When to potty train?

As a physician of a significant pediatric population, I am often asked questions about potty training… when it goes well, it goes well. When it does not, parents think/talk about it for years.

When to start potty training? More than 2/3 of US children achieve what is considered the cognitive and emotional development necessary for toilet training by 18 to 30 months of age. This also means that as many as 1/3 of children are NOT ready until nearer to age 3 or afterwards.

How do parents assess a child’s readiness? They need to walk, put on and remove clothes, follow simple instructions and have social awareness including an interest in using the toilet. Children may also show awareness of the need to urinate or defecate and discomfort sitting in soiled diapers. Other signs of readiness are asking to wear “big kid” underwear, regular predictable bowel movements and nighttime bowel control, stays dry for 2 hours at a time or during naps.

What if the child can urinate into the toilet, but refuses to defecate in the toilet? This happens in about 20% of children. The causes are many: pain from constipation, fears regarding defecation or using the toilet, local sin irritation. This is more common in children who bgin training after 3 1/2 years of age. First, your physician should rule out organc causes. Once that is done, avoid any advances in training for a few weeks and just observe to identify psychosocial issues causing the child to not want to defecate into the toilet. Some children will only defecate in a diaper or will hide to defecate. These issues will resolve. Rarely, your physician will refer your child to occupation or physical therapist, behavioral therapists or developmental pediatricians. Children with Down syndrome, autism or cerebral palsy may have more issues with toilet training.

I hope this helps.

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As an academic family physician, I have taught hundreds of medical students at and resident physicians over my 20+ years of teaching.

The article below is a powerful reminder of each of our vulnerabilities and what we think we are teaching may be different from what the learner learns.


My loves…
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Do Omega-3 fatty acids prevent cardiovascular disease?

Do Omega-3 fatty acids prevent cardiovascular disease?

Omega-3 fatty acids are primarily found in fish oil.  An American Heart Association report suggested that omega-3 supplements may reduce death from coronary heart disease, possibly through a reduction in ischemia-induced sudden cardiac death.  The report found that the omega-e supplements do not reduce the incidence of recurrent nonfatal heart attacks.  The AHA stated that the benefits of taking omega-e supplements may outweigh the risks. 

There was a recent meta-analysis of 79 research studies with a combined 112,000 patients.  This showed that there was no significant benefits with long-chain omega-3 supplements for preventing all-cause mortality or cardiovascular mortality or cardiovascular events or irregular heartbeats or stroke. 

It is possible that omega-3 fatty acids that are found in foods may have different health effects than a capsule because they may replace consumption of less healthy foods (like decreasing saturated fat intake or salt) as well as provide other beneficial nutrients (like selenium, magnesium, calcium).

My advice is to spend your money on better food (fish anyone?!) and not on omega-3 supplements like mackerel, sardines, herring, oysters, salmon, anchovies, AND flax seed.

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Electronic cigarettes.

Electronic cigarettes

Department of Health and Human Services e-cigarette picture

E-cigarettes are popular devices that head a liquid that becomes an aerosol or a vapor. 

Are e-cigarettes healthier than smoking cigarettes? Long-term health effects of e-cigarettes are unknown.  They are not known to be healthier.  Despite this, many adults try to reduce or quit cigarette smoking by switching to e-cigarettes. 

What are the risks of c-cigarettes?  Exposure to heavy metals and toxicants and nicotine poisoning.  When youth start using e-cigarettes there is an increased risk of subsequent cigarette and marijuana use. 

Rampant use:  In 2017 one in five high school students reported using e-cigarettes in the previous year.

What else are e-cigarettes called?  Juuling.  Vaping.  Digital cigarettes.  E-hookahs, Personal vaporizers. Vape pods. Vape pens.

What are e-cigarette brands?  Blu. Juul. Logic. Njoy. PHIX. Suorin. Vuse.

Why is vaping in teens especially detrimental?  It is accessible. The devices are small enough to fit in their pocket for ease of use, even during class. Nicotine has a greater effect on their brains, which continue to develop into their 20s.  Nicotine can impact brain pathways that control learning, mood, attention, and addiction.

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Burning Man. Musings from the playa

Burning Man. Musings from the playa.

As I biked around Black Rock City during the 2019 Burning Man Event, I came across so many poignant signs. One that I was especially drawn to was a bright pink lounge with a quote “Love more, fear less. Float more. Steer less.” This may be my mantra from this year’s Event.

Picture courtesy of Dr. Greenberg while biking along the Burning Man Esplanade.  The “steer less” was cut off…

I have always loved with my whole heart and have not been fearful. So, that part of the phrase was not as meaningful to me. But, I am a woman who steers like there is no tomorrow.

As a forward-thinking professional I have always worked a to-do list with an end-goal in mind: Doing well at Northwestern to position myself well to get into medical school, master new physician skills to perform better patient care, schedule the births of my first two children (our third child was just an unexpected blessing!), orchestrate a move back to our hometown to practice medicine.

