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His mother had a mental illness, and his father was often absent, as well as often becoming violent towards Alex and his mother. Alex began wrestling in college, and eventually physically confronted his father - after this, his father did not return. Alex has a younger brother, Aaron, and a younger sister, Amber; they were all placed in foster care for 5 years. Though Aaron and Amber only had a few foster families, Alex went through 17 foster families in 5 years before he reunited with his siblings. It is revealed in later seasons that Aaron was diagnosed with schizophrenia and tried to kill Amber. Alex was present when Aaron had to be committed to a psychiatric ward.
Alex appears from the first episode of Grey's Anatomy, having secured a position in the surgical residency program at Seattle Grace Hospital after graduating from the University of Iowa. He initially makes a poor impression on his fellow interns meeting fellow interns Meredith Grey (Ellen Pompeo), Cristina Yang (Sandra Oh), George O'Malley (T.R. Knight), and Izzie Stevens (Katherine Heigl) whom he later taunts when he discovers she used to be a lingerie model. After initial disagreements, Alex reveals to Izzie that his father was a heroin addict who used to beat his mother. He became a wrestler so he could defend his mother, and attended university on a wrestling scholarship. He and Izzie begin a friendship. At the end of the first season, George contracts syphilis from Alex through nurse Olivia Harper, causing animosity between the two.
In the show's second season, Alex asks Izzie out in a date, but he is thrown by the news that he has failed his medical board exams. Izzie is offended since he pays no attention to her during their date and so informs him that she no longer wants to go out with him. He later freezes during an emergency operation, needing George to take over from him. Alex's relationship with Izzie is damaged when he experiences erectile dysfunction with her. He goes on to sleep with Olivia again, and when they are caught by Izzie, she breaks up with him. After retaking his exams, Alex manages a pass, and reunites with Izzie after a bomb scare in the hospital. They break up again, however, when Izzie falls for cardiothoracic patient Denny Duquette. Alex helps Izzie recover from Denny's death as his "big gesture." They kiss in the stairwell, but Izzie backs away since she is still in the process of getting over her loss and they remain friends. Alex spends a period of time working under neonatal surgeon Dr. Addison Montgomery (Kate Walsh), and though he is later released to work for plastic surgeon Dr. Mark Sloan (Eric Dane), he finds his interest returning to Addison's firm. Addison is attracted to Alex, and the two share a kiss and later sleep together. However, Alex refutes her further advances. In the aftermath of a ferry accident, Alex rescues a pregnant woman (Elizabeth Reaser) who awakes with amnesia, and grows close to Alex as he helps her forging an identity for herself, picking out the name Ava. After she gives birth to her daughter, Ava's memory eventually returns, although she tries to hide it from Alex as she had recently left a bad marriage. He convinces her to tell him her true identity, and she reveals herself to be Rebecca Pope. When Rebecca's husband arrives at the hospital, she asks Alex to give her a reason to stay in Seattle. Alex turns her down, feeling that he is not good enough for her. Addison urges Alex to reconsider, but when he returns to the hospital, Rebecca has been discharged.
Rebecca returns in the show's fourth season, and she and Alex sleep together before she goes back to her husband. Alex has a brief relationship with intern Lexie Grey (Chyler Leigh), but chooses to be with Rebecca when she returns and tells him she is pregnant. However, Izzie discovers that Rebecca is in fact not pregnant and warns Alex. After Rebecca attempted to suicide, Izzie convinces Alex to admit her for psychiatric help. Alex discovers that Rebecca's husband has left her and taken their child, and that she is mentally ill. Alex later breaks down in Izzie arms, and the two kiss. They later go on to begin their relationship anew. Later in their relationship, Izzie begins hallucinating about Denny, and uncovers the fact she has metastatic melanoma (Stage IV) with an estimated chance of 5% survival. It is revealed that Izzie's hallucinations of Denny are, in fact, caused by her tumor. Alex is shocked by the news, but finds the strength to stay by her side. Izzie plans a wedding for Meredith and Derek, but when Derek finds Izzie has another inoperable tumor in her brain, they give the wedding to Izzie and Alex, who marry in front of all their friends.
After their impromptu wedding, Izzie debates whether or not she should undergo a risky surgery to remove her tumor. Alex supports her, but eventually insists that she should have the surgery. Izzie agrees but signs a DNR form. Alex begs her to reconsider, but Izzie refuses and tells him that "if it comes down to it" he must let her go. Izzie loses her short-term memory after the surgery, and although she regains it,her heart rate flat-lines. The fifth season ends as Izzie's friends and coworkers ignore the DNR order in an attempt to resuscitate her. In the next season, Izzie regains a heartbeat. In a turn of events due to the failing economy, Seattle Grace has to make job cuts as they merge with "rival" hospital Mercy West. Fearing for her job, Izzie returns to work even though she is still undergoing treatment for her cancer. Izzie makes a grave mistake on a patient and gets fired. After being let go, Izzie disappears, leaving Alex a Dear John letter and no clue as to her whereabouts. She later returns to the hospital and says to Alex, thinking he had a hand in getting her fired, that she could not forgive him for talking to the Chief. Alex says he could not forgive her either for not giving him the benefit of the doubt and leaving without talking to him first.
