at the Heart of Medicine: What You Do Matters Glatter: Amy, how did the show impact you and your colleagues? Did you feel that you were in it as you watched the episodes? Ho: I think so. I feel what Nick said and obviously what Mel said about it being so medically accurate. To me, the pieces that tug at your heartstrings are not the medical accuracy. To be honest, I was inspired to ultrasound more because I'm like, they ultrasound everything , I should ultrasound more . The parts that get me, my colleagues, and many women, especially, in medicine are the humanist pieces. I don't think this is a big spoiler, but there's a miscarriage of a physician on shift. The response that had from women who had the exact same experience — went to the bathroom, miscarried, popped back out, and saw more patients — was so true and is not talked about. It's those pieces of what makes emergency medicine special and what makes it hard that we don't talk about that The Pitt brought out and gave us the feeling like we were seen. The pediatric death was another incredible example of that. Mel, I have say that I'm a big fan of what you do and what you say on EM:RAP all the time—that what you do matters. The Pitt did an incredible storytelling of exactly that, of what you do matters. Glatter: The storytelling is so impactful. It really resonated with me to the point where you can't stop watching it. You go episode to episode because it's that hour-to-hour transition and you want to know what happens next. I do want to quote one of the paragraphs that Nick wrote in his Time piece. It resonates with me and hopefully with others: 'For an emergency medicine physician, a typical shift is a front-row seat to the worst day of people's lives — a whirlwind of drama, frustration, quiet victories, devastating losses, and unfiltered humanity. And then, it's onto the next patient's room to do it all over again.' That really resonated with me. We do it all again because that's our training. We're tired, we're fatigued, we're hungry, but we move on to the next patient. We're dedicated. I want to commend you on this piece because after watching the show and then reading your piece, it just really made complete sense. Cozzi: Thank you very much. I've heard from physicians around the country, and those in healthcare that, like Amy said, are 'feeling seen in a way that The Pitt depicts.' If my piece helps with individuals feeling that, it's a great honor. When I think about Noah Wyle, for example, being the star as John Carter in the 1990s show ER and now the burnished, seasoned attending physician later on in his career on The Pitt as Dr Robby, I think of the transition we're all making in our own lives, whether we were practicing back then or now we're taking on the next step of our journey. People who saw ER in the 1990s and now are watching The Pitt see somebody making that full circle in his own life. Teaching, training, communicating, but not being afraid of showing emotion and being a human being in unrealized or unimaginable situations. Amy, you brought up the loss of a child and dealing with a pandemic — themes that, for example, Mel on EM:RAP covered during COVID for emergency physicians. It wasn't triggering, but rather created a cathartic environment where emergency clinicians felt seen. In a way, Noah Wyle has come full circle in his role as an emergency physician and also has never lost sight of not only optimism and realism, but also being able to be a human being in unimaginable situations. On the Brink: A Character That Captures Us All Glatter: Mel, I'll commend you. Dr Robby's character is so well developed. He's on the brink every time and about to break down. He goes into a room, he's crying, and needs another resident to pick him up. That, to me, is emblematic of the system and where we're at. The emotional weight of what we deal with on a daily basis impacts us, and Nick's article points to that fact. The character development was very important here. I assume that you made that clear to the directors and producers. Herbert: Again, I have to give real props to Joe Sachs, who is really the guy when it comes to the medical stuff. Noah Wyle is one of the nicest human beings you'll ever meet. He is just a good person, and he cares deeply about emergency medicine. For his arc as an actor, the most important thing he ever did was be on ER . He's had physicians over the years come up to him and say, 'I became a doctor because of you.' 'I became a nurse because of you.' He really wanted to come back because physicians and nurses were coming to him and saying, 'We're in trouble. Emergency medicine is in trouble, we're burning out, people are dying. Could you come back?' That's when he got together with John Wells, Scott Gemmill, and Joe Sachs to say, 'Let's do this again. Let's do it right.' They wanted to depict what's it really like, not like on other TV shows, but what's really happening — the boarding crisis, the stress, COVID, the burnout that physicians are feeling, and the systems issues — and they wanted to make that real. Noah is such an incredible actor now. He was a pretty good actor back on ER, He is now the full professor of emergency medicine acting. He's so good. When you see that scene where he loses it, I think every emergency physician, myself included, has been there and are just like, oh my God, that's me . This theme we keep hearing — which is that for the first time, emergency physicians feel like they're being seen — is one of the most gratifying things. Family members can now look at the show and know what Dad or Mom does for a living for the first time. Will The Pitt Inspire or Deter Future EM Docs? Glatter: Amy, as residents and medical students are watching the show, do you think in some ways it might turn them away? The Match this year was very productive, but when you look at a show like this that depicts emergency medicine and what we deal with — obviously, there's positives and negatives with any specialty — do you feel that it has the potential to scare away some very promising residents and medical students? Ho: That's a great question. I'm a millennial so I was a bit too young to watch ER , and there were really no shows until The Pitt that were as accurate. I think The Pitt will have the effect that ER did, which is actually get people more interested in emergency medicine. You see what's really great about it, and you see the downsides of it, but it sparks something in us and what attracts us to emergency medicine. We want to make a change for the patient that is so vulnerable in front of us, that we're helping, but we also want to make a change for the system, which is oftentimes why we get so frustrated. The Pitt will help captivate the right people to go into emergency medicine, and in many ways, show an incredibly honest depiction for people who maybe thought they wanted to go to emergency medicine and didn't. Rob, you and I have talked about this on Medscape before. One of the biggest reasons for people leaving emergency medicine is because the field isn't what they thought it was. The Pitt helps give you really honest story of what you're getting into. It's incredible. Yes, it's hard at times, but you can make a difference. Pulling Back the Curtain on a Broken System Glatter: It's dedication. In his 2022 article in The New England Journal of Medicine , Walter O'Donnell talks about administrative harm and the systemic issues. Addressing administrative burden is certainly relevant