I'm a primary care physician, but with my young adult patients, I'm secretly a therapist, too.
When a new patient between the ages of 18 and 25 arrives at my office, he or she generally has a specific request: a physical exam as clearance for football season, a refill of an asthma inhaler, reassurance that a sore throat isn't strep. These young men and women are healthy and don't expect to be asked very much, or little beyond the usual waiting room questionnaire.
My job, as I see it, is not only to respond to any requests or questions, but also to ask them about the things 18- to 25-year-olds do: attend college (or consider it), search for employment, separate from (or return to live with) parents, find romantic partners, shrug off one-night stands, run out of money, feel confused or depressed or anxious, experiment with drugs and alcohol.
The last topic is of special concern for me. I've seen too many people get sidetracked by drugs; I don't want to miss any signs.
Early in my career, I wasn't planning to act as a therapist — I was trained mostly to listen to hearts and lungs and feel for lymph nodes — but once I started seeing young adults I discovered the unspoken problems and hidden distress I should be looking for. Not that these young patients think of encounters with me as psychotherapy, God forbid; we're just talking.
In my experience, most young adults rarely, if ever, have a personal, 30-minute conversation with an adult. They talk mostly to people their own age. To my patients I'm a curious stranger with whom they're stuck for a while in a small room. Fortunately, most of them like talking about themselves, about their decisions and doubts. They know that after half an hour we will part company, that what they've told me goes no further. If I do my job well, they might just stumble into telling their story.
Lidia, 22, and soon to graduate college, comes in wearing jeans and a T-shirt that reads OBEY. Some minutes after we've discussed the reason for this appointment — eczema — I say: "I'm interested in how you would compare yourself today to your 18-year-old self. Do you feel like you're moving along into adulthood?"
She looks surprised by my question. But to hear about Lidia's life, I need to be broadly interested and indirect. The question defuses the pressure of asking about private things and gets her talking.
"I'm better at handling problems than I was a few years ago," she says. "I don't depend on my parents for everything. In the old days, when I had trouble with a roommate, I might have called my parents and moved home. Now I just wait for the lease to end."
I want to hear a full self-portrait, so I ask, "What things are most important to you at the moment?"
"Getting a job, completing school, putting my parents' minds at ease, making my own happiness even if it feels hard at times or I don't know what will make me happy."
By bringing up "happiness," she has given me an opening to wander into the topic of drugs.
"Does marijuana or alcohol play a part in your happiness?" I ask.
"I don't drink much because I don't like feeling hung over, but I'm smoking more weed than I was last year. I'm flipping between if I should stop and if I'm just gonna have some fun. Back and forth."
Marijuana use peaks between the ages of 19 and 22. According to surveys, 15 to 20 percent of this age group has smoked in the past month. Yet these young adults often have exaggerated perceptions about their peers' use, estimating more than half the people their age smoke pot. Sometimes I set them straight about the norms, but with Lidia I withhold this information because I don't want to break the flow of our conversation.
Rather than ask about the specifics — the amount and her frequency of use — and put her on the spot, I ask, "It's hard to think about the next week, but where do you think you'd like your marijuana use to be in a year?"
Look back to when you were 18, I'm suggesting again, and now look forward.
"I don't want to stop completely because it would weird out my friends. But I could if I had to, like if my job was going to test me, or if I had to save money."
I listen carefully for the reasons Lidia gives, trying to hear if I should be worried that her marijuana use is problematic. I'm not overly troubled when she says, "I don't think marijuana affects me like it does a lot of people." She may underestimate the effects of marijuana or perhaps marijuana does not affect her negatively at all. What's key is that she doesn't mention that she smokes to forget her troubles, or because she's sad or nervous, phrases that would suggest there's a larger problem.
With David I worry. David, 19, short-haired and big-eared, a part-time community college student, informs me that he wants to be "a great decision-maker." He reports the pride of owning a new laptop, telling me "bills create discipline." But then, as if the word "discipline" reminds him of something, he says: "My mom is going back to jail. She didn't make the right decisions in the free world." He adds: "That makes me push toward drugs. It helps me deal with it."
David isn't sure how to deal with the stress he's under. "I want to be a man of stature, but there's pressure on my shoulders," he says. "I'm not sure how to cope with what I'm going through."
As with Lidia, there is no specific amount or frequency of marijuana use that is acceptable or unacceptable; there is no magic number I'm waiting for David to announce so that I can give him a label, and offer him counsel. But if someone is smoking daily and during daylight hours, I pay special attention, so when David tells me he smokes "either before or after noon," a red flag goes up.
Here's what I'm trying to differentiate: Is this person using marijuana for fun, because it's what friends do when they're together, or to mitigate negative feelings? Using marijuana "to cope" is often a marker for other pathology — serious mental health problems, anxiety, attention deficit disorder, concurrent alcohol abuse, major depression. That's what I'll want to hear more about next time with David.
Although I'm concerned about his drug use and his admission of distress, this first visit is an orientation, an introduction. I will ask him to come see me again, and soon. Sometimes a person like David will return for more primary care, interested in himself, worried about himself, intrigued by the idiosyncrasies of an adult conversation, and I will continue to evaluate him. Sometimes people like David never reappear, perhaps embarrassed by what they've admitted or upset by my prying.
Life often changes dramatically in a matter of months at their age, sometimes physically, but more often psychically. New pleasures come along, and also new risks, new forms of distress that are deep and real and need attention. But this is not likely to be revealed unless a young adult is encouraged to find his or her way to a primary care doctor, and unless that doctor accepts that this may be the one conversation with an adult for this patient this season, and tries to understand what's happening in the full life of a David or a Lidia, a young adult who may have arrived asking simply for a refill.
Some details have been altered to protect patient privacy.
Michael Stein, a professor of medicine and of health services, policy and practice at Brown University, is the author of "The Addict: One Patient, One Doctor, One Year" and "The Lonely Patient: How We Experience Illness."