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Interviewer: For patients with lung disease, deciding what medical center you'll partner with for a lung transplant is a big decision and there are a lot of factors to take into consideration. But today, we're going to help answer some of those questions you might have.

Dr. Matthew Morrell, he's dedicated his career to ensuring patients who need lung transplants get them and also have the best outcomes possible. He's been at some of the biggest lung transplant centers in the United States, and now he's the medical director of The Lung Transplant Program at University of Utah Health.

Dr. Morrell, thank you for sharing your expertise. And the first question is I learned that sometimes a patient diagnosed with lung failure isn't even told that a lung transplant is an option. That really surprises me. Explain that for me.

Dr. Morrell: Honestly, it's interesting. Not a lot of people or lung doctors in the community even think this is an option. There's a lot of misinformation, miscommunication between providers and patients that are out there. So our goal has really been to reach out to providers, to reach out to doctors, to really educate them about lung transplant as a potential option.

Interviewer: So if a patient has been . . . if that's never been mentioned, or they've been told, "Maybe that's not an option," it might be a good idea to seek out a second opinion.

Dr. Morrell: That's exactly right. So we here at the University of Utah, we're always willing to talk to any patient that has any questions, even those that don't necessarily even have a referral from a lung doctor, their lung doctor isn't in the community. We've seen patients that call up and just want to say, "Hey, I want to speak to somebody that can give me more information about lung transplant," and, "Hey, am I a candidate? What makes a good candidate? What doesn't?"

Interviewer: Yeah. Obviously, you know all those things. You live it every day. Let's say a patient has been told that they are a candidate for a lung transplant, or maybe that's an option they should consider. Based on what you just said, maybe a patient thinks that a transplant would be a good option for them. Does the patient get to pick the medical center where the procedure is done, or is it kind of when I've got a cold, I'm going to go to the nearest InstaCare?

Dr. Morrell: Well, patients, yes, they have the option of choosing where they want to go to get their lung transplant. Insurance sometimes does dictate where they can go, but honestly, if a patient says, "Hey, I want to come to University of Utah," they just talk to the provider, and that provider can make that referral down to us.

Interviewer: So that's great that a patient gets to choose. In a way, that's great, right? But it also comes with a lot of decisions that have to be made, a lot of things that have to be weighed. So what would you say to a patient that's trying to make that decision of choosing a center? What are some of the things they should consider?

Dr. Morrell: Well, honestly, you want to look at the center's history. How long has that center been doing lung transplants? How many patients have they transplanted? How many patients do they transplant a year? Are they doing research in the field of lung transplantation at that institution?

And also, talk to patients that have actually had transplants there. We can give you the names of a couple of patients that have had transplants and you can call them, speak with them, and they can tell you their personal opinion about how that process was for them.

You can speak to a coordinator and get your questions addressed even before even coming to the University of Utah. And when you do come for your initial appointment, it's mostly a meet-and-greet. No pressure. It's just an information gathering. How do you feel? Have you made that bond with that physician? Is that physician someone who you can trust? Is that someone who you want to be your advocate for you going forward as you get evaluated for lung transplant?

Interviewer: One of the challenging things for lung transplantation is you're on that waiting list and you're waiting for that match, that donor match to come. And sometimes, it can just by chance come very quickly, or sometimes it might take a while. Are there things that are done at particular institutions such as University of Utah that could help increase the chances that a lung donor gets a match more quickly?

Dr. Morrell: Oh, absolutely. So we are the only lung transplant program in the Intermountain West. So that means that not only do we see a lot of patients from not only inside of Utah, but the surrounding states, Colorado, Nevada, Oregon, Idaho, Montana, parts of Arizona. We're getting patients referred to us.

On top of that, we have to get donors. If there's a donor that is in another state, that does come to us. So we do have a lot more access to some of these donors versus if you were living in a city like Los Angeles. There are a lot of other centers there. There's a handful of lung transplant centers.

And so there's a lot of competition when a donor becomes available to try and match that to a recipient versus us. We're it in the Intermountain West. So if you get evaluated and get placed on the list, your chances of getting a transplant are pretty good.

Interviewer: Another consideration with lung transplant is rejection. But technology and techniques are improving. Tell me about some of the things that are done at University of Utah Health that help reduce that risk of rejection and help treat rejection.

Dr. Morrell: We are very aggressive once a patient gets a transplant in terms of keeping an eye on someone's lung function, on their blood work. We have patients coming pretty frequently after surgery for follow-up when rejection is the highest. So if rejection is going to happen, we catch it firsthand and we deal with it.

