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Yeah, it's tough to imagine Grey's without its resident scruffy underdog, but according to IMDb, he wasn't initially part of Shonda Rhimes' pilot script. He had to be added into the first episode after the fact — through re-shoots and digital alterations — when the producers added Alex to give the show another male intern and a foil to the hospital's more sympathetic characters.
As Alex explains to TV Guide, "They had shot the pilot a year before it aired. They felt they needed to tinker with it a little more. I had done a pilot for ABC [Secret Service] that didn't get picked up. They liked what I did in that, and they brought me in to do a screen test with Ellen. I guess they felt they needed a jerk, so they brought in this jerk. It worked out."
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