A lot can happen in a hospital elevator. Perhaps that is why elevator scenes are so popular in television and movies. The geometry of that enclosed space creates interesting possibilities between human beings. Over years of my career and many elevator rides, I’ve observed a wonderfully interesting and broad range of behaviors and incidents that have informed my life and medical practice. The situations with ethical dimensions are worth exploring.
The most common elevator event with a decidedly ethical dimension is the discussion of patient care by health care providers. Their professional obligation to maintain and protect patient confidentiality limits what can be said in the confines of an elevator, so much so that most hospital elevators now have signs clearly prohibiting discussion of patient care. This expectation is probably clear to most providers, and in my experience is most likely to be followed when these professionals and the public are in the elevator together. What may be more common is the willingness of hospital and clinic staff to discuss the care of specific patients when the members of the public or patients are not present. Even in those cases, however, patient care should not be discussed.
The ethical principle of confidentiality demands not just keeping patient information private and secure, but also to only divulge the minimum amount of information necessary to people on a need-to-know basis. So even if I have a hospital ID around my neck doesn’t mean I am entitled to hear about the patient on the 8th floor with the post-procedure complication. What if I could deduce who that patient was based on the clinical description? What if that patient was my family member or friend? In either case, I’m not privy to that information.
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Although the ethical principle of confidentiality is central when traveling in elevators, the value of modeling professionalism deserves consideration as well. Some observational studies have found that unprofessional behavior in elevators is almost as common as breaches of patient confidentiality.1 Elevators are public spaces where health care professionals’ behavior can have as significant an impact as when they are engaged in patient care. The public’s experience of a health care providers’ unprofessional behavior can damage the integrity of both the local institution where they receive care and the health care profession in general. For example, the public’s trust in the profession can be damaged when a health care professional disparages another colleague or is demeaning of the quality of care in the organization where they work.
Elevators aren’t just ethical mine fields. They bring people together. It confines us in a cramped space for a short time, forcing us in some cases to interact and engage with strangers. Although it’s common to keep our heads down (or perhaps just staring up at the floor numbers), some people appreciate the elevators’ ability to create community. I recall a moment earlier in my career when I was taking a crowded elevator up to my office on the 16th floor in the hospital. On the 8th floor, the doors opened and a transporter attempted to wheel a patient onto the crowded elevator. Most of us stood there dumbfounded. Before any of us even had time to react or say, “Can you wait for the next one?” a custodial staff member leaped off the elevator to make room and proclaimed, “Patients come first!”
This was undoubtedly true, but what made it remarkable was that the mission of the institution could be so clearly embodied by a single person in the health care organization. Rather than a culture than only leads from the top, here was a prime example of how anyone in the organization can be an exemplary leader and show patients and other employees what makes their organization great.
The patient’s takeaway from that experience might be that every employee in the organization cares about what’s good for patients and ensures that patients are always the focus of their efforts? That’s a more powerful message than one found on any billboard, magazine advertisement, or internet search. What do I do now when a patient needs to get on a crowded elevator? I make room by getting off the elevator and take the stairs because I want to be as exemplary as that employee taught me to be years ago.
Finally, the elevator remains one of the few tightly enclosed spaces where we share our lives with strangers, albeit briefly. Some patients who have come to the hospital or clinic in recent weeks continue to wear masks even though the institution no longer requires it of patients or staff. So even if I may no longer wear my mask in the elevator, I always carry an extra mask in my white coat or briefcase in case I have to share the elevator with a masked patient who asks me to wear one. No, masks aren’t required, but out of respect for patients’ preferences in a place they come to get well, I make sure I can honor that request and put on my mask while we share that space together.
Elevators are a unique space we share together in our work and personal life. A lot happens waiting for them and in them that relates to our ethical behavior. If we pay attention, we may get the chance to do good.
David J. Alfandre, MD, MSPH, is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.
Reference
- Ubel PA, Zell MM, Miller DJ, et al. Elevator talk: observational study of inappropriate comments in a public space. Am J Med.1995;99:190-194. doi:10.1016/s0002-9343(99)80139-9
This article originally appeared on Renal and Urology News
