Thomas International

American TV Series ER is unanimously considered a milestone in the history of TV drama and it has been a pop phenomenon known far and wide. ER has definitely imposed, by emphasizing it, the standard of representation of work that began more than ten years before with the seminal series Hill Street Blues.

An organizational behaviour competence supports the scripts of this medical drama. A deliberate selection of psychological elements and their studied blend in his heroes’ profile offers in ER a powerful insight on workaholism. The portrayal of work in ER, in its extremeness, is thus worthy of consideration in order to realize that fortitude and temperance are essential virtues for people on the workplace.

…I think television shows, dramatic television shows, are really sort of small manufacturing companies. I mean, we have 300 employees here, involved in every area of manufacture…

…in the first couple of years, it’s 12 to 14 hours a day, everyday, and then a minimum of eight to ten hours of work on the weekend, sometimes more. So you end up doing most of your writing and reading and note-giving off hours. It's very time-consuming…

…The most difficult thing to get used to is ending day after day not having finished everything you were supposed to do, and the awareness that you’re not going to get everything done that you’re supposed to get done, and that you have other people who are going to pick up all of that slack. …

…choosing where you think it's important to put your energies on that day [is decisive]…”.[1]

This is how John Wells describes his job. Mr Wells is the best executive producer in American TV. He’s responsible for the writing process, for the production, and also for the budget of long running series such as ER and The West Wing. This means his company must churn out 22 episodes – 40 minutes and 5 million dollars cost each – during the TV season, from September through May. It’s the equivalent of 12 movies per year, in order to feed a show that often lasts more than a decade.

Considering the above quotations, it’s easy to imagine which are the themes and the atmospheres better known and portrayed by a writer/director/producer like Wells: his preferred subject is work, highly involving and “time consuming” work. John Wells is in fact a master in depicting skilful people doing their job.

Obviously, we’re not talking of documentaries, but of entertainment, i.e. of TV series aimed to bring to the networks, every week, the wider possible audience. Thus, approaching Well’s opera, we must abandon any expectation of strict or immediate realism. We must always remember that the purpose of a Thursday 10 o’clock show is to engage viewers in the story, by multiplying heroes’ adventures, by using a lot of romance and by scattering sudden twists all over the plot.

Nonetheless, apart of their mere spectacular side, Wells series usually stem from organizational behaviour researches concerning the professional environment where the story takes place. Well’s touch precisely consists in adopting a point of view empathetic with his characters while they are on duty, on the workplace. A deliberate selection of psychological elements and their studied blend in his heroes profile makes Wells insight powerful, often extreme, and thus worthy of consideration in a cultural analysis perspective.

I want here to discuss world wide NBC hit series ER and to focus on the peculiar mix of feelings which in ER qualifies the effort of professional work.

The original idea of medical drama ER comes from a Michael Crichton inquiry on Massachusetts General Hospital. Produced by Steven Spielberg and by Warner, ER premiered on the NBC network on 19th September 1994 and still airs every week on NBC, as well as on many other networks around the word. The show tells the story of a team of physicians who are on duty at the first aid ward of Cook County General Hospital in Chicago. The staff of doctors, composed by an average of seven people in their thirties, cope night and day with the medical emergencies of the city. All of them are devoted to the many sacrifices and to the constant high level performances requested by their position.

Fast-paced like no other series before, hyper-realistic in its depiction of medical treatments and operations, with a “dirty” look due to the intensive use of hand-held camera shots, interweaving a record number of storylines in its average episode, ER is unanimously considered a milestone in the history of TV drama and it has certainly been a pop phenomenon known far and wide. ER has definitely imposed, by emphasizing it, the standard of representation of work initiated more then ten years before by the seminal series Hill Street Blues[2], a creation by Well’s master Stephen Bochco.

ER draws raw material for its stories from the direct experience of people working in hospital, which testifies that an organizational behaviour competence supports the script of the series. The writing staff of ER, actually, counts on the advice of several doctors, included Crichton, who graduated from Harvard faculty of medicine and is the author of the pilot episode of the series.

