It's well documented that primary care physicians help many of our patients with psychosocial problems. Our medical student today was surprised that nearly all of the patients had some such issues that we addressed. One middle-aged man who suffers from attention deficit disorder was a Polaroid photograph of a man depicted in one of the later chapters of Edward Hallowell's book "Delivered from Distraction" His wife is so angry at him for all of the unfinished tasks in good intentions, and he feels so guilty for his years of inability to "function normally" that it is nearly destroyed their marriage. Medications are helpful, counseling is helpful, but this disorder has certainly taken its toll and he is now working very hard to learn new skills and applied his extraordinary aptitude to this persistent problem. And an elderly man with depression who told me that "I never thought that I would be someone who was referred to a counselor for problems with my mental health." and as I (insensitive Lee) explained to the medical student who was listening to her conversation, I suggested that he was of the generation that considered counseling to be unusual and abnormal. Turning to her, I asked what percentage of her medical school class had likely sought the assistance of the counselor. She surprised me by responding with what I expect was a rather accurate response "50%." All of this led to a rather interesting conversation of normalcy and "what is normal." he described his personal efforts and hopes that he would be able to "self analyze" his predicament and then give himself advice for how to resolve things. I took a rather different perspective. "I don't speak Portuguese. It's not because I'm stupid or weak or abnormal. It's just that no one taught me. He looked at me funny. "So couldn't it be just that you haven't learned the skills to help you with this?" That's how I see counseling. Patients who do well with counseling are patients who learn new skills to help them cope with the enormous pressures and problems they encounter in their daily lives. By marketing counseling in this way, I think it makes the whole experience more palpable for patients. Unfortunately, it doesn't always work out that way. Some counselors are excellent and share this vision and expectations. And other counselors (at least as my patients report the interactions) take notes, listen, interject their own personal agendas and so on. So I'm never quite sure what my patient will be getting on and make such a referral. Most of the time things go very well. And that's good.