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The Real ER: 'Code Black' Looks at Healthcare from a Physician's Point of View

By Nayantara Roy

The explosive, polarizing debate that is healthcare in America has long been backed by outrage and advocacy from patients and policy makers alike. Code Black, a new documentary from Ryan McGarry, resonates from the pent-up perspective of the physician, bent beneath the crushing weight of insistent regulation and crumbling idealism. Shifting between the tumult of an overburdened emergency room teeming with patients, etherized and spliced open on tables, and the quiet desperation of a team of young doctors, the documentary is an existential ode to the Hippocratic Oath and all that medicine and physicians should stand for. This is McGarry's debut feature, one that he directed in the emergency room of the Los Angeles County General Hospital (County/USC), where he toiled at his day job—as a medical resident. McGarry, now an assistant professor of emergency medicine and a physician at The Weill Medical College of Cornell University/New York Presbyterian Medical Center in New York City, desires a vacation, as he grapples with the demands of his dual professions, medical and film. This does not look likely, however. Code Black, which premiered last week in New York City, opens June 27 in Los Angeles, and will roll out in theaters across the country through the summer.


A distressed man lays on a hospital bed with a woman sitting next to him and a doctor examining his foot
Filmmaker/medical resident Ryan McGarry (right), from Code Black

By no means is McGarry an accidental filmmaker. A subscription to American Cinematographer Magazine when he was younger nurtured a persistent interest in film. Medicine intervened, as did the decision to finish his residency first. In 2008, however, McGarry was witness to a marathon transition for the public hospital, which was shifting operations from the cramped, dated "C-Booth" facilities of an old building to a brand new chrome-and-glass tower. Sensing a story, if only for archival value, McGarry obtained permission and began to shoot. "I was a first-year resident—the lowest rung of humanity, the least important person [in the ER]—and nobody really cared if I was there with my camera," he says.


a man lays on an operating table with a large group of medical professionals around him
The "C-Booth" ER, at the old Los Angeles General Hospital.

It is this physical shift that constructs Code Black's prime metaphor—an antiquated, yet deeply personal way of healing replaced by a system equipped with the latest technology while crippled by a bureaucracy that widens the gap between the sick and underprivileged patients and their doctors. When McGarry and his classmates found themselves caught in a political mire of paperwork, rather than doing their jobs, Code Black came into focus. "I think there's a very saddening paradox when you look at healthcare in America, and I was living it firsthand," he reflects. "I think it's a conundrum to put profit and healing in the same box. There's no point in villainizing capitalism or those who want to make a profit in healthcare. Doing that is very easy. The issue is the human experience, and that's what really made this so interesting to me, to record this from the perspective of the ER. This duality can often be so heartbreaking and so real, and the physician is the provider left to deal with it, in a very direct way. We don't have the benefit of being the indirect [insurance] provider. We have to be the ones to tell people, 'No, you're not going to get help today.'"

The film needed the authority to delve deeper into the innards of the County/USC's ER. For a screening for veteran documentary filmmaker Mark Harris—a professor at the USC School of Cinematic Arts—McGarry compiled and cut the footage he had shot so far. Describing this as a turning point, McGarry desperately needed a vote of confidence. "Had Mark said no, there was no going back," he admits. "A less prestigious producer and endorsement might have been possible, but he made me believe that what I shot was valuable, that I could proceed responsibly and make this film. When Mark said there was potential to the film, that really helped me pitch to USC for permission." McGarry went on to shoot with full access to County/USC.

However, the relationship with County/USC was to remain "an unofficial partnership, extending only to permission to shoot with full access." McGarry, wary of risking any censorship, went elsewhere for financial support. Together with other producing physicians from County/USC, he formed a limited liability corporation (LLC) to fund the film. "The more we shot, the more we were at risk for editorial control," he admits. "[USC] displayed extraordinary compassion for [physicians] and the patients. But Code Black was already so internal to that world that keeping the film exclusive, and in some ways independent to its subject, ensured more objectivity."

For the documentary filmmaker, however, any alliance with a corporation is an unusual one, and Fujifilm's sponsorship of Code Black raises inevitable questions. McGarry realized that "the best chance at quick funding was an entity, individual or corporation that held the same values as the county hospital system, particularly that of the ER provider. We take in every patient. Fujifilm's SonoSite, a division that produces ultrasound equipment for ER physicians and primary care doctors, came along. A huge theme in Code Black is the patient connection. And they wanted to do it because compassion is a good image for the brand. We made sure that [Fujifilm's] presence was strictly in the credits alone, with no editorial control or product placement. It is of course a slippery slope when corporations fund artists; there are departments in companies that believe in supporting the value of a documentary and the image that stems from that. That becomes their brand." 

As the overflowing desperation of the county hospital's waiting room spills into the doctors' conversations, the film finds its focus in idealism caught in a chokehold by the insurance claim form. At the time, American politics provided the context of a raging healthcare debate. McGarry states an entirely apolitical stance, even a non-polarizing one. "It was the larger issue at stake, about for-profit hospitals that turned these people away and the county system that struggled to cope," he explains. "It was deliberate non-partisan ideology where I wanted to stay away from a film that became dogmatic or had a pulpit. In a waiting room, when you have to actually deal with being denied medical care repeatedly, there isn't really any room for partisan rhetoric." 


A doctor leans over a patient in bed, holding their hand
From Code Black

With Code Black, McGarry hopes to "disarm healthcare dialogue." For himself, he dreams a dual existence—that of practicing ER physician and a filmmaker writing his next (fiction) feature. "I want to shoot something loud and beautiful about World War II- era Pittsburgh," he says. "I think blast furnaces and steel mills around the time of the war are the setting for a great narrative..." McGarry's fondness for stark contrast extends beyond his choice of careers, into his marketing campaign. With editor and co-writer Joshua Altman, he has just finished Reconnection, a three-minute, narrative short film intended to promote Code Black. Inspired by Wim Wenders' stylized, abstract documentary Pina, McGarry describes the short as "another disarming way to tell a story about healthcare. It was cool to inject something like that into an issue as polarizing as healthcare. And it's a gamble because nobody really makes a short to broaden the reach of a feature."

Nayantara Roy is a journalist and documentary filmmaker who will begin pursuing a business degree this fall, at Columbia University.