here. The show opens up the whole hornet's nest on what really is going on — a broken system, Nick, that you write about, the boarding crisis, the shortage of nurses — things that have to be addressed that are still not being addressed. When I started practicing, these issues were there. They still have not been handled. Why isn't there a larger movement to address the systemic issues so that personally, individuals can survive? How do we fix this broken system? What is the real key to finally gaining traction? Cozzi: That's an excellent question. I think about the most common questions people are asking me about The Pitt . They aren't, 'Can you really do a burr hole with an IO (ie, an intraosseous device)? Can you do that type of procedure? Is that accurate in terms of a cardiac arrest?' What they're asking me more often than not is, 'Is that what it's really like trying to save someone's life, and a hospital administrator is asking you about patient satisfaction scores?' Is that what it's really like when you try to take care of a patient and there's no beds upstairs that have nursing staff assigned to them?' That to me is fascinating because that's the first step. It's getting the general public to understand beyond the resuscitations, and beyond the complex saving of lives. It's making seen what is very complex and has been behind the barrier. When patients come to our ER, as Amy, you, and Mel know, and they see that 14-hour wait, they don't understand. They think it's indifference. They believe it's because we're not taking care of them. This is trying to unlock that door so people could see the systemic issues that, for a long time, had been behind the curtain. The first step is the public understanding how broken this all is — the mismatch of finance, the mismatch of allocation, and the value-based system that we're not having right now. How do you have a complex conversation about hospital boarding that isn't throwing facts at people, but in a way of putting yourself in that position if you're the family member with your loved one in the hallway and you're not seeing them being taken care of? That's the first step. That's what The Pitt does differently than any other show is that they're talking about those issues —staffing, nursing shortages, and the boarding crisis — in a way that's palatable and can be received by the general nonmedical public. From ER to Capitol Hill: Educate, Advocate, Legislate Glatter: Amy, on a congressional level, is there any way to address what Nick is pointing to? There needs to be systemic change, legislative changes, not just at the state level but really at the national level. Ho: Absolutely. Nick makes a good point that the first step is to educate. Educate yourselves, voters, patients, and anyone in the healthcare system, which is really all citizens. The second step is advocate. We have multiple national organizations — the American Medical Association, the American College of Emergency Physicians (ACEP) — and most of them are very involved in the boarding crisis. There is a boarding summit. Multiple states have passed various legislation about boarding and wait times in EDs. There is always discussion on Medicare reimbursement. There's always discussion on value-based programs, including the Merit-based Incentive Payment System (MIPS), on which ones matter and which ones are just administrative burden. There are many national health care safety scores like Leapfrog, which is really incentivizing for hospitals to address. All of these are avenues to advocate. You can advocate by voting. You can advocate by getting involved with your organization. You can advocate by just speaking. This is the age of social media where you can talk about it. We're starting to see changes. The National Boarding Summit had multiple, very discrete recommendations. Leapfrog just added ER boarding onto one of the tenets that they're trying to get data on to help rank hospitals. We're seeing a move because people are getting educated and then advocating. Telling the Truth, So Change Can Begin Glatter: Mel, have you seen any changes as a result of your national involvement in a show that's become such an impactful type of experience for not just physicians, but for the public? Herbert: The answer to that is yes, because of what's happening right now. Noah, Joe, and I are constantly trying to write, and in between the writing, we're talking to people across the country and across the world. It's elevated this discussion and that's the most important thing. We are not saying what the solution is. There are people with degrees in this who need to come up with these solutions. If we can show exactly what it's like, how bad it is, and how close it is to falling off the cliff, then maybe people like Amy can help us push it across the line. We don't have the solutions, but we can tell you what the problems look like. I was just interviewing Al Sacchetti, David Schriger, and Peter Vicellio— three legends in our field — and they had very different ideas about what to do. Some of them were saying we should go on strike; the only way this is going to get fixed is if we make a crisis and we fix it. There were other guys like Al Sacchetti, who was like, I can't do that . I have to look after the patients. I can't not be there and do this . Part of the problem is that ER docs will always try to fix the problem. We will always go into the waiting room and try to go as fast as we can to help people. That is actually not going to fix the system. We need somebody from outside to say, 'You're going as fast as you can. We need to get you help.' If we can use this show to tell those stories in Congress or wherever it needs to be, have at it. 'It Is Normal, but Not Acceptable': Violence in the ED Glatter: One thing I want to focus on is violence against healthcare workers. There's a scene where the charge nurse gets punched in the face by a patient who retaliated for a long waiting time. That resonated with so many of us because it's happened where I've worked and I'm sure where many of you have worked. How did you set that scene? What was in your mind and how did you approach it? Herbert: Again, that's all to Joe. You need to know that Joe was my attending at UCLA when I first got off the boat from Australia. I love Joe. It was him and the writers sitting around like, what are the issues? Workplace violence was one of the top issues to talk about. There was a study that came out that reported that, for ER nurses, about once in every three shifts, there is violence against them, either verbal or physical. I think it's about three times a shift, depending on how you define it. It's really a problem. During COVID, it became worse. There was this weird thing where people would stop believing in science and stop believing in doctors, but then when they were critical, they would come in, ask for their ivermectin, and would be outraged when you said, 'That doesn't work. Let's try and help you with stuff that does work.' It has become an epidemic. It was always bad in emergency medicine. As Nicholas pointed out, we get to see people on their worst day. We get to see all of the problems of society filtered to the ED. Violence is a big problem in this country, as it is in many countries. Guess where that all comes to? It comes to the ED, and it is often then displayed against emergency physicians, nurses, and everybody that works there. It is a crisis. I got an email recently from somebody saying, 