Besides, it’s Well’s professional experience itself which endows him with an insider perception of organizations where responsibility, decision making ability, independence and team effort are requested. Wells personally knows the challenges and the risks of being a professional facing deadlines, with a lot on his mind and with choices to be made fast.

From Variety to The Hollywood Reporter, the “type A question” is a steadily established topos in interviews with show runners, and interviews with John Wells don’t make an exception. The fact is that life in the show business is frantic, and the A personality profile is very common.

Like cardiologist Friedman and Rosenman defined it, “Type A Behaviour Pattern is an action-emotion complex that can be observed in any person who is aggressively involved in a chronic, incessant struggle to achieve more and more in less and less time, and if required to do so, against the opposing efforts of other things or other persons.”[3]. Since time limits and huge work to be done prod every executive or scriptwriter in Hollywood, they are regularly asked how they keep their balance. That’s why they know pretty well the problem. They are aware of being on the edge of Type A condition, and they try to take precautions. As it’s evident in the following remark by Wells, they think clearly about the ghost:

…It’s kind of like if you're an ironworker, you know, you never look down. You can certainly wake up in the middle of the night with a lot of anxiety dreams, but that’s if you’re trying to look at the whole picture. But you don’t have to do the work at once. You do the work day by day, and once you get a sense of how to do the job, if you can keep it organized and you have some very good people working for you, you simply move through what needs to be done that day…[4]

And the ghost is a strong inspiration for executives and scriptwriters creativity when they are up to a “procedural” series, i.e. a series aimed to depict a professional category from inside: like in ER, where the Type A issue is at the very core of the story. The authors who conceived and then, episode after episode, measured the evolution arch of Doctor Mark Greene, of Doctor Doug Ross, of Doctor Susan Lewis, of matron Carol Hathaway and that of all other characters, actually have been keeping as a referent a clear system of psychological coordinates. Psychologists of work[5] fixed these reference marks to define the range of attitudes which, if displayed by someone in an organization, he would be judged a well-balanced guy, and therefore in the position of mastering his job.

The system corresponds to a virtuous curve, and equilibrium consists in the ability of moving along it, without going beyond its limits.

At one end of the curve lies one’s capacity to exert an outward influence to defend his ideas, to take a reasoning to its conclusions with authoritativeness, to compete within a frame of accepted rules and, if necessary, to play tough, as long as it’s not to the detriment of anyone personal dignity – which also means that one shouldn’t look for the source of his self-esteem in overworking –. Seen in an other perspective, the capacity in question consists also in being able to say “no” to whatever one finds, according to the circumstances, unacceptable: it could be either a false accuse by a colleague, or an order that appears immoral, or a prejudice shared by the majority.

In short, at this first end of the curve lies what psychologists consider a correct use of “aggressiveness” within the relationships one has on his workplace: they call it “assertiveness”. In moral terms this psychological attitude is a virtue named “fortitude”.

At the other extreme of the curve, on the contrary, is the capacity to exert an inward pressure – thus, again, “aggressiveness” –. In this case, one exerts a force in order to curb his feelings. The capacity now in question is that of someone who can keep his drives into a form that, on one hand, sincerely reflects the nature of his emotions, on the other hand, doesn’t undermine the dominium of his reason nor is perceived as annoying by people in the organization. Many career women, for example, are uncomfortable with this end of the curve: they perceive that the female side of their emotiveness doesn’t fit the environment they work in, thus they repress it and turn it in a peculiar, outward aggressiveness, well known by their male colleagues (in consulting firms they call it the “diversity” issue).

The correct use of inward aggressiveness is usually called “self control”, which, in moral terms, corresponds to the virtue of “temperance”.

4. “That’s what I like about you: naked ambition tempered by arrogance”

Since the frame of references which is behind ER is now explicit, we can go back to the drama to see how the system works in it. First season episode 12[6] offers a wonderful insight in the series exploration of aggressiveness in organizations. In the episode, the story lines of four characters overlaps on the fortitude/temperance issue. Each character exemplifies a position one could take on the curve of aggressiveness. This way of conceiving the structure of a 40 minutes show is called “blossoming”, because it puts a specific topic at the core of the plot, so that singular story lines, like petals in a flower, blossom around it, depicting different attitudes about the problem in discussion. The result is that ER, like few others American procedural series, is often suitable as a source of o.b. case histories.

