An Advocate’s Guide to CYA

One of the simplest best practices for patient advocates is also the one with the fuzziest line. Sometimes it can be difficult to know at what point that fuzzy line will be crossed, and since crossing it can lead to problems for a client, put a private advocate out of business, or even result in a lawsuit against the advocate, we need clearer definition to be sure we C our own As (that is, CYA = Cover Your A**.)

Let me explain.

Recently I heard from an advocate member of APHA with a question about billing her client. She had accompanied him to a second opinion appointment, and he had balked at her charges for that service.

The client, a man of 70+ years, had depended on his advocate to help him resolve some strange symptoms he was having.

So I asked the advocate to walk me through the work. She told me, “Finally I made an appointment for him with a friend of mine who is a dermatologist” …which made me raise my eyebrows…

I asked her what sort of discussion she had with her client before she made the appointment.

“We didn’t need a discussion. He was having trouble with this, this, and this, and that just made the most sense,” she told me. “He needed another opinion and I thought my friend could provide that.”

Except – that’s what the client was disputing. He believed the visit to the dermatologist was a waste of time because no opinion was rendered except a suggestion the client see an endocrinologist instead. Dermatology was the wrong specialty for the symptoms.

“Did you talk to your client about other second opinion possibilities?” I asked. “Who decided he should see your friend?”

She ignored my question. “Well – I went to the appointment with him so I think he should pay my bill.”

(I expect you are beginning to see the problem here…)

I asked what made her think he needed a dermatologist. She then described his symptoms, but never mentioned a conversation with her client, or any recommendations that might have come from her client’s primary care physician.

My reply surprised her. “Based on what you’ve told me, I agree with your client. You should not be billing him for your time and service as it regards this visit,” I told her. “You should never have made a recommendation that steered him toward any particular specialist, least of all a friend. As a patient advocate, your code of ethics means you never make medical decisions for a client. Instead you help him make his own decisions.”

“But!” she protested… “I wasn’t making a medical decision for him! I just recommended a doctor!”…

Resulting in today’s blog post – and the CYA reminder.

Recommending a doctor is a medical decision. Any task or decision that results in a medical outcome is a medical decision. Advocates should never undertake such tasks, or make those kinds of decisions, or even make recommendations, for their clients. Advocates are not licensed to do so (we aren’t licensed to do anything at all!) and we aren’t insured to do so either.

Further, recommending a friend is an even bigger problem because it subtracts any objectivity in the decision, even if it was an innocent gesture.

Here’s what could have happened: the doctor might have ordered a test or an invasive procedure like a biopsy, or a surgery, or a drug that wasn’t well tolerated by the client. The client could have gotten sicker or contracted an infection. The client could have died!

Those horrible outcomes could have been the result of the advocate’s recommendation – which means the advocate could have been sued. Her next problem would be that her liability insurance would not cover her for such a lawsuit the moment the insurer realized the client had visited the advocate’s doctor-friend on the advocate’s recommendation.

So what should she have done instead?

To protect clients and advocates alike, any decision that remotely relates to a medical outcome must be made by the client. Period.

Further, smart advocates will document those decisions in some way, to create a paper trail (or email trail) proof about how those decisions are made.

Since the client was searching for a diagnosis (and relief) for his symptoms, here are some alternative steps the advocate could undertake for her client:

  • Return with him to the primary care physician for a specialist referral. Even if the client preferred a different referral doctor, at least he would know what specialty could help. Further, ask the PCP if other specialties might be good options for that set of symptoms.
  • Make up a list of potential specialists based on the input from the PCP. Then check the client’s insurance coverage for the names of possibilities as well as the number of opinion-visits covered.
  • Research and present information about each of the specialists such as payment coverage, hospital affiliations, and their relationship (or, more importantly, lack of relationship) to previously visited doctors, reminding the client that two doctors who know each other will rarely contradict each other.
  • Important! Document the client’s choices through email or on paper by asking the client to circle choices and to provide a signature and date. (documentation = CYA).
  • Make the necessary appointments. Accompany as requested.
  • Help the client create a list of questions as they relate to his symptoms and possible testing needs prior to those appointments.

There is no sense in jeopardizing your own advocacy practice by taking shortcuts and making decisions for your client. Even if you have the medical capability to do so – you are simply putting yourself and your advocacy future at risk.


1 thought on “An Advocate’s Guide to CYA”

  1. This may be one of the most important concepts of private advocacy there is. Yes, our clients want to find answers to their issues and may even expect that we have them in our back pocket. But in this case it is the soft skills involved in determining what attributes clients find most desirable in their medical team and illuminating other considerations they might not have thought about that differentiate good advocates from truly empowering ones. The hallmark for me that I have been tempted to cross that line is when I feel myself about to “should” on someone. “I think you should ____________ (fill in the blank.)” When I feel that word at my lips, my automatic response now is to quickly rephrase to “One option you can consider is…..” And then I have time to step back and reflect as to why that recommendation felt so right that I directed rather than offered options, sharing the impact of the downstream effects. If my “should” actually does align with the goals and preferences I so carefully elucidated with a client, then the alternate response is still the right way to express it.

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