'Please be careful about how you depict this, because we don't want people to think this is normal or it should be acceptable.' Unfortunately, it is normal. It is not acceptable. Glatter: Absolutely. it is not acceptable. We can't normalize it, but we have to depict it. Unless you show the public what's truly going on, they won't understand. As emergency physicians, we get it, and we have to put a stop to this. Legally, I believe it is a felony for attacking a health care worker. Is that correct? Herbert: It's state by state. Arizona has a very strong rule. One of the things that we do on The Pitt is we bring in experts to talk to the writers within the writers' room. There is legislation in Arizona, for example. I don't know exactly what this legislation passed, you got in more trouble for kicking the neighbor's dog than for punching the ER nurse, literally. In Arizona, they've passed these laws, and there are many more laws in other states that are working their way through the system, which as we all know is quite slow. We need things like that, and it needs to be very clear. Just because you're pissed off, angry, and have waited a long time, violence is no way to get this fixed. You could be in big trouble if you pursue that. Glatter: Absolutely. Nick, in your ED, are you seeing quite a bit of violence against healthcare workers? Cozzi: Every day, whether it's physical violence or the violence that Mel so eloquently stated is happening. Perhaps gender-specific differences, with women being more likely to experience that violence, suggestive comments, and things of that nature that are being underreported. Mel answering that person's letter, saying that it is normal but not acceptable is absolutely the right solution. I think back to Time in the early 1990s. They had a cover article that said the ED is at the brink. We're in 2025 and the ED is still at the brink, but it's worsened because of the social issues that we're talking about. Healthcare workers and those in the ED did not choose law enforcement. No one should feel unsafe going to work every day that their lives are in trouble. We had an emergency physician in Chicago that got stabbed in the chest during a patient encounter a few months ago. Luckily, he survived, and I understand he's doing well. That's just one story of so many. We see it every week and every day around this country. There has to be an opportunity. I'm very thankful that the airline industry has found the opportunities to understand the violence happening on airplanes or in airports, and how those individuals are being dealt with in a very firm fashion. If we're bound by the Emergency Medical Treatment & Labor Act (EMTALA), a federal mandate to evaluate anybody who walks through our doors, then there should be federal things on our books to be able to protect our workers, with caveats for those who do not have medical decision-making capacity and those experiencing crisis in different ways. We have to find unique solutions, and this is one of the areas that I think is different from the early 1990s because of the way society perhaps has caught up. We can't waste this moment that Mel, Joe, and Noah have provided us at this time. Glatter: I agree. Amy, any thoughts you want to add to that? Ho: Workplace violence is a huge problem, extremely common, and rampantly underreported. Luckily, the majority of states have a felony or some kind of zero tolerance law, so this is an instance where advocacy has really worked. The piece that The Pitt really helps with is people who are angry because they've been waiting, and they think the charge nurse, the attending, or whichever staff member is representative of that and part of that. What the Pitt does beautifully is it divorces the staff, who are just as frustrated, from this concept of the system. Since The Pitt came out, I've already had patients that I see in the ED, where they'll be in the hallway and will tell me, 'Wow, this is just like The Pitt,' and they mean it positively. They are in a hallway bed and they kind of understand why in a way. They're not mad at me, which is this change that I've really seen since the show came out. That's been an incredible testament to what it means for not only us in the field, but also for laypeople in understanding what is healthcare today. Tough Training, Tender Tensions: The Struggles of Residency Glatter: One last thing I do want to discuss is how residents relate to other residents. This was depicted in the show — showing toxicity, microaggressions, and other things that were tolerated. This is an area that was well documented in the show, Mel, and is so important to highlight. Herbert: Residency is hard. You just think about these poor young adults who have gone through high school and achieved at the highest level. Then they go through college, achieve at the highest level, then go through med school, achieve at the highest level. They have hundreds of thousands of dollars' worth of debt and then they do residency, and they're sleep deprived and shifting from days to nights. It's a very difficult job, and trying to depict that is really important. My experience, though, is that residents are really good to each other. In general, overwhelmingly really good to each other. There are some that sort of crack. When you see that resident that's having these microaggressions toward other residents, your first thought should not be that this is a bad person. Your first thought should be that this person is struggling. How do we help them? It is a very difficult thing. At LA County years ago, we did a snap survey of over 60 residents, and 30% of them had had suicidal ideation in the past month. Just think about that — 30% of them. It's a tough job. I think residency directors are much better now than they used to be about understanding the mental health of the residents and being much more in tune with it. I hope that comes through in season 2. Unpacking the Backpack: Why Every Emergency Physician Needs Support Glatter: Absolutely. We're looking forward to that. Amy and Nick, I want to get your thoughts about mental health in your EDs. How is that approached, and is there an acute awareness as Mel is describing? Ho: Every person that goes into emergency medicine, just like any person, has their own demons. What emergency medicine forces you to do is it not only puts you in a pressure cooker just by the setting, the time issues, and many frustrations, but oftentimes it puts you face to face with some of your own weaknesses and some of your own fears. It's very obvious in the show when a resident is triggered by something that she clearly experienced in her own life, and now a patient is reflecting back to her something that she herself had been extremely traumatized by. We all have that. One of the most interesting things to me is that we also all develop a callus to it. In order to be able to move on from a devastating trauma in a room into a low-acuity knee sprain or something similar, and put on a happy face and think about patient satisfaction, our ability to emotionally task switch like that is very unnatural. It's a defense mechanism we come up with, which means that when we leave shift, often times we take that emotional whiplash and we just put it aside. As Nick was saying, maybe this is why people can't watch it. In many ways, what's best for us is to stop, reflect, think about it, and honor the feelings that you had in that moment. Even though you had to put them aside