In episode 12, Dr Susan Lewis’ story line states the matter. In the previous episode, full of himself, Dr Kayson rejected his assistant Susan correct anamnesis on a patient, who then died because of the wrong treatment he consequentially received. In the controversial circumstance, Kayson’s conceit stopped Susan far before she could explain her point of view about the situation of the man she and, especially, Kayson were in charge of. Now Susan is received by Dr Morgastern, the primary aid ward head physician, who’s looking forward her explanations. When Susan has finished, Morgastern agrees with her version, but, unexpectedly, he reproves her for her lack of positive aggressiveness:

As it’s evident in the dialogue above, the question is: “what degree of outward aggressiveness one has to exert in a first aid ward?”. Obviously, not Susan’s low degree.

Neither Dr Greene assertiveness is strong enough in the episode. This character is a colleague and friend of Susan’s. He is also chief resident and thus he knew what Morgastern was going to blame on Susan, but he didn’t anticipate her the topic of her interview with the head physician, nor he tried to stand for her against Kayson.

Compared to these two last cases, Dr Doug Ross assertiveness is stronger, but still not sufficient, considering the momentous situation he’s in. Dr Ross is attending a child with permanent brain damages, arrived at the hospital in a coma. Ross thinks that, with the proper care, his young patient could live a long time and he believes it to be the right thing to do. The suffering of the father of the boy yet overwhelms Ross’ assertiveness, living him silent and confused about his own ideas, because the man is at the moment overcome with grief and thus doesn’t want his son to be resuscitated.

Another story line – Dr Benton’s one – sets a higher level of aggressiveness in the plot. Benton’s life is totally focused on his career as a surgeon. In a dialogue with Morgastern, he is grateful to his boss who has just offered him to cover his first assistant while this one is in Detroit for a series of lectures. It’s hard work, nevertheless Benton’s answer expresses all his determination to achieve his professional goals: “It’ll be good training for when I’m chief surgical resident”. Morgastern replies to Benton’s enthusiasm with sarcastic satisfaction: “That’s what I like about you, naked ambition tempered by arrogance”. Morgastern perfectly knows that job is all what matters to Benton, which the episode shows immediately afterwards: the character, in fact, will have a hard dispute with his sister because he has always neglected their old mother, even now that she is ill with Alzheimer (“The only one Peter is responsible for is Peter” is his brother in law bitter remark).

This time, we face a too high degree of aggressiveness on work: so high, that no more good aggressiveness is left to be spent outside the organization.

Two further subplots complete the picture. They treat the topic of aggressiveness with irony.

In the first one, episode 12 shows the youngest member in the staff, apprentice John Carter, unusually relaxed. Carter airs his competence, since new apprentice Debra Chen’s insecurity makes him feel overconfident. He will end accidentally defibrillated by her: being assertive means also that one must not lower his guard.

In the second subplot, a sociologist – specializing in violence – is recovered after someone has beaten him. While doing a survey, he had gone around in Chicago, asking people questions to probe for their insecurities, then antagonising them until they assaulted him. In hospital, the researcher interviews matron Carol Hathaway while she’s medicating his wounds with painful disinfectant. The nurse is living difficult moments with her future husband: they disagree about everything that concerns the preparation of their wedding. The perspicacious sociologist realizes it and initiates his series of tactless questions (“Think you are too good for him? Scared of spending your life with someone who doesn’t meet your standards? Got high opinion of yourself, don’t you?”). He will soon receive a triple dose of disinfectant, which will allow him to record Carol’s twenty one seconds PAI (“provocation-to-assault interval”) and to put her in the top percentile of “hostility index”.

Carol’s subplot means that to keep a balanced attitude towards work, one has also to do his best and preserve it from private worries.

