“And in the naked light I saw

Ten thousand people, maybe more

People talking without speaking

People hearing without listening.”

Sound of Silence by Simon & Garfunkel

There’s a small park on the other side of First Avenue across from Bellevue. To those that work here, it’s rather well known. I’ve often found myself walking home through this park at the break of dawn after an overnight shift in the Emergency Department. With the morning light showering the pavement, I’ve had to saunter quietly through this square block of outdoor refuge, home to some our most familiar patients – some of whom I would discharge just a couple hours prior. Though I typically attempt to tread lightly so as to not waken them, I needn’t worry for there seems to be an unspoken agreement – they are not to engage me and I am not to bother them. How this came to be, I’m not quite sure.

As a sub-intern during my fourth year of medical school, I was frequently shielded from seeing certain patients – those with substance abuse issues, the grossly psychotic, and other “frequent fliers.” What I imagine sounds familiar to many of my peers, I was often told that seeing these patients “would not have much educational value.” Now as an intern, I find myself devoting a significant amount of time in tending to this group. Given how challenging it is to properly and thoroughly treat this demographic, I can’t help but feel inadequate – am I doing enough? Am I assessing all of their needs? And most frighteningly, what if this is the last time they see a healthcare provider?

As residents in this program, we are taught to ask ourselves: where is the lesion in the healthcare system that brought the patient to us? And I’m slowly beginning to realize how difficult it is to answer that question. Instead, I find myself merely uncovering more questions: why is the patient re-presenting within 24 hours? What are the psychosocial issues that led the patient back to the ED? Is it food? Shelter? Concern for safety?

If nothing else, I’ve come to learn that much of intern year is learning to deal with a sense of professional inadequacy. By the time I begin to engage the above line of questioning, a new chest pain or shortness of breath pops up on the triage board – what some would call, “real medical pathology.” I am suddenly forced to decide between picking up a potentially acute life-threatening medical case or fleshing out the societal issues that led my initial patient to me. And whether it’s right or not, I find myself pursuing the former.

It’s been said that while our bodies go through puberty during adolescence, our minds go through puberty in our twenties. I would extend that line of reasoning and put forth that as physicians, we go through professional puberty during residency. We begin to question standards of practice, challenge the status-quo, and look for deficiencies in our thinking. As ED physicians who bridge the gap between the outside world and the inpatient setting, I humbly submit that this demands that we evaluate the societal issues that bring our patients to us. I would pose the following question: who deserves a more thorough evaluation – the chronic inebriate who has been seen daily for the past week or the new onset chest pain? The politically correct answer is obvious. But what happens in practice?

With each passing shift, I am amazed at how easy (and dangerous) it is to become desensitized to issues of homelessness, poverty, substance abuse, and a wealth of other social inequities; how easy it is to talk to our patients without actually speaking to them and to hear our patients without actually listening to them. There can sometimes be a deafening quietness to a seemingly ordinary medical encounter – though words are spoken, much can be lost and in the process, our patients are hurt. After all, “silence like a cancer grows.”

I used to avoid walking through this park after my shifts; I now instead find myself willingly taking the long way home in order to course through this green sanctuary amidst the concrete jungle that is Manhattan. And not because I enjoy it; but because it serves as a humble reminder that while my twelve hour shift eventually ends, reality does not for some of our neediest patients.