so you can keep working, come back and honor those feelings so that you can process them and realize that being a person and being human is what also makes you a great doctor. Don't get rid of that. You see that with so many of the characters in The Pitt in a way that is just so beautifully written because in different various stages of my life and of my training, I have experienced those exact same iterations that the different characters go through. Cozzi: I remember when Damar Hamlin had a cardiac arrest on the Buffalo Bills field, and 50,000 people saw him in cardiac arrest and the excellent display of medical teamwork and communication that ultimately saved his life. We talked about the psychological impact of every one of those individuals in the stands, and we're not minimizing that. What they saw was a traumatic event, but like Amy eloquently discussed, that's something that happens every day and the ability to task switch is a defense mechanism. There are still opportunities for us to do much more when it comes to mental health. We're still looked at as superheroes, but we're not. We're human beings. We bring our own issues into work every day — struggles with our spouse, difficulties with our own children — that are traumatizing to us in and of themselves. Second, there are still areas around the country for credentialing that are mistreating emergency physicians as it relates to mental health struggles and being on prescription medication, and we have to make that okay. We can't make emergency physicians want to hide the humanity of their own lives because they feel ashamed about it. That's part of the problem. I wonder, Mel, what we would do right now if we asked emergency physicians in training, or even those practicing, what the rates of self-harm, suicidal ideation, or just overall fatigue as it relates to dealing in this own crisis, having your own issues, and having to hide them. We have to do more work. Herbert: I can tell you that every emergency physician I talk to is burnt out, is feeling the struggle, and has moral injury. I've talked often about the fact that I developed severe depression and suicidality at the end of my career. I had to get ketamine and it really helped. I don't like to talk about it because of my position, but I feel like I need to talk about it. When I go to ACEP, I get overwhelmed with people saying, 'Thank you for talking about that. I have the same thing. I need to get help.' It's underrecognized and we don't want to talk about it. We're supposed to be superhuman, but we are not. I was talking to the Lorna Breen Foundation yesterday, Lorna Breen, as many as you know, was an ER doc, the head of her department, who died by suicide at the beginning of COVID because she couldn't cope. W e talked about the fact that ER docs have this backpack, and we throw these things into the backpack. Dead baby? Let's just throw that in the backpack. A 32-year-old woman dying of cancer? Let's just throw that in the backpack. If you don't unpack that thing, it will catch up with you. Nobody gets away from this. For many of us, like for my generation, you just chuck it in the backpack. Let's not deal with that. It will catch up with you. I honestly believe that every ER doc and every ER nurse should be in some form of therapy for the duration of their career, from day one until it's over, and then for 5 years afterward, because this is not a normal job. It's not normal. Glatter: Therapy is so critical. It's not just a debrief or a huddle after a difficult case. It goes deeper. I agree with you, Mel, that therapy should be something that is almost required because of the nature of the work we do. We have to be able to talk about it and to at least describe our struggles. I appreciate you sharing with our audience your personal journey and struggles because that resonates with all of us. I truly appreciate that. Herbert: This is the most important thing to me right now. I see so many ER docs struggling, and I don't know an ER doc that doesn't have a dead baby story. I, for years, still can see the faces of the kids that have died on my shift. Even now, you can hear it in my voice. It doesn't go away. You just have to learn to cope with it and get help if you need it. We're all the same. We have all got this experience. If we all get therapy, and this is a really important point, if it's mandatory that we are all in therapy and we're all getting help, guess what? The stigma's gone. Even if you're mandated to write something about that on your credentialing, if we all do it, we're done. A Final Word: Seeing Ourselves Through a Different Lens Glatter: I want to thank everyone for a very impactful and very insightful discussion. These topics are obviously so important to emergency physicians, and they resonate. The show is such an important teaching tool, in my opinion. In season 2, I'm looking forward to seeing what struggles and what events happen because based on season 1. It really will provide a real good springboard to go forward. Any other final thoughts? Herbert: I've got one to tell you. I'm very excited to tell you that Noah Wyle and Joe Sachs are coming to ACEP. We're going to do a little panel after the keynote where we'll take questions from the audience, and then Noah is going to walk around a little bit in the trade area. It'll be an opportunity for people to talk to the real geniuses behind the show, including Noah and Joe, and there are many others. If you can make it, it's on September 7 at around 10:00 AM MST. Ho: I'll say coming off a late shift to do this on a fairly early morning, it is worth saying that what we do, to us, loses the shininess because we do it every day. It feels routine. To be able to see ourselves the way other people see us, which is that it's a little crazy and erratic, but boy does it have really great and long-standing impact. Remember that as you walk into your next shift. Cozzi: Echoing that, it wouldn't be my final word, it will be Mel's final word — what you do matters. I think this eloquently displays that. Glatter: Excellent. Thank you all again. I truly appreciate your time. Many thanks. Robert D. Glatter, MD, is an assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is a medical advisor for Medscape and hosts the Hot Topics in EM series . Mel Herbert, MD , a professor of emergency medicine at the UCLA School of Medicine, is widely recognized for his innovative spirit, global impact, and commitment to education. He is the founder of EM:RAP , a pioneering medical education platform, and EM:RAP GO , a nonprofit organization that delivers free emergency medicine education to clinicians in more than 160 countries. A passionate advocate for making excellence accessible, Herbert explores this theme in his book, The Extraordinary Power of Being Average . Beyond the clinical world, he has lent his expertise as a medical consultant to television, including the iconic series ER and the current Max original The Pitt . Nicholas Cozzi, MD, MBA , is an emergency physician, EMS medical director, and assistant professor at Rush University Medical Center in Chicago, Illinois. He is a co–course director for Practice Essentials of Emergency Medicine and leads several key modules, including reimbursement and operations. Cozzi is dedicated to expanding access to business education for emergency physicians and cofounded the Health Careers Pipeline Program, which has helped over 130 Michigan high school students pursue health careers.
