Maria Yang, MD

While driving to the clinic, Ms. Blue thought about what she would tell her doctor. She didn’t want to come across as needlessly anxious, but she wanted him to understand how unwell she felt. Was there something wrong with her?

Soon after she was escorted into the examination room, Dr. Refer entered the room.

“Ms. Blue,” he greeted. “How are you?”

“I think I might—well, I’ve been really tired lately.” Ms. Blue paused. “My dad died about a month ago. I haven’t been able to sleep.”

Dr. Refer nodded, inviting her to continue.

“He just didn’t wake up one morning. I guess he died peacefully. He was taking care of Mom, though, and since he died, she’s moved in with my family. I have no idea how he did it for the past five years. She’s… not well.”

“Mm hmm,” Dr. Refer encouraged.

“He had mentioned that, sometimes, she had problems sleeping at night, but he never said anything about her walking around and trying to leave. She gets upset and says something about having to go to work. She can’t get herself together to correctly unlock the door. Thank goodness. But then she screams more.”

Ms. Blue sighed.

“And on those nights when she isn’t going on like that, I find myself lying there, thinking, thinking, thinking. It’s like my mind won’t shut up. I wish I had helped my dad out more. Maybe he would have lived longer.”

“Ms. Blue,” Dr. Refer interjected, “have you been feeling a lot of guilt about his death?”

She looked away.

“I don’t know,” Ms. Blue eventually said.

“With the amount of sleep you’re getting, do you have enough energy during the day to take care of things?”

“Not really. I’ve been taking naps during lunch. The kids have made comments about the coffee I’m drinking after dinner. Even if I had more energy…. I just don’t want to do anything. Things aren’t interesting anymore.”

Dr. Refer nodded.

“Has all of this gotten to the point that you’ve thought about….” He paused and nervously coughed. “… hurting yourself?”

Ms. Blue looked at him and said nothing. He waited, internally wincing.

“I can’t, I can’t,” she said as tears welled in her eyes. “We’ve got kids to support, my husband’s job situation is shaky, and someone has to take care of my mom.”

Dr. Refer coughed again and said, “Let me listen to your heart and lungs, just to make sure they sound okay.” His gaze settled into the middle distance as he moved his stethoscope first across her back, then over her chest. After pushing on her belly, he murmured, “Everything’s fine.”

He settled back onto a chair and looked at her while she wiped her nose with a tissue.

“I think,” he began, “that you might get some benefit from seeing someone. A specialist. Someone who can provide better care for someone in your situation.”

“What do you mean?” Ms. Blue said.

Dr. Refer coughed again.

“Well, some doctors have more experience in helping people who are feeling as… stressed as you are right now.”

She looked at him quizzically. He quickly added, “Your situation is difficult. I can’t imagine how difficult it must be.”

“What are you saying?” she asked.

“Well… I think you might want to consider seeing a psychiatrist.”

She looked at him blankly. He heard the quiet whir of the office ventilation.

She didn’t move. He coughed.

“You think I’m crazy,” she flatly said.

“No, I don’t,” he hastily said. “I think you’re in a tough situation and—”

“You think I’m nuts. You think I need a shrink. Am I really that crazy?” she continued, looking at the floor.

“No, you’re not crazy,” Dr. Refer said. “You’re in a stressful situation. I’m worried about you and I think you would get better care from a psychiatrist right now, given everything that is happening.”

“But why? Don’t you think my reaction is normal? My dad just died, my mom has Alzheimer’s, my husband might get laid off, I want to make sure my kids are provided for—I mean, isn’t this normal?”

“Well, yes—”

“Then I don’t need to see a psychiatrist,” she said. Her eyes began to glisten with tears again when she asked, “Can’t you help me?”

Dr. Refer looked at her. He opened his mouth, then closed it again.

“Yes,” he finally said. Her shoulders dropped and she exhaled. Taking out a prescription pad from his pocket, he scribbled something onto the top sheet and handed it to her.

“What is it?” she asked.

“It’s an antidepressant, but I think that it will help you sleep more through the night. In a few weeks, you should feel better. You might experience some dry mouth, headache, or stomach upset, but that should all go away within a few days,” he said. After scratching his head, Dr. Refer added, “Call me next week to let me know how you’re doing.”

“Okay,” she said. “Thank you, Doctor.”

She walked out of the office, feeling tired, relieved, and embarrassed. What did he give her again? Oh, she could look at it later. She just wanted some time alone.

---

Later, Dr. Refer finished the note for Ms. Blue’s chart.

“Attempted to refer patient to psychiatry for further evaluation and treatment,” he murmured as he moved the pen across the page. “Patient declined referral, but agreed to follow up with me. Provided an antidepressant and asked patient to call me in one week for follow up.”

He dropped the pen on the chart and rubbed his temples.

“I don’t know what I’m doing for her.”

---

This is part of a series about why some physicians write many prescriptions for psychiatric medications. You can read more stories here.

The physical therapist watched the elderly man guide himself with the walker down the hallway. His steps were small, but he walked with confidence.

“How do you like the walker?”

“Oh, I like it,” the elderly man said. “I like the walker. I can lean on it.”

He purposely leaned into the walker to demonstrate its stability.

“It’s like a friend,” he said. He looked down at the walker, then up at the physical therapist.

“Actually, it’s better than a friend because it doesn’t complain.”

They spotted her in the hallway of the hospital. Sensing people approaching, the doctor turned around and saw two young men walking briskly towards her. She recognized one of them. They both looked eager.

