An Appointment with Dr. Death

It's the sound effects that stick with you. The deep sucking noise of a spinal disc yanked from its vertebral column. The shrill grinding of metal drilling into bone. The ghastly clanking of a mallet against cartilage. And this is the restrained version of Peacock's Dr. Death that Patrick Macmanus envisioned when he set out to adapt the hit Wondery podcast about Texas neurosurgeon Christopher Duntsch, who is serving a life sentence after maiming and killing multiple patients.

"With the very first draft of the pilot, I said to the writers, we're going to see it all — the viscera, the blood," says Macmanus, showrunner and executive producer of the limited series. "My original intent was a gore fest at the very top."

His fellow writers persuaded him to back-end most of the blood and guts.

"It's the shark under the water, versus the shark on the surface of the water," he says.

The eight-episode series stars Joshua Jackson as Dr. Duntsch and Alec Baldwin and Christian Slater as Drs. Robert Henderson and Randall Kirby, the surgeons who spearheaded an initially Sisyphean effort to get Duntsch's medical license revoked.

But if Macmanus, Jackson and the rest of the cast and crew have done their job, viewers should be mad as hell at the systemic failures in the American healthcare system that allowed Duntsch to keep performing surgeries at three hospitals between 2011 and 2013, even as he was maiming and killing patients.

"It's a system that is neither good for doctors — who have to carry massive weights of [malpractice] insurance — nor for patients who, God forbid something goes wrong, are facing a system that will crush them rather than fix them," Jackson says.

It is an indictment of a uniquely American healthcare industry that prioritizes profit over patient care.

"When you dig down into Dr. Death, the problem was that the mangled bodies were less valuable than the potential surgeon," Jackson says. "Which is the ugliness inside the system. They literally did an actuarial table: 'One malpractice case costs us $500,000, but if we keep this surgeon, he might generate millions of dollars. And since we've given up on the idea of being patient-first, we're going to follow the dollars.'

"That ultimately is where the show lands — that the system benefits only the corporate behemoth and the insurance companies, not the doctors or the patients."

At Baylor Plano Hospital, Duntsch operated on the wrong part of a patient's back, leaving him partially paralyzed; he erroneously cut a ligament in another patient and misplaced hardware in that person's spine; another patient bled to death during what should have been a routine back operation. He was expelled from Baylor Plano but was able to move into a new surgical position at Dallas Medical Center. He was there less than a week when he killed another patient. And yet, he went on to a third hospital, where he would maim several more patients.

"Christopher Duntsch is an extreme outcome inside the system," Jackson says. "But he's not impossible, and that's the problem."

The philanthropy arm of Macmanus's Littleton Road shingle has created a campaign called For The Patients to raise awareness and promote engagement from medical institutions and political representatives on the need for patient-centered care.

"I'm a fan of true crime," Macmanus says. "But I believe that what fundamentally allows this [series] to stand out over some of its predecessors in the genre is, it has something to say about the world we live in right now."

During a Zoom conversation from NBC's Universal City studios with emmy contributor Marisa Guthrie, Jackson and Macmanus exude a brotherly affection, each professing deep admiration for the other's skills and empathy. The following excerpt of their conversation has been edited for length and clarity.

Watching this was pretty horrific, and to think that this actually happened to people is truly shocking. What was it that you both found compelling about this story?

Patrick Macmanus: The true-crime genre is well-worn territory right now. But Christopher Duntsch is not simply a black-hat character. He's really complex. He's a villain, but had he made a couple of different choices in his life, we might be talking about him in a different way. His research was legitimate. His patents are still being used today. The idea that had he turned right instead of left, he might be a hero in the medical community — that was fascinating to me. To be able to track that character's journey from his education to his incarceration makes this stand out from most of the true crime out there.

Joshua Jackson: In the beginning, he is not the monster that we come to know at the end. He is just a human being trying to figure it out. He was at the forefront of a revolutionary medical advancement. If he had stayed in research, he might have been the Elon Musk of non-invasive surgeries, or gene-based therapies. To tell the story of that man as he starts to psychologically decompose was an opportunity like I've never had before. The richness and the turns of that character were immediately on the page for me. And I was in. It took seventy-two hours to make the decision.

