Slicing A Patient's Complaints Down One Layer At A Time
- Stephen Barrett DPM FACFAS
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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.