Now that I am nearing my 50th birthday and my teenagers are “leaving the nest” I am waxing poetic on the whys and pace of life. I indeed would like to float more and steer less. I would like the future to unfold and for me to orchestrate less. This is emotionally freeing. I urge you to find a mantra that speaks to you and explore it.

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Burning Man Physician.

Burning Man Physician. I recently worked at the Burning Man event. What an experience! I doctored in the main medical tent on the main Esplanade.

It was a refreshing experience as the patients were thankful and had varied medical ailments and the paperwork side of doctoring was minimal. To make the experience even better the medical care (including physician care, x-rays, tetanus vaccines, and medications) were given free!

The medical tent was staffed with both family medicine and emergency medicine attending physicians, resident physicians, and a few medical students. There was always a full time pharmacist and x ray technician. Nurses and EMTs started many IVs to help patients receive IV fluids and medications. Many of the first-aid workers at the outlying minor medical tents were physicians themselves in other states and gave excellent care “in the field/playa.”

I worked four 12-hour shifts at Burning Man and I was known as “Dr. Leslie.” I went from cot to cot treating abscesses, dehydration, corneal abrasions, fractures as well as routine medical issues that any town of 70,000 people would have. It was an excellent experience for all involved. The patients frequently thanked all the members of the medical tent for providing their services. And, I think they also appreciated the clean and cool environment as a respite from the austere Black Rock Desert with the associated heat and dust storms.

I definitely enjoyed my first Burn.

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The male exam.

The male exam. What is the purpose of the male exam? It should incorporate evidenced-based guidelines, focus on prevention and health care promotion, ask about substance abuse, sexually transmitted diseases, diet, exercise, safety and depression screen.

Men aged 50-74 are doing poorer health wise than in the past. This is often due to self-imposed factors: substance abuse (tobacco, alcohol, or drugs) and not being safe.

Your physician should be a support system for you and should help with depression intervention.

In fact, well men often do not come in to see a physician. So, a physician’s should address possible depression.

What screenings should be done?

1. Blood pressure. The bp goal is less than 135/85,

2. Cholesterol screen (if older than 35),

3. Abdominal aortic aneurysm. An ultrasound of the abdomen is warranted for men aged 65-75 if they have ever (!) smoked.

4. Prostate cancer. Should you have PSA screening? There is insufficient evidence to screen for prostate cancer with a PSA lab test. You and your doctor should talk about should YOU be tested. If the patient has BPH with increasing symptoms or a strong family history of prostate cancer, this may be a warranted lab test. We also have to consider how good are the treatments?

5. Colon cancer. Should you have colorectal screening? Yes! If you are between 50 and 75 years of age. Colonoscopy is the gold standard (meaning the best test).

6. Lung cancer. Low dose CT scan of lung, if you have a 30 pack year history of smoking and you are between the ages of 55-80.

We no longer screen for testicular cancer and COPD. Although, patients should know their bodies… if they feel a lump on their testicle or have lung issues, tell your physician for an appropriate work up.

Physicians should Ask about safety issues: helmet use (motorcycle and bicycle and horseback riding), gun use (store guns and ammunition separately in locked safes), risky behavior including drugs, tobacco and alcohol.

And, obesity. 35% of men older than 50 are obese. Obesity is considered a BMI > 30. Want to know your BMI? https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Alcohol intake should take in 2 drinks or less per day to maintain health. When binge drinking men should drink 4 or less drinks at a time.

Make sure you have age-appropriate vaccinations. We suggest the influenza vaccine every fall. Tdap vaccines should be given once as an adult (or if you have exposure to infants) and even though it is a needed vaccine, your insurance may not pay for it. Td should be given every 10 years. Shingrix (2 vaccines) should be given after age 50 and be prepared for needing to be on a waitlist at your pharmacy to get this. Two pneumonia vaccines should be given: one vaccine at age 65 and one at 66. Your vaccine schedule may differ from the above if you have specific risk factors. Talk to your physician.

Statistics: 48% of men do not exercise regularly. 33% are obese. 32% have 5+ alcoholic drinks at least once. 31% have hypertension. 22% of men smoke. 20% of those under age 65 do not have insurance (How do they get routine medical care?). 12% of males rate their health as “poor.”

How to be healthier?

1. Drink less than 14 drinks per week.

2. Address depression.

3. Eat a healthy diet (4 helpings of veggies, decrease sodium and saturated fat and cholesterol and sugar).

4. Decrease lifestyle risks. Exercise 30 minutes most days of the week (The goal is 150 minutes or more). Cross-training is helpful. As we age, our muscle mass decreases and so strength training is important. Balance training over the age of 70 will help you not fall (and break a hip or have a head injury.)

I hope this helps…

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