But on this night, a chilly Wednesday in November, the magic hour was holding: At 3:30 a.m., my last patient in the department, a fifty-year-old man complaining of “itchy feet for three months,” was well on his way to being cured. There was no rash or infection, just a man who needed lotion. The pharmacist on duty was willing to oblige by sending over a tube of generic moisturizer for the patient to take home to commence the healing, and I could finally sit down at the computer to scroll through my queue on the electronic medical record tracking board to ensure that all my medical notes and orders had been signed. But first I would grab some coffee—I was so tired that my bones ached. Four a.m. tired is nothing like being sore from yoga class or a hard run; it’s a deeper throb, a psychic ache.

Here is the blessing and the curse of the 4 a.m. downtime. When everything goes quiet—the techs running back and forth; the patients requesting Percocet, ice, and turkey sandwiches; the nurses asking you to enter all your verbal orders from last night into the computer; a physician on call for a specialty service asking if the consult you placed from the ER is really an emergency or could wait until tomorrow or, better yet, until whatever month a clinic appointment could be made for the patient in question—the inner voice swells until it becomes an existential nudge. Why am I here? What am I really doing? What’s my purpose?

But who has the energy to navigate this conversation at 4 a.m.?

Yup, it was a good time to get coffee.

Just as I had pushed my chair away from the desk, my screen flashed blue, the color code that told me a new patient had arrived. The magic hour evaporated, and what came up in the complaint tab completely dispelled any charms 4 a.m. usually held: “Hemorrhoid.”

The nurses had triaged the patient, Mr. Erik Samuels, with an “emergency severity index” of 4—given that the scale of patient urgency goes, in descending order of severity, from 1 through 5, only a 5 was less critical. So, I wouldn’t need to rush. I scrolled through the chart to make sure I didn’t miss anything. (Five years later, my memories of rounds with Dr. Jaiswal were still with me.) The patient didn’t have a fever, and his other vitals were insignificant: blood pressure 145/86, heart rate 76, respiratory rate 16, saturating 100 percent on room air. I skimmed his electronic medical record. He had a history of hemorrhoids, which each time appeared to have been treated appropriately with a brief course of steroid cream. He also had a history of an inguinal (groin) hernia. Five years before, he had been seen in the hospital’s outpatient surgery clinic but had declined any surgical intervention, and then had never returned to that clinic again. It didn’t appear to be anything serious.

But then I saw it: A yellow flag appeared on one of the patient’s earlier notes, from three years before: “Violent Behavior Alert.”

We deal with all kinds of threatening behavior in the ER. By federal law, we are required to evaluate anyone, at any time, with any ailment. For many people, the ER is the only place they can go, particularly those without medical insurance. But it’s not the uninsured who use the emergency department the most; it’s the insured.

A 2011 survey by the Centers for Disease Control and Prevention explored the reasons the insured find themselves in the ER. Often it is because they feel their health needs aren’t being met by their primary care provider; perhaps their doctor doesn’t respond quickly enough to their phone call, email, or text. Even when a patient is able to reach their physician to schedule an appointment, they may feel they are simply too sick to wait for the appointment. So, when patients arrive at the ER, they may be delirious from infection or psychotic from a chemical imbalance; they may simply be belligerent drunks, or so entitled from unchecked privilege that even polite questioning causes them to blow a fuse. Whatever the case, it pays to be extremely cautious in the ER.

Actual statistics on violent incidents in emergency departments are sparse; only a small number of dedicated studies have been done. The more pressing issue is that these incidents go largely underreported. The reasons for this are manifold. Many health care providers feel that nothing is done when reports are made, which effectively diminishes the impetus to disclose assaults. Others, fearing they could face scrutiny or blame for not having prevented the violence, become habituated to it: It simply becomes part of the job.