When Meredith fears Alex will start sleeping around again to forget about his pain, she calls Izzie and tells her Alex might be moving on. At the same time, Alex has a one-night stand with Lexie. When Izzie arrives back home next morning, Alex almost immediately tells her he slept with someone else, but Izzie tells him they will get through this. When she later sees him with the results of her head scan earlier that day, they hug and Alex tells her he loves her so much, and that she made him a better guy - but being that better guy now, he finally understands he does not deserve to be treated like this, so he asks her to move on with her life, like he will; without each other. Alex seems to have recently found that his calling is actually Peds and not Plastics as he had decided in the earlier seasons. Seeing Alex's ability to handle child patients, Dr. Arizona Robbins shows an interest in mentoring him for that specialization. Initially, considering it to be a girls' job, Alex does not want to consider it; however, he eventually develops a knack for it. Alex's brother Aaron comes to Seattle Grace for surgery, and lots of painful memories resurface because of this. Meredith discovers Alex, along with Aaron and their sister Amber, had been in foster care for five years when their mother could not take care of them. Alex has trouble adjusting to the fact that his brother is back, but they later make amends after the surgery, and Aaron thanks him for always protecting him from their father when he was young. That day, Alex is also served with divorce papers from Izzie.
During the season six finale, Alex is shot in the hospital by a grieving deceased patient's husband, but survives with the help of Lexie and Mark. While undergoing treatment, he mistakes Lexie for Izzie, he apologizes to her and continues by telling her " came back" and tearfully begging her never to leave him again; Lexie, declining to correct him, assures him that she never will. Following the shooting, Lexie has a mental breakdown in front of Alex. Mark asks Alex to help her but he refuses and walks away. He returns to being very promiscuous and refuses to have the bullet from his chest removed, saying that it's "his war wound." After insulting Lexie, she cuts him down to size, stating that he is not "badass" for living because she is the reason that he survived and that while he was dying, he cried out for the wife who left him. Alex is left speechless. Later, Dr. Bailey bars Alex from surgery until he has the bullet removed, which he later allows her to do. It is also revealed in the episode "Superfreak" that Karev is using the staircases because he is afraid of the elevators which remind him the shooting. Chief Webber notices this and forces Alex to ride the elevator with him until he is no longer nervous inside it. Following the first few episodes of this season, Alex realizes that his passion lies in Pediatric Surgery. He is further shown to be excellent with children, comforting with a young patient while growing her a new trachea.
He immediately gets on the wrong side of new Pediatric attending Stark, who then steals his idea for a infant liver transplant patient. Alex then attempts to sleep with virgin April Kepner in an on-call room but when April asks him to go a little slower, he blows up at her, telling her that he will not hold her hand and that he cannot take care of everyone. When Alex arrives to Cristina's housewarming party, Jackson Avery (Jesse Williams) attacks him after a hysterical April tells him the story. Alex later confesses to Meredith he was in Iowa, and had gone home because his brother Aaron had been diagnosed with schizophrenia, discovered when Aaron had tried to kill his and Alex's sixteen-year-old sister, Amber. Alex tells Meredith how he could not bear to stay with his family. Alex and Meredith perform an emergent surgery on a young boy by themselves during the night shift, dealing with the angry fallout from Stark (who would not answer his pager) but gaining the wordless approval of the Chief. Alex is thrilled when Arizona returns from Africa and hopes she will come to work for the hospital again. When a shooter goes on a killing spree at a University nearby, patients are brought in, and Alex must operate with Stark on a young girl. When an infection in her leg threatens to shut down her entire body, Stark decides to cut off her leg. Arizona witnesses this, and after a desperate cry out from Alex, she begs the Chief to give her back her privileges, while Alex makes sure Stark does not touch the girl's leg.
In the meantime, Alex falls for the new OBGYN attending, Lucy Fields, and they start a relationship after she kisses him. When Alex is offered a job in Africa, he goes to tell Lucy that he is staying with her but she informs him that she took the job instead. Alex later finds out about Meredith sabotaging her Alzheimer's clinical trial with Derek and rats her out which ends with him getting evicted by Meredith from her house. This causes tensions between Meredith and Derek and after hearing that Meredith got fired, the adoption counselor takes away Zola, the child they wanted to adopt. Realizing his mistake, Alex apologizes to Meredith who forgives him shortly after. Alex, still feeling responsible for the adoption gone bad, works feverishly to keep Zola who just underwent a surgery, at Seattle Grace and also takes the adoption case to a judge. Meredith and Derek eventually get a court date regarding Zola.
As the end of the fifth year of residency is near, the surgical residents, including Alex, prepare for their boards exams for the different fellowships they plan on joining. Though Alex is late for his exam because he had to treat a patient, he ends up passing. The following day, the former Chief of Surgery Dr. Webber tells him that Johns Hopkins Hospital, which has the best program in the country, has been very impressed with him and has decided to create a position in pediatrics surgery for him. Once word spread, both Johns Hopkins and Seattle Grace, two of the best programs in the country, offer him a spot and try to woo him into accepting them. Dr. Webber reveals him that this is due to him finishing first and he eventually chooses John Hopkins Hospital. After finding out his decision, his current boss, Dr. Arizona Robbins, yells at him and takes his place on a plane that later crashes. Following the rescue of his colleagues, Robbins' health deteriorates and orthopedic surgeon Dr. Callie Torres (Sara Ramirez), who is married to Robbins and busy operating on Shepherd's hand, tells him to amputate her left leg. He extends his stay at Seattle until a replacement for Robbins is found but when he learns that the replacement will send the exchange program to UCLA, he decides not to leave.
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