Slicing A Patient's Complaints Down One Layer At A Time

Stephen Barrett DPM FACFAS

The “onion” is more common than rare and every practice is filled with them. Onions are easy to identify most of the time as Ms. Tuber, our fictitious representative of the onion phyla, always presents with a list of multiple complaints. (By definition, a patient can still be an onion with only one chief complaint. We will get to that later.)

Some common complaints are: “This toe hurts, the side of my heel hurts and sometimes the back of it burns. Oh, and then after Zumba, I get this pain in the center of my arch.” (Usually, at this early time in the encounter, it takes all the mental strength you can muster to focus on what they are telling you and not imagining them in a Zumba class.) Naturally, most “onions” have very lengthy histories. Most of that history has absolutely zero relevance to their actual condition whatsoever but it is impossible to interrupt these patients or coax them stay on point. That is the point: surviving the clinic day without having an explosion of angry patients in the waiting room. (Forgive me. I meant the reception area. We would never want to give the impression that a patient may have to wait to see you.)

Your occipital hard drive is already pulling up a long list of your onions and they are flashing across your screen so rapidly -- and with such indelible pixilation -- that you begin to feel full piloerection within every hair follicle on your body, shaved or not.

Okay, so how do we deal with the onion? First, it might help if I gave you the exact profile of what the “onion” patient is just so we are all on the same layer. Now you get it. The onion is the one who has multiple complaints, multiple pathologies (almost always real). When you take care of one of the complaints or layers, take the post-Zumba midfoot pain for example, another source of pain rears its ugliness. You have simply peeled one layer off and the next is pungently exposed.

The honest onion will tell you, “Thanks. That Zumba pain, which was really bad, is not there anymore but now I’ve got this other thing going on.”

Then there are those disoriented, untruthful or just clueless tubers who can never admit anything you do has helped, and that everything is always related. These are very dangerous patients indeed whereas the “happy onion” is a virtual practice management annuity.

Sad onions are another story. They are just like their counterpart vegetable buddies. You cut into them and your eyes start tearing up and burning to a level like the guy who has never lived in the desert and can’t help himself from staring wide eyed at the witnessing of his first haboob. These are the patients we are going to deal with now. Hopefully, I can provide some slight nuggets of insight that may help your clinic day go well. They can be tricky, nasty little veggies but you can manage them with Ginsu-like dexterity. .

Incisive Strategies For Dealing With ‘Onion’ Patients

First, cut them off. I’m talking about stopping patients during the history and physical, not an amputation. Interrupt the patient and say bluntly: “You have many problems, all of which undoubtedly are contributing to your overall pain. However, we have to limit and focus this visit to just two -- your top two concerns.” Smile nicely and add, “That is all we can really effectively deal with during your allotted amount of time today. We have so many other patients to take care of today.”

That’s right. Two complaints. No more. Do not let them give you a list. This will accomplish several things. First, it forces patients to decide what is/are the real problem(s) they want taken care of. Second, this allows them to prioritize their care. They now have some control. Most importantly, you have just limited their 30-minute visit to one hour, instead of that 1.5-hour herbaceous marathon. You just “saved” your clinic day while only losing one or two of the patients from the reception area.

Now what can you do to control the onion further? Educate patients on how you are only going to be successful with the one or two things they have identified and when that pain is gone, they will still have other pains that we can work on together. Then document that. Use drawings, digital photos, voice recordings, videos or a contract written in blood — preferably theirs, not the ooze which is coming out your ears by this time — but document it well. When patients return for the next visit, repeat all of the above and then put your documentation in front of them. Remind them you knocked out onion layer one and two, and move on to the next layer.

With the true onion, your best care ever rendered with the greatest of skill will only do one thing: reveal another pathology. That’s right. The “Zumbaosis” is now cured and magically, another malady appears. You simply cannot win. I have some “onions” that have literally chased me all over the country. One gets into his van yearly for a pilgrimage from the swamps of Louisiana to the desert of Phoenix to show me his new annual layer. Oh, they will often have years, maybe decades, before they get to that next layer but that is the exception. Usually, as soon as you deftly peel one layer, the next appears.

Time to call in the cavalry — the psychiatrist. Really, don’t hesitate. I used to be shy about telling patients they need psychiatric consultation but not now as my corneal sensory nerve endings (branches of the trigeminal nerve by the way) have been so violated by syn-propanethial-S-oxide. What better time to recommend psychiatric care? They might mistake your copiously flowing eye juice as the deepest of doctoral empathy and true concern. Remember, though, you’ve got to be able to manage your onions.


Just mean! Mean-spirited, arrogant rubbish. Each patient is an individual and to dump them all in the same vegetable bin is rubbish. Retire from your profession if it's so bad. Sure, Miss Onion pays her bills, doesn't she? See, not so bad!

Totally disagree with Ned!! Anybody that has a busy practice can totally empathize with Dr. Barrett's blog. We all have these type of patients who can really drain the positive life force out of you. I do exactly what Dr Barrett mentioned, which is try to get them to focus on two main pain generators and treat those before going after the next 20 complaints.

We still treat them with the utmost professionalism and respect in trying to alleviate their podiatry problems in the most conservative manner and hopefully get them to counseling which they sometimes truly need.

So Ned, I will send you Miss Onion for surgery which I would not do, and let you deal with the patient forever being unhappy or even worse getting into a litigation problem. Keep the informative blogs coming Steve as they are always enlightening and informative.

I laughed so hard reading, I almost fell of my chair!! I'm hopeful you wrote this very tongue in cheek!

If you're not, I can't imagine treating a person the way you describe. Do you really tell your patients that are difficult that they only have a certain allotted time with you??? There is certain talent/art to dealing with patients like this, but actually telling me as a patient (even if I'm being difficult) that there are other patients you have to deal with, that I only have a certain amount of time with you, and that you will only deal a couple of my problems outright would have me get up and leave your office.

For those of us that deal with capitated insurance plans, this could turn into a financial disaster. If you don't know why, e-mail me and we'll talk about it.

I've only been in practice 10 years but there are better ways to handle that patient group in my opinion. Maybe I'm just naive.

If one is going to allow 5-10 "Onions" a year to turn the practice into a financial disaster because of capitated insurance plans, that is a sad state for podiatric practices. Dr. Barrett is only giving his opinion on how he deals with the onions. Onions are not the life blood of a practice but a infrequent bump in the road. I like Dr. Barrett's take on this and agree 100% with him.

All it takes is for a couple of disgruntled patients to complain incessantly to the PCP who holds the "Cap" and they can pull the "Cap" from the practice without warning. If you don't have to deal with this situation, you're not really clear on how tenuous a situation this can be.

Glad you agree. I deal with the "onions" differently.

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