He doesn't just psychologically decompose — he transforms physically as his crimes and legal problems mount. In high school, he's a wannabe jock with an obvious learning difference, so he presents as very vulnerable. By the end of the series, when he's facing trial, he's heavy, bloated, stooped. What was it like to play those physical and psychological extremes?

JJ: The emotional path was what got me hooked. Very rarely do I read a villain character that is given a truly sympathetic piece of the story. Not only does he have a potential learning difference, but emotionally he's kind of stunted. He's looking for his place in the world, for approval from his parents, his peer group. The character has all of those shades, and you get to go back in time and start with him in that raw form and see the steps along the path as he starts to devolve into the person that he becomes.

And then the technical path was gait, carriage, voice, temperament. Before I got to the full prosthetic, we were using fat suits in some timelines, but not facial prosthetics yet. And that changes the way that you carry your body, it changes the space that you occupy.

Audiences are accustomed to prosthetics, but some prosthetics are so over-the-top they become a distraction....

JJ: There is freedom inside of a box. It defines your range of motion, the things that you can do. Just a belly suit changes so much: it informs the way that you sit, where you put your hands.

I wanted to play with the idea that he gets both larger and smaller with the weight of the world. When he's a kid, he's loose-limbed, and by the time we get into the courtroom at the very end he's this hulking thing, almost stuck to the ground. The difficulty of that for us was, we didn't shoot it chronologically. So there was quite a lot of brain work, which I did not appreciate. Nobody said there would be a test. [Laughs]

PM: It was important in the writing that we tapped into the devolution of the character, not just mentally but physically. I've been doing this now for about a dozen years, and there hopefully comes a point when you're behind the camera and you see [an actor] fully lock in. Sometimes it doesn't work out that way, quite frankly. But in this case, it happened really early on.

One of the hardest things to do — and as a former shitty actor, I never figured it out — is to be able to play that range. It's a testament to [Josh's] skill and his craft as an actor that he was able to run that gamut. Very early on we knew we were in good hands.

I think you're embarrassing him. Josh, you've done long-running network series such as Fringe and Dawson's Creek. So much of television has now adopted the premium model of smaller or limited-episode orders. Are there advantages and disadvantages to each?

JJ: It's really about the volume of work and the ability of the writers to keep the narrative fresh. The old network idea of putting out twenty-two or twenty-four episodes a year, it's impossible to ask any group of people — actors, writers, directors, crew — to maintain a high level of quality. It just grinds everybody to dust.

I like the ability to tell a story over time. But the six, eight, ten, twelve-episode story is a beautiful amount of time; everybody still likes each other by the time you're done working. The character is always fun to play if there's some fresh material.

PM: I agree wholeheartedly. What you get with limited series is also the opportunity to enter knowing what your endgame is. And that, in my opinion, is fundamental to how you write good shows.

There is a great scene in episode four, in which Alec Baldwin's character confronts Duntsch in a bathroom and punches him in the face. While it becomes clear at the end of the scene that this is a fantasy sequence, it nevertheless feels like needed catharsis for the audience. Is that what you were going for?

PM: I knew that there had to be a moment in which Duntsch and Henderson, in particular, had to come head-to-head. In reality, they never met each other. But in real life, they were both invited to a welcome dinner [hosted by one of the hospitals].

One of my favorite short stories of all time is [Ambrose Bierce's] "An Occurrence at Owl Creek Bridge," which is what the title of the episode ["An Occurrence at Randall Kirby's Sink"] is an allusion to. And this brilliant writer, Ahmadu Garba, who wrote episode four and cowrote episode seven, took that and ran with it. He handed in his first draft, and I didn't touch it. It was absolutely perfect.

It also enabled us to drill down on the systemic failures. Because something that Henderson and Kirby in real life said over and over again was that they entered this situation believing in the system that they dedicated their lives to. And this upended everything for them. And so [that episode] opened the door for us to have a broader conversation about the failures of the medical community.

The surgical community is still very patriarchal. You cast a male nurse (played by Hubert Point-Du Jour) in the role of the metaphorical moral compass, which Dr. Duntsch very much lacks. Was that gender choice intentional?