Medscape
13-05-2025
- Health
- Medscape
Running the ED Like a Pro: Your Residency Playbook
This transcript has been edited for clarity. Robert D. Glatter, MD: Hi, and welcome. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today to discuss tips for success in emergency medicine (EM) residency is Dr Amy Ho, an emergency physician and also a member of Medscape's advisory board. Welcome, Amy. It's really great to have you join me. Amy Faith Ho, MD, MPH: Thanks again for having me, Rob. Glatter: Preparing for success in EM residency requires careful planning, especially in the age of a plethora of informational apps and digital technologies that we all know about. It also involves anticipation of the needs of patients, finding hacks to maximize efficiency, and most importantly, developing a great rapport with all members of your team and your emergency department. There was a recent Reddit thread that my editor, Anya Romanowski, had sent to me, and it brought back thoughts of our prior interviews in which you had explained MacGyver-like techniques as approaches to patient care challenges in the emergency department. I was hoping you could share a list of procedural and informational approaches and hacks to help ensure success for those entering EM residency, in the spirit of MacGyver and also the Reddit thread. One of the first things you and I had spoken about is that EM is a team-based have to treat your team well. I'll let you go from there. Teamwork Makes EM Work Ho: Absolutely, Rob. I love this topic because it's really the art and the style part of being an EM physician. You mentioned this is great for residents, but I think it's great for anyone practicing EM, not only residents and not only if you're new at a job. You're totally right. EM is a team-based sport. On the Reddit thread that you referenced, the number one tip was not something medical at all, but it was 'Definitely don't date your coworkers,' which I'll not comment on. I do think there is a large amount in terms of the team. Know who your team is and respect them. Introduce, acknowledge, and thank everyone, and try to learn their names. This isn't just your nurses and technicians, but also scribes, chaplains, the radiology technician, environmental services, and the police. There are so many people we depend on, and it means so much to acknowledge who they are. With that, it's not only acknowledging them, but also helping with all tasks. Nothing will fail you more in a department than the attitude of 'not my job.' Help roll and transfer patients, clean up if you have time, and always clean up sharps yourself from any procedure you do. That is just the fundamental safety point. Knowing Names and Pitching In Glatter: You mentioned knowing names. Obviously, we all forget names, but knowing someone's name is very personal. When you know their name, it makes them feel better and shows respect. It shows that you're focused, and I appreciate you pointing that out. Ho: Absolutely. Knowing what the team members bring to the table, being willing to help, respecting them, even learning parts of their trade and helping. Like I said, rolling, knowing how to turn off the beeping monitors and drips, getting a sandwich or a blanket for patient. It's really about being considerate. Glatter: It's not that it's not your job. Everyone pitches in, and when that happens, team building occurs naturally. Ho: As you build rapport with your team, you just start to know how you practice, you know how they work, and many things just become natural. One of my big things is doing sensitive exams for patients all together. As the staff get to know me, they know that if we're going to do a pelvic, we'll all go in together, we'll knock it out, we'll be done, and then the patient also only has to do it one time. Utilizing Apps Can Significantly Improve Workflow Efficiency Glatter: Moving on to apps. The number of apps is just exploding by the week and by the month. I would love to know what you think are the best apps going into residency, and for attendings as well. Ho: There are so many apps out I trained, we had numerous cards, which we would have on our badge tag, ready to use. These days, who doesn't have their phone on them at all times? Apps are only as good as you know how to use them. I've broken this down into the apps I think are key. One is MDCalc, because we are the specialty of knowing very little and trying to risk stratify. I think MDCalc is so core, but you have to know which tools you use and when. Second, I think you need one core EM app. There are many of them. There's EM-RAP Core Pendium, there's palmEM, and there's WikEM. I suggest to try them out, see what's natural to you, and then just commit to that one. Third is an electronic health record (EHR) app. For example, Haiku for Epic, It's key to your workflow for adding pictures, looking at the board, signing orders, and so on. It's also worth talking about artificial intelligence (AI) apps (eg, ChatGPT and OpenEvidence). We literally have intelligence at our fingertips now to ask any question of, 'Hey, what's the workup for X, Y, or Z?' Of course, do not share personal health information (PHI), but AI is really the future for references. Lastly, our special EM apps (ie, Emergency Ultrasound Handbook, epocrates for meds, UpToDate, Full Code, and Pedi STAT). There's a handful that might be really relevant to your practice. So, just pick which one those are and again, get familiar with them. AI Tools Are Becoming Integral in EM Glatter: Do you find that your residents are starting to use more AI right now in terms of that immediacy and being able to get answers? Are there too many hallucinations you're seeing from the AI in reference to, say, more specific things in EM, or more nuanced things that AI hasn't yet caught up to? Ho: Absolutely. I see residents using AI often. I think the big danger is that, especially if you are a new resident, you haven't built in the gestalt to be like, wait a second, that doesn't feel right . I do always say for anyone, but especially residents, take it all with a grain of salt. Anything that you're going to act on needs to be cross-referenced yourself manually to make sure that is actually true, and again, not a hallucination. I feel like, as an attending, having AI as a reference is great. I'll read something as a response and be like, yep, that totally cues . I just couldn't get it at the tip of my tongue . Efficiency Hacks: Templates Now, AI Tomorrow Glatter: You made a comment about discharge instructions that, if you're typing them in multiple times, you need a template. I'll let you expand upon that. Ho: I'm actually an informaticist as well as being an ER doctor, so I love efficiency and workflow. Anything you're typing or clicking more than three times (eg, discharge instructions), you need to save as a template such as RICE. Favorite orders or order sets with the instructionsand the dosing, you need to have saved as template. Same for things such as medical decision-making (MDM), if you have common differentials you always use for certain chief complaints, and for history of present illness (HPI), because we do ask the same questions over and over. I think all those just let you fly out of notes in like 60 seconds. Glatter: In terms of scribes, I don't know if you work with scribes or even if AI now is integrated into your EHR, but things are changing quickly. Scribes had been the advance in the last decade, but AI now is coming into the forefront. It's not ready for prime time in my opinion, but maybe 10 years from now there may be a role. How do you see the role of AI in EM as sort of a hack? Ho: It absolutely is a hack. I think it'll be faster than 10 years. I think in 3 years, we will all be using AI. I know many people using AI scribing platforms. There are ones that are released by EHRs. There's Abridge, which I think is one of the really common ones. Not only do they help you in terms of scribing, but they also offer you some MDM. They give you pearls to look for. You can customize them for cues for yourself. They're incredible and will likely be a key part of residency soon because you have to know how to use these tools. I will just say, please do not use those tools without the explicit approval and rollout by your hospital, because that is all patient data. Using Ultrasound to Engage Patients and Speed Diagnosis Glatter: You talk about using the ultrasound machine in the midst of doing a physical and multitasking in this capacity. Sometimes it's difficult to do, but what's your hack for doing that? How do you do these things all together? Ho: I love ultrasound, as do most EM physicians. I make sure that I actually do the ultrasound as I'm talking to the patient. They love it. I show them what I see on the screen, and it gives me some immediate answers on what's going if I see cholecystitis, I already know the answer. Staying Prepared: Keeping Essential Supplies Within Reach I think also keeping equipment nearby is key. In general, I always have a flush and an IV because you never know when you're going to do an ultrasound-guided IV. At the beginning of shift, I'll grab one of these big pink buckets and just fill it with the suppliesI think I might need. For example, bandages, if I'm working in urgent care area. If I'm working trauma, I'll have Dermabond and all the common things that I might want for that shift, and having it near so I can just grab it and go. Anticipating Needs: Preparing the IV for Seamless Care Glatter: If you spot a patient who has poor access, why not put the ultrasound-guided IV in ahead of one of the residents or nurses and just save time? That's an aspect of team building that I see working in the department. If you're going to go ahead and be proactive, that says something about you. Ho: Absolutely, and it's good for the patient. It decreases pokes and it is procedurally amazing for getting good at central lines, too. Fighting Anchoring Bias: Stay Open-Minded Glatter: In terms of anchoring bias, we have kind of fallen victim to this at times. It's hard to fight this. You think something is quite obvious, but it may not be obvious. How do you deal with anchoring bias, specifically? Ho: This was one of the arcs that I felt like I really went back and forth on in residency. There were times when I wanted to chart review everything before seeing the patient. There were times when I chart-reviewed nothing and just went and saw the patient. What I settled on is doing a really light chart review. I read the chief complaint, I look at vitals, I look at meds, and maybe their last office note. I already know that I might've been anchored by a nurse, especially an experienced nurse in triage, on how they write the complaint. So, I just keep that in my mind. If the patient says something that doesn't quite sound like what the nurse documented or what's documented elsewhere in the chart, then I try to explore that so that I mitigate my own anchoring bias. Avoiding the Nastygram: Staying on Top of Core Measures Glatter: I wanted to talk about nastygrams because you brought those up for the core measures. What's your approach in terms of avoiding the nastygram? Ho: This was always what I found most demoralizing. I'd work a busy shift. I'd feel great about seeing a sick patient, and then the next day I would get the nasty email from the quality department that said, 'Hey, you missed sepsis by50 cc.' It was soul crushing. It's really important to identify at your facility what those big core measures are that are going to get you into trouble, whether it's sepsis, stroke, STEMI, trauma, or open fractures. Those tend to be the big ones. Then I constantly think about it when I'm running my list. I look at the sickest, and then I look at the things that are in this nastygram bucket. Then, I look for all my other to-do's, things that will move dispositions, and so on. The Human Side of EM: Navigating Family Conversations in Crisis Glatter: How do you multitask and deal with a family member