Episode 12 traces therefore a scale between a level of too weak assertiveness and an excessive degree of it. Authors yet don’t give here the solution. They wait for the following episode to show a virtuous, paradigmatic example of determination. It will be Susan Lewis, the character who raised the issue, to master her job wonderfully in a conflict situation. Dr Kayson, the arrogant boss himself, is admitted to hospital as an emergency patient for an almost lethal hart attack. Susan, who happens to attend Kayson – after all, it’s always fiction – resists the attack of a senior cardiologist who tries to take away her patient for a wrong treatment, and saves Kayson’s life with her providential operation.

Someone who doesn’t know ER could now imagine that the series always uses its organizational behaviour competence and its psychological knowledge to produce edifying examples like Susan’s one. Unfortunately, it’s just the opposite. Balanced personalities, in fact, are rare within the characters of the show and Susan storyline is an exception. The characters of ER are skilful doctors indeed. They are certainly familiar with techniques and surgical practices a real first aid doctor would never use in his entire career, yet, as to fortitude and temperance, they’re regularly less then beginners: ER makes uneasiness with assertiveness and with self control the essential personality trait of its professionals. In other words, ER is a huge, twelve year lasting hymn to Type A syndrome.

On their work, ER doctors behave steadily out of the aggressiveness virtuous curve. Wells gives us a so sharp image of organizational behaviour disturbs that one could even think that he studied Kets de Vries’ theory on neurotic workplace. They alternately show the blend of emotions typical of too much outward aggressiveness on work – workaholism – and the one which is associated with too much inward aggressiveness – inhibition, sometimes till an extreme form of it called alexithymia –.

This is how the former blend looks like: irascibility; sense of guilt; absent-mindedness; low self-esteem; Sisyphus like eagerness of completing a never ending task – a task which in ER a genius scriptwriting invention identifies with the defeat of death itself –; bursts of enthusiasm which are actually attempts of escaping for a moment one’s obsessions.

The latter blend, that is to say inhibition, looks instead like this: no empathy with colleagues nor with patients, mere tolerance to work, no sense of humour nor creativity, passive application of protocols.

To be constructive means to have a positive and proactive attitude toward job matters; to be unproductive means to be too positively inclined and thus relaxed about work: now, no physician in ER behaves this way. To fear work means to be active but moved by a negative feeling; a depressive attitude means to be passive because of a feeling of inadequacy in the organization: these are the usual conditions at Cook County NBC Hospital.

None out of the seven characters has a private life worthy of this name: they have no time for it. Colleagues substitute everybody’s own family. When a doctor is married it’s always a problem for him: marriage is something he can’t manage with because job priorities follow him even at home – where he’s very seldom, anyway –. Home, thus, is a guilty, fleeting pleasure and children are either a one-day-may-be thought, or an actual responsibility these pros feel sorrowfully obliged to neglect.

Significantly enough, before dying in the eighth ER season, main character Dr Greene’s last words to his adolescent daughter will be “be generous with your time”: exactly like he had never been with her. Likewise, in the last episode before leaving Cook County Hospital, over achiever Dr Benton finally understands that “the goal wasn’t outside, but inside me”, that is changing and not being anymore a Type A.

It’s interesting to study the many subtext messages of the series. They set the specific mood of the show by creating a particular atmosphere for every area its fictitious world is made of. Three types of subtext messages, however, are essential to ER peculiar flavour .

In examination rooms, authors make the characters face their ghosts and sense of guilt. Very often, in fact, patients are subtly introduced as living metaphors of the private disastrous life of the doctor who is in charge of them. It could happen, for example, that Dr Benton, incapable of taking care of his deaf-mute son, has to cure a man who has made a suicide attempt because he had the time, but not the money to sustain his son and his wife; it could also happen that, since Dr Kovach is in a crisis of faith, he has to cure the Archbishop of Chicago who is in the same condition. This kind of subtext messages stresses the fact that work never fits. Examination room scenes suggest the following remark: “to be balanced on work you must have put order in your life, but you can’t do it since you’re always working, and it’s not sure that a way out of this loop really exists”.