PM: No, it wasn't. Josh Baker is a composite character. What was very intentional, obviously, was to talk about the hierarchical structure inside an operating room. But it had nothing to do with gender. Hubert is just one of the finer actors I've had the opportunity to work with. That character could very easily shift into the saccharine or the preachy, but Hubert grounded it and made it very real.

The scenes in the operating room are very specific. Josh, how much guidance did you need to pull that off in an authentic way?

JJ: First, I will say the best actor is a good editor. So many thanks to everybody in post for making me look good.

We did quite a lot of [preparation] before we got to set to make sure that what we were portraying would pass the surgeon sniff test. That was very important to us. Having the knowledge of what the tools were, what the tools did, what the order of the procedures were, was very helpful. And then there's this strange dichotomy, because as the actor you get lost in the doing of it right — and sort of forget the horror of what you are performing. When I watched it, I was like, "Oh my God, this is terrible!" It really sticks with you. So, thank you, Patrick.

PM: You're welcome! It was obviously very intentional. A [large part of the story] is the trial. But there's only so much you can do to make a trial engaging. Thank God I work with smarter writers than me, and they came up with this idea to hold back and pack a lot of that into the final episode, when Henderson is doing his recitation of [Duntsch's botched surgeries] at the trial. And that was the greatest pitch I heard. If you watch it again in 5.1 surround sound, it's a completely different experience. Our sound design team was absolutely spectacular.

I'm not sure I can handle that. It's also interesting to see the juxtaposition of Dr. Duntsch — the tall, handsome, confident surgeon — and his patients, who are desperately looking for someone to deliver them from agony.

JJ: That was also interesting. In the middle of Duntsch's journey, instead of learning how to become a surgeon, he became an actor. He learned how to play the character of the surgeon. He learned all of the affectations and had, by all accounts, a very good bedside manner.

I think that Duntsch thought he was an amazing surgeon. So anything that failed to meet his expectation of himself, since he was amazing, had to be somebody else's fault. And that's a spectacularly twisted psychology. But I think that's what is so compelling and terrifying about this man. I bet if you sat with him right now, he would still tell you that he was a brilliant surgeon failed by the people around him.

He did get away with it for a long time. There are parallels to the Catholic Church, which kept moving its pedophile priests to new communities rather than hold them to account.

JJ: He ticked off all the other boxes. He's tall, he's white, he's erudite, he's handsome. And once he ticks off all those boxes, the whole system of the world that we live in — not just the medical system — allows him to keep going. He learns to be that guy.

By the time he transitions out of research and into a place where he's physically mangling bodies, he has learned the character. And the system has already decided that he's okay. That's when we get to the place that you're talking about. No matter how many times he got it wrong, he was going to be allowed to continue to essentially learn on the job. And Henderson and Kirby had to go to extraordinary lengths to hold him to account.

Patrick, tell me about the creative decision to do the Dallas homage in episode five. It was a bit of nostalgia and some comic relief from the heaviness of the narrative.

PM: We knew that it was vitally important from the beginning that there be a release valve. For the most part, Christian's character of Dr. Kirby played that part. And by the way, we were underplaying who the real Randall Kirby is. The real Randall Kirby is like a twelve to Slater's seven in real life.

One of my idols is [writer-producer-director] Vince Gilligan [Breaking Bad, Better Call Saul]. I've always loved the fact that you never knew exactly where you stood with his storytelling, whether it be on the page, or the music, or what feels like a non sequitur but actually ties into the whole.

I wanted the audience to feel something unexpected at least once. We told at least half of that episode as fantasy. It's shot differently. The color grading is different. The sound design is different. All of it stands apart. It was an opportunity to let the audience, for a moment, take a deep breath and have a good time.

Besides Macmanus, the executive producers of Dr. Death include Todd Black, Jason Blumenthal, Steve Tisch, Taylor Latham, Hernan Lopez and Marshall Lewy. Dr. Death is a production of UCP, a division of Universal Studio Group.

This article originally appeared in emmy magazine issue #6, 2022, under the title, "In Harm's Way."