when you have a sick patient? Do you tend to bring in the resident or a nurse or someone from the social work team that could help a family when you're in the midst of a crisis? How do you nuance that? Ho: I'm with you. There's a large amount of nuance there. I do always bring a social worker, case manager, or chaplain to help because there's so much support that's needed. This is the human side of EM. We are not just 'moving meat.' We are really helping save lives and give support to families. There are some conversations where it really should take as long as it needs to take. Telling a family about a bad outcome is something where I actually give my phone to someone else before I come in the room. I tell them to come physically grab me if they need me, but I need to spend as much time as this family wants from me. There are other times when you are going to bounce between rooms. That is part of what you learn in residency, and you'll pick up what resonates with you as your style, too. Glatter: One of the things I was taught is that sitting down in a chair really helps, too. If you consult a patient in a chair vs standing, there's a big difference. Ho: Sitting in the chair is probably the number one tip we get from a patient experience standpoint as well. We do not always have chairs in emergency departments though, so I am known for sitting on top of trash cans often. Getting on the level of the patient or the family that you're talking to slows you down and puts you in the moment at a time when you really should be in the moment, Glatter: These are serious issues. If you spend that extra minute at their level, they feel something. Your energy is there, and that you're relating to them. That really is worth a mountain of gold. Ho: It's worth noting that we go into the ER every day, every other day, or whatever it is that our shift schedule is. It's normal for us to be there, but for most people, they probably don't go to the ER but maybe once in a lifetime. It is an extremely important, vulnerable moment for them, and you're the one that is supporting them through it. Documentation Is Crucial for Legal Protection and Continuity of Care Glatter: Are there any additional things you'd like to bring up that you feel that merit discussion at this point? Ho: Document well. Document what you said, document what the responses were, document what consultants said, their names, and what family members said. It's not only a medical legal thing, but it also is a document that you're passing on to the next clinician that sees the patient. For me, it actually helps me work through that thought process. Don't shortcut your documentation because of time. Sometimes it really matters. Glatter: What about copy and pasting? This has always been a big issue that I've faced. Obviously, it goes on. Medicolegally, there can be some aspects to this, too, because of things your recommendation? Ho: I usually do not copy and paste, because you run yourself into trouble. However, I do believe in templates. On those templates, I leave many clear blanks where I think I shouldcontemporaneously free text what it is that's happening. 'Note bloat' is real. Also, copy and paste is hard to review sometimes. If you are copy and pasting, maybe that information is not that important, and maybe it already exists somewhere else. So, I really like to spend my time on the free text part of it, such as the MDM, the real-time changes in emergency department course, — those sorts of things. Running a Smooth Procedural Sedation: Break It Into Pieces Glatter: One last thing I wanted to talk about is procedural sedation. We've all had a busy shift where we have a patient with sepsis, a shoulder reduction, or someone who's screaming in pain. We want to get them medicated, and we want touse techniques that maximize our time. We may not need a full procedural sedation. There are other hacks and techniques. Ho: Something like procedural sedation is the definition of a team sport because there are many moving parts. I try to chop these longer procedures into pieces. Piece one is getting all your orders, getting all the consents in, and all the medications. That can happen really anytime as you're running between other patients. Piece two is getting all the human resources together. That's when you're about ready to start respiratory therapy then x-ray after. We always forget about x-ray. Splinting, so maybe having a technician ready to help you in case you have to run out. And, obviously, nursing and pharmacy. The procedure itself doesn't take that long. You push medicines, you do your procedure, and you get your confirmatory x-ray. You splint them up, which you can have someone help with, but you need to be in the area in case there are any complications. What I do is I try to save my charting to come up to that point, and I'll grab a mobile computer or just be on the computer right outside the room and work on all of my charting. I still need to be within earshot and eyeshot of the patient while the nurses and the rest of the staff help them,as they're finishing up the splint, coming out with sedation, and those sorts of things. Ordering an X-Ray Remains the Standard of Care Glatter: Would you ever use ultrasound in place of x-ray to save time and confirm that the joint has been reduced? Ho: I actually do love using ultrasound, but I think standard of care is still an x-ray. For me, I personally still always wait for the x-ray. I make sure that I ask the technicians to be right there as I'm doing the procedure so we're ready to go with the board in place and everything else. Glatter: This has been an excellent tutorial from an expert like yourself who is very seasoned, efficient, really knows the hacks, the apps, and the ways to relate to patients. I want to thank you so much for joining me and sharing your knowledge. Robert D. Glatter, MD, is an assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is a medical advisor for Medscape and hosts the Hot Topics in EM series .