In operating theatre, on the contrary, the climax moments of defibrillation on patients with heart failure give the impression that ER physicians are liberated by their obsessions. It seems like they are fighting an enemy they finally can see and thus, for a moment, it seems they feel in the right place at the right moment. Unfortunately, these are the cases of the ephemeral fits of stamina mentioned before. To give proof of heroism by resuscitating people doesn’t necessary means to be true heroes.

Third subtext is typical of homes and of the ward staff room. There, often at the end of an episode, after their efforts, doctors find themselves alone, in a sad silent which is only broken by the sounds of the city outside. It seems here that they are wandering about the sense of what they’re doing, longing an happiness they feel themselves excluded from.

I can synthesize the short analysis I’ve just made of ER by saying that its stories purposely disregard leadership handbooks. The feeling of having things to do overwhelms the knowledge of what to do in the long term and, most of all, the why of it. This statement suggests some finals remarks.

My conclusion is made of three points: the first one concerns the functioning of TV industry; the second point is about contemporary pop culture; the third one is a suggestion for a better representation of work.

[1] Lisa Chambers, “A Week in the Life of a Showrunner” in Written By. The Journal of the Writers Guild of America, 2 (1997), 32-41.

[2] Hill Street Blues aired on NBC from 1981 to 1987.

[3] Friedman M., Riesman R.H., Type A behavior and your heart, Alfred A. Knopf, New York 1974, 67.

[4] “A week…”

[5] See on this Kets de Vries, Manfred F.R. Organizational Paradoxes: Clinical Approaches to Management, Tavistock, London - New York 1980; Giampiero Quaglino, La vita organizzativa : difese, collusioni e ostilità nelle relazioni di lavoro, Cortina, Milano 2004.

[6] Luck of the draw, written by Paul Manning, directed by Ron Holdcomb, aired on January 12^th, 1995.

[7] Greg Braxton, “The Doctor Is In and He Is The Producer” in Los Angeles Times, June 24, 2001. About the issue of media elites and the responsibility they have in influencing people’s lifestyles through TV, see the clear-headed examination by Armando Fumagalli in L’industria televisiva e il suo impatto sociale, in Gianfranco Bettetini, Paolo Braga, Armando Fumagalli (eds.), Le logiche della televisione, Franco Angeli, Milano 2004, pp. 17-44.

[8] Thomas Schatz , “Hill Street Blues” in AA.VV. The Encyclopaedia of Television, Fitzroy Dearborn Publishers, 1997.

[9] Helena Sheelan, Hill Street Blues: an Analysis of Text and Context, www.comms.dcu.ie/sheehanh/tv/hillstbl.htm

[10] Todd Gitlin, Inside Primetime, Pantheon, New York 1983.

[11] Ursula Ganz-Blattler, “Stephen Bochco” in The Encyclopaedia of Television.

[12] In my Dal personaggio allo spettatore (Franco Angeli, Milano 2003) I have drawn a map of American TV series where I’ve put procedural dramas of the last generation in an area called: “The predestinateds’ arena”. Characters, in fact, seem here to be often in the situation of asking destiny why they have to fight an enemy they can’t even well define, without any chance of succeeding. I’ve elsewhere sustained that these melancholic atmospheres are influenced by a Gnostic conception of life widespread among media elites, both in the United States and in Europe. See on this Paolo Braga, Without God, Resentment and Utopia in Mainstream Fiction, lecture presented at the conference Ethics Without God?, Jacques Maritain Institute, Notre Dame University, Indiana (Usa), July 2003.

[13] See Karol Wojtyla, Osoba i Czyn, «Polskie Towarzystowo Teologiczne», Kraków 1969; eng. tr. by Anna-Teresa Tymieniecka, The Acting Person, D. Reidel, Publishing Company, Dordrecht-Boston-London, 1979; it. tr. Persona e atto, Libreria Editrice Vaticana, Città del Vaticano, 1982; now also Bompiani, Milano 2001; Idem, Milosc i odpowiedzianlnosc, Wydnwnictwo “Znak”, Kraków 1960; it. tr. Amore e responsabilità, Marietti, Genova 1983⁴ See also Giacomo Samek Lodovici, La felicità del bene. Una rilettura di Tommaso d’Aquino, Vita e pensiero, Milano 2002.