“Hey Doc! Here’s a question you can answer,” the familiar face said. Though not even old enough to legally purchase alcohol, he unfortunately had many experiences with hospitals and emergency rooms. His young body, for now, was able to keep up with his often frenetic mind that often propelled him into conflict.

The other one, a close friend of his, had never been a patient in a hospital. He looked at the doctor and gave a half smile in greeting.

“Okay,” she said, inviting them to speak.

“Benadryl,” the naive one said. “That’s an allergy medication, right?”

“No, no, Benadryl is a sedative, right?” the experienced one said. After exchanging glances with both his friend and the doctor, he blurted, “That s— keeps you down!”

An uncomfortable smile crept onto her face. “It’s both. It can help with allergies and, well—”

“—they put it in the needles in the emergency rooms all the time when people are out of control, right?” the experienced one said again, pushing his shoulders back and grinning as he looked at his friend.

She paused.

“Right,” she eventually said. Though her voice was even, her eyebrows furrowed. “Sometimes it’s mixed with other medications to help… people calm down.”

By now, they weren’t listening. The naive one looked surprised. The experienced one was waving his arms in triumph as he exclaimed, “See? What did I tell you?”

“Yeah, but it’s an allergy medication, too,” the naive one countered. They walked away, absorbed in their conversation.

Her eyes watched them slip into the stream of people. She caught herself rubbing her shoulder.

The white coats formed a small circle in the hallway. Rounds were under way and the intern finished presenting the patient. He looked up at the attending physician. The two medical students and other intern followed suit. The senior resident looked blankly at the attending. The nurse taking care of the patient walked by and slowed down, hovering outside of the circle.

Other small circles dotted the hallway, all different teams rounding on their patients.

The door to the room was open. After telling the young physicians that he was tired, the patient asked them to come around another time. He then rolled over and ostensibly fell asleep.

The attending took a sip of coffee from the small paper cup and swallowed.

“Nice presentation,” he began. “But, you all should know that this patient is an sociopathic s—head and should be treated as such.”

The nurse looked down and stifled a cough. The medical students reflexively glanced at each other and raised their eyebrows. The intern scratched the back of his neck. The senior resident looked blankly at the attending.

Thereafter, they all avoided that room as much as possible.

For fun, some people collect things like stamps, coins, and music. I apparently collect data.

One of my goals in 2010 was to keep a record, using Google Maps, of all the restaurants I dined in. New York City has 24,000 restaurants, many of which feature dishes from countries around the world. I wanted to make a record of my culinary travels.

Other than that, I didn’t have further goals in collecting this information. I did wonder what the map and list would look like at the end of the year: What types of cuisines did I eat? Where did I tend to dine? How many restaurants did I visit?

The act of collecting this information is called “self-monitoring”.

It appears that I visited 146 unique restaurants in 2010. Most of them, marked by blue icons, are in Manhattan:

I apparently did not eat in the Upper East Side in 2010. (The lone blue marker near Marcus Garvey Park is Taco Mix, which is essentially an indoor taco truck. The staff there do not speak English and there are no menus, but the tacos are tasty.)

Here is a a graph that describes the types of cuisine I most frequently ate:

That American category includes diners, those establishments that are open 24 hours a day and feature hundreds of items of their menus, ranging from silver dollar pancakes to broiled lobster tails. The “Mexican fast food” category includes two different Chipotles and one Taco Bell. (I had not eaten at a Taco Bell in over a decade and went there for that exact reason.)

Here is the remainder of the list:

• Korean
• Middle Eastern/Mediterranean
• Burgers
• Vietnamese
• Italian
• Lodging (1 hotel restaurant and 2 bed and breakfasts)
• Greek
• Jewish deli
• Vegetarian/Vegan
• South American
• American fast food
• Malaysian
• French Caribbean
• Asian fusion
• Caribbean
• Russian
• Cambodian
• Himalayan
• Airport (not a type of cuisine, but a class in its own right—Charlotte, NC, in this case)
• Polish
• Filipino
• Bagel
• Cuban
• Peruvian
• Venezualan
• Indonesian

I apparently favored restaurants that feature cuisine from the Asian continent. Foods from Africa, Australia, and Antarctica (…) are missing. Now that I know this, I could seek out foods from those regions. (I am surprised that I did not eat any Ethiopian food in 2010. There is an Australian savory pie shop in Manhattan that I visited in 2008.)

While most of the restaurants I ate at were in the state of New York, I also ate elsewhere:

Other things I could look at:

• What was the average cost of my meals over the year?
• Who did I eat with most often?
• On which day of the week was I most likely to go out to eat?

Is this sort of data gathering self-indulgent? Sure. But, ample evidence supports self-monitoring as a means of changing behavior. This kind of data gathering helps people figure out (1) where they are now and (2) where they want to go. It helps with setting and reaching goals, even if there is no initial intention to change.

Tracking weight over time is a strategy used to help with weight loss. Doctors and nurses encourage people with diabetes to track their blood sugars regularly because the act of following it increases the likelihood that the values will fall within a healthy range. Measuring how much time you spend checking your e-mail each day may give you some information about how connected—or disconnected—you are.

Consider tracking some data about yourself in 2011. It doesn’t have to be anything “serious” like tracking your finances. If you’re not already doing that in some capacity, jumping straight into that may actually be punishing. The initial exercise should ideally be interesting and fun. (Try Joe’s Goals.) Once you’re comfortable with self-monitoring and have found it useful, then you can tackle more “serious” topics.

Self-monitoring can help you change your own behavior and your own story for the better.