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Victor R. Cotton, MD, JD. This publication analyzes medical-legal issues that you might also read about in the news and gives Dr. Cotton's straightforward approach to risk management. Learn to reduce your risk, not just manage it. |
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"Just Covering Myself"
Last month, a person with a drug-resistant form of pulmonary Tuberculosis received national attention when he boarded a plane and risked infecting his fellow passengers on a trans-Atlantic flight. The patient admitted that his doctors told him to not travel because he might infect someone. But, he stated that when he pressed his doctors for specifics, they stated that his risk of infecting another person was actually very low and that they were "just covering themselves" by telling him to not travel. Although the patient's recall may not be accurate, many of us have used the phrase "just covering myself." Its appearance in the context of this story is thus worthy of comment.
If we take this patient at his word, it appears that his physicians appropriately informed him of his risk of transmitting TB and advised him to not board a plane, where the close quarters would place others at risk. Unfortunately, the patient was to leave for Europe in a few days and he did not want his travel plans ruined. He thus proceeded to pressure his doctors to amend their recommendation. This is a common occurrence. We advise a patient to not lift more than 20 pounds, to avoid weight bearing, or to not drive, and the patient attempts to negotiate with us. Rather than simply ignoring our advice, the patient prefers for us to change our recommendation, so that he can then proceed with a clear conscience.
These situations can be difficult. In our efforts to appease the patient without actually changing our recommendation, we sometimes resort to using the phrase "just covering myself." In this case, the patient was told to not fly. That was the correct advice. But, the patient was not happy and pressed for permission. In response, his doctors could not just come out and say, "Well OK, if your heart is really set on it, I guess you can go." That would have looked silly. Instead, what they (allegedly) stated was that although his risk of infecting someone was actually very low, they had to tell him to not fly "just to cover themselves."
Unfortunately, when used in this manner, the phrase "just covering themselves," does just the opposite. It is, in fact, a very effective way of availing oneself to liability. If we translate the conversation that allegedly occurred here into practical terms, the phrase "just covering ourselves" means: We are telling you that you should not fly so that we are not legally responsible if you infect someone, but you are allowed to fly." This is a completely inappropriate and nonsensical way to communicate with a patient.
Either he is safe to fly or he is not. Either the patient can lift more than 20 pounds or he cannot. Either a patient should keep his leg elevated or he should not. We are required to issue the proper recommendation and the patient can then choose whether to follow it. It is certainly appropriate to explain the degree of risk, to answer patient questions and to offer alternatives, if they are available. However, the "just covering myself" approach is unacceptable. The phrase effectively undoes whatever was just recommended, and it thus avails the physician to liability, just as if he had never issued the recommendation in the first place.
When this patient pressed for permission to fly, it would have been better for his doctors to say, "We cannot make you stay home, but you are at risk of infecting other people and you should not board an airplane. I know I would not want to be on the plane with you, and I don't think anyone else would either. But, ultimately, it's your choice as to what you do." Those words allow the physician to address the patient's concern, without compromising the proper recommendation - which is always the best way to "cover oneself."
If a warning or recommendation is appropriate, we should issue it and stand by it. If it is not appropriate, then there is no reason to issue it. And, if a recommendation was issued in error, it can be retracted. But, it is never appropriate to undermine necessary communication with the phrase, "I'm just telling you this to cover myself." As such, the phrase should never be used in our communications with patients or in our documentation.
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