First and second class passengers who arrived in New York Harbor were not required to undergo the inspection process at Ellis Island. Instead, these passengers underwent a cursory inspection aboard ship; the theory being that if a person could afford to purchase a first or second class ticket, they were less likely to become a public charge in America due to medical or legal reasons.
This scenario was far different for "steerage" or third class passengers. These immigrants traveled in crowded and often unsanitary conditions near the bottom of steamships with few amenities, often spending up to two weeks seasick in their bunks during rough Atlantic Ocean crossings. Upon arrival in New York City, ships would dock at the Hudson or East River piers. First and second class passengers would disembark, pass through Customs at the piers and were free to enter the United States. The steerage and third class passengers were transported from the pier by ferry or barge to Ellis Island where everyone would undergo a medical and legal inspection.
If the immigrant's papers were in order and they were in reasonably good health, the Ellis Island inspection process would last approximately three to five hours. The inspections took place in the Registry Room (or Great Hall), where doctors would briefly scan every immigrant for obvious physical ailments.
Doctors at Ellis Island soon became very adept at conducting these "six second physicals." By 1916, it was said that a doctor could identify numerous medical conditions (ranging from anemia to goiters to varicose veins) just by glancing at an immigrant. The ship's manifest log (that had been filled out back at the port of embarkation) contained the immigrant's name and his/her answers to twenty-nine questions. This document was used by the legal inspectors at Ellis Island to cross examine the immigrant during the legal (or primary) inspection.
Despite the island's reputation as an "Island of Tears", the vast majority of immigrants were treated courteously and respectfully, and were free to begin their new lives in America after only a few short hours on Ellis Island.