USA Today
07-02-2025
- Health
- USA Today
Flying with an infectious disease in 2025: Do's and don'ts
Flying with an infectious disease in 2025: Do's and don'ts Show Caption Hide Caption How airlines keep flights running smoothly during winter storms What airlines do to prepare for winter weather and keep passengers safe More airline passengers are choosing to fly while sick, raising concerns about the spread of infectious diseases. Experts advise seeking medical advice if feeling unwell before or during a trip and recommend travel insurance that covers illness. Passengers seated near someone who appears sick should consider wearing a mask, using hand sanitizer, and requesting to be moved if uncomfortable. On a recent flight from Charleston, South Carolina, to Newark, Sukrut Dwivedi noticed a passenger a few rows ahead of him coughing violently and uncontrollably. "The man appeared feverish and kept reaching for tissues," said Dwivedi, a physician who works for ID Care, an infectious disease care provider. "I could see the passengers around him were very uncomfortable." With flu season taking off, you might find yourself in a similar situation soon. Maybe someone seated near you looks sick. And maybe you're wondering what to do about it – or if you can do anything at all. Check out Elliott Confidential, the newsletter the travel industry doesn't want you to read. Each issue is filled with breaking news, deep insights, and exclusive strategies for becoming a better traveler. But don't tell anyone! I'm not going to mince words, folks: If you fly when you have an infectious disease, you win the award for the biggest jerk on the plane. You're worse than the negligent parent with the toddler running free on the plane, worse than the honeymooners trying to join the Mile High club – worse, even than the whiny elite-level frequent flier in business class who calls the flight attendant "honey." Your negligent actions could literally kill someone. "Staying home could save the life of a baby, young child, or older person who is immunocompromised, is undergoing chemotherapy, or is not up to date on important vaccinations," said Robert Glatter, an emergency medicine physician who is also an editor at large at Medscape Emergency Medicine. You'll be needing a vacation from your vacation if you're traveling like this Everyone hates tourists: Here's how to be a better traveler More airline passengers are flying sick Here's what Dwivedi did when he saw the sick passenger on his flight: He offered the coughing man a face mask, which he "gratefully accepted." "The passenger confessed that he had been diagnosed with the flu the day before," he recalled. "But he felt compelled to travel for work." With memories of COVID-19 fading, people like Dwivedi are concerned that too many passengers are flying with an infectious disease – perhaps more people than at any time since the pandemic. Under current disability rules, airlines can only remove a customer if they present a "direct threat" to the safety of the passengers and crew. New government regulations, set to go into effect in April, will require airlines and ticket agents to issue non-expiring travel credits if passengers are restricted or prohibited from traveling because of a serious communicable disease. But that wouldn't stop someone like the Influenza Man from boarding his flight. It's not always that simple Reality check: Things can get complicated when you're traveling. For example, deciding to postpone a trip if you get sick before your flight may be a no-brainer. But what if you get sick when you're at your destination? And what if you don't have the resources to extend your hotel stay? All the experts I spoke to seem to agree on this: If you think you might be contagious – even on your return journey – seek the advice of a medical professional. Sometimes, it might be fine to fly with a face mask, but ask a doctor and don't assume you're OK to fly. There are two things you can do to avoid flying while sick. First, ensure that you have a travel insurance policy that covers you if you fall ill. "Insurance to cover hospital bills is essential," said John Gobbels, chief operating officer of air medical transport and travel security program Medjet. But insurance can also cover a hotel if you become ill or have your travel interrupted. (For more serious problems, you may need a more robust medical evacuation membership like Medjet.) And you should also travel with a basic medical kit. It should include hand sanitizer, tissues, over-the-counter medications for common ailments, and a few disposable masks, according to Eugene Delaune, an ER physician and senior medical advisor to Allianz Partners. "Treating your symptoms not only helps you feel better but also reduces the risk of spreading the illness to others.' Travel fakes exposed: Simple steps to protect your trip – and your wallet I travel nonstop. Here are 5 places you can't miss in 2025. What should you do if you feel sick before your flight? If you don't feel 100% before your flight, see a doctor, for goodness' sake. 'If you have any signs or symptoms of a possible contagious ailment, you should be tested prior to traveling," said Jeff Weinstein, the medical operations manager for Global Rescue. "It is impossible to tell the cause of your symptoms without the appropriate testing." And if you are sick, ask your doctor to recommend your next steps. "But if your doctor advises against travel, heed the advice," said Bob Bacheler, managing director of Flying Angels, a medical transportation service. (This is also important if you need to file a travel insurance claim.) Bacheler said the best way to avoid the question of: "Am I OK to fly?" is to take all necessary precautions. He's taken the flu vaccine every year for the last 30 years, and he gets a COVID booster whenever it's available. He also takes sensible precautions when he flies, like avoiding crowds and not touching surfaces that might be contaminated (he travels with disinfectant wipes). What should you do if you're seated next to a sick person on a flight? If your seatmate looks unwell, I think you have a right to know if you're going to end up in the ER after the flight. So striking up a friendly conversation and maybe an "Are you feeling OK?" is a good idea. Raymond Yorke, a spokesman for Redpoint Travel Protection, said Dwivedi had the right idea. During the peak of flu season, you should wear a mask on the plane – and bring extra ones. Hand sanitizer is a must, too. And share. "Wearing a mask and practicing proper hand hygiene can help minimize the risk to others," he said. "This has become an expected practice post-pandemic." But what if the passenger next to you won't talk to you and tells you to mind your own business? I've seen that as well. In that case, asking a flight attendant to move you might be the best solution. If the passenger is sneezing and wheezing uncontrollably, you may want to privately ask a crew member if they would consider removing the ill passenger. Remember, this person is a selfish moron for flying sick. What's the solution to people flying while infected? The solution to people getting infected on a plane isn't as simple as sick people refusing to fly. There will always be selfish knuckle-draggers who fly even when they could infect the entire plane. The government took a necessary step by requiring airlines to issue flight vouchers to infected passengers starting this spring. But it's not enough. The only way more travelers would cancel their plans is if it didn't affect them financially. That's right – airlines would have to refund the entire ticket if passengers get a doctor's note. Some forward-looking, compassionate airlines already quietly do this for passengers on a case-by-case basis. But it needs to become a formal policy so passengers can safely cancel their flights when they fall ill. There's no telling how many lives this policy would help. But even if it saved just one person, wouldn't it be worth it? Christopher Elliott is an author, consumer advocate, and journalist. He founded Elliott Advocacy, a nonprofit organization that helps solve consumer problems. He publishes Elliott Confidential, a travel newsletter, and the Elliott Report, a news site about customer service. If you need help with a consumer problem, you can reach him here or email him at chris@