According to the 2003–2007 Workplace Safety Survey by the U.S. Bureau of Labor Statistics, workers in health care and social services are five times more likely to be victims of a nonfatal assault than average workers in all other industries combined. A 2009 Emergency Nurses Association study showed that 20 percent of respondents had been physically assaulted at work more than twenty times in the past three years.

Many television programs don’t depict hospital departments accurately. No, the ER staffs are not Hollywood beautiful—you won’t find us in the pages of Vogue or GQ, and we’re not all sleeping with one another (I’ve worked in only one hospital like that)—and given the size of your average American, it turns out it would be extremely difficult to create an emergency airway using a steak knife, a straw, and a bit of twine. But TV does get one part of ER life right: Medical personnel in hospitals are often attacked by the patients they’re trying to help. In the most horrifying instances, people walk into hospitals and clinics with guns to murder providers who save lives. Anything can and does happen.

Once I saw the yellow flag on Mr. Samuels’s file, I took a deep breath and clicked on the alert note:

Patient grabbed the left breast of female physician while she was performing an incision and drainage on his neck abscess. When it happened, the female physician put down her instrument and left the patient room. The procedure was completed by a male physician.

The rest of the chart read like any other for an abscess treatment, recommending that the patient return in two days for a wound check.

Hot bile constricted the back of my throat, and my face flushed. I didn’t know what bothered me most: the patient having committed sexual assault, the offhand manner in which the attack was described, or the fact that the patient was instructed to return to the ER for routine care after he had perpetrated a crime against one of our providers.

Yes, this patient would wait. He would wait while I pushed my chair back, stood up, walked to the break room, poured myself a cup of coffee, went to the restroom, and finished some notes. He would wait until I was done with everything. In the comment section next to the patient’s name, I typed in “History of assault on staff,” and then called the triage nurse to request that he assign Mr. Samuels to one of the male nurses.

“Sure thing. He just has some swelling on his bottom,” the nurse responded.

I stood up, secretly hoping that the coffee pot would be empty and I’d have to beg someone to teach me how to brew a new pot. Then I’d wait, drip by drip, until it was ready.

As I turned the corner to head to the staff kitchen, I heard someone shuffling back to Room 7, where Mr. Samuels had been assigned. I heard the dragging of feet and a groan of pain. With my stainless-steel mug in hand, I continued past the sounds to the kitchen.

There are plenty of occupations in which employees have no choice but to deal with anyone who shows up: restaurant server, flight attendant, shoe salesperson, hair stylist. Emergency medicine is the same. But before I became a doctor, I had always assumed there would be less violence and more civility in medicine. We train for a minimum of seven years and spend countless sleepless nights restarting hearts and resetting bones, and yet, now that I was practicing, I knew that we in the ER were no different from those working in service industries. We aren’t spared from rude or belligerent patients. We are punched, kicked, called “cunt,” and even shot at—none of which should ever happen to anyone in any line of work, but it does. And as doctors, we are exposed to this violence by the very people the law mandates us to treat.

As a resident, I had trained and lived in the South Bronx. Mercy Hospital, one of the busiest hospitals in the country, had good reason to have an in-house police precinct complete with a jail cell. Given the prevalence of violent crime in that part of New York City, and the fact that Mercy was one of the highest-volume trauma centers in the country, people assumed we were under constant threat, but that was not my experience. It’s true that we were in the trenches as community members, standing side by side with the South Bronx residents. We knew the police officers, firefighters, and EMTs by their first names. They’d often send the ER staff donuts after we’d helped them unload the fourth gunshot wound, second cardiac arrest, or first pediatric stabbing of the day. We at Mercy might not have had the newest equipment and our scrubs might not have been handsomely monogrammed, but we showed up every day (many of us fueled by the strong and delicious Cuban coffee from the bodega across the street) to take care of as many patients as humanly possible. The faster we worked, the more patients arrived; the more patients, the sicker they seemed to be. If we began a 7 a.m. shift by attending to the twenty-five patients still in the waiting room from 10 p.m. the night before, that simply meant it was a regular Tuesday.