We're involved in some of these research trials for some of these new medications to treat rejection. So if rejection is going to happen, we catch it early, we handle it, we treat it, we resolve it. And for those patients that may have rejection that is more difficult to control, we're using the cutting-edge research technology to cure rejection, to overcome it, and to improve survival.

Interviewer: Another component of lung transplantation is the average life expectancy after a lung transplant, which kind of shocked me. It's about five years. I thought it was a lot longer than that. But are there some things that you can do that actually will help stretch that out?

Dr. Morrell: We are very vigilant at catching problems if they do happen. We have access to nutritionists, a physical therapist that if someone has something that could affect their overall survival, we have access to state-of-the-art therapies even outside of lung transplant here at the hospital that can really help and improve survival.

Interviewer: What I'm really getting about lung transplantation, the skill of the team that is doing the transplant is super important. But with lung transplantation, it sounds like the work that's done before the transplant, and even the work after the transplant, is really important. And that a patient should feel as though when they're at an institution, that if they have an issue, they're going to be able to contact somebody, and that they're going to hear back from the department. I mean, it sounds like that could be a matter of getting more years out of your transplant or not.

Dr. Morrell: Exactly. There's always a nurse coordinator here on call 24/7. There's a pulmonologist on call 24/7. And along that pre-transplant side of things, as you mentioned, I want to add that we encourage patients to come early for their evaluation so we can take a look at you. And if there is a problem, if there's something we can work on, if you're a little bit overweight, we can address that, get you to lose weight. If you need some exercise, some rehab, we get you plugged into that too. If your heart needs to be looked at, we get you into the cardiologist.

We want to have that time to really optimize you, to get you in the best shape you can be prior to your surgery, prior to your transplant, to really have you be that patient that exceeds that average survival, that you're that patient that 25 years out from transplant, you're loving life, you're active, you're traveling, you're living life to the fullest, and you're as healthy as you can be.

Interviewer: So the average time of survival is five years, but you just mentioned 25 years.

Dr. Morrell: Oh, yeah.

Interviewer: It can go much longer than that.

Dr. Morrell: Oh, yeah. That's the average survival. You take everyone that's had a transplant.

So sometimes in transplant . . . and again, not just here, this is everywhere in the world. Sometimes patients are super sick at the time when they go on that list. They may have some medical problems that ultimately recur after transplant, and sometimes they die within that first year.

On the opposite end of the spectrum, we have patients that are over 20 years out. It's so rewarding to me to see these patients that are doing so well. It's wonderful. That's why I do what I do.

Interviewer: Are you pretty good at being able to determine when a patient gets a lung transplant kind of what the average survival rate might be for that particular patient?

Dr. Morrell: Yeah, I think we get a general sense when someone does come. We take a look at somebody, we know their medical history, we go into very, very good detail, and so we do know risk factors. "Hey, I say because of X, Y, and Z, because of your previous chest surgery, because you're on this medication, this specific one, that you do fall into this high-risk category. You may be somebody that we really have to hope for the best for after transplant. If we choose to put you on the list, complications may happen."

When patients come for their evaluation, we don't want to commit them to a transplant early. We don't want to potentially shorten your survival by saying, "Hey, we're going to do a transplant even though you're not quite sick enough for a transplant." We do these early referrals that allow us to work on some of these modifiable risk factors that can influence survival.

But if we have time beforehand, we'll say, "Hey, you know what? Things look good right now, but let's have you come back in six months and if you start getting sicker, if you start needing more oxygen, and if your lungs start limiting your activity level, you may kind of be pushed into that gray zone where we say, 'Okay, now is the time. Now is the time when we need to get you on that list because based upon my assessment, you may not live without a transplant longer than a year. So now may be the time to get you on the list to really improve . . .'" The goals of transplants are improve longevity, improve quantity of life, and also improve quality of life.

Interviewer: If you want to learn more, just Google "lung transplant at University of Utah Health." There are a lot of great resources on that page there, including types of lung disease and the transplant surgeries that you might need for those. There's "The 10 Things to Know About Lung Transplant," patient stories about their transplant experience at University of Utah Health. Again, just Google "lung transplant University of Utah Health" to get those stories.

Dr. Morrell, thank you very much.

Interviewer: You hurt your back. What can you do on your own, and when should you go see a doctor? Dr. Andrew Joyce is a physical medicine and rehabilitation specialist. He's also an expert at helping patients manage neck and back pain.

Dr. Joyce, I was shocked to find out that low back pain is the number two reason Americans see their healthcare provider. Is it for this kind of acute back pain that we're talking about that they're usually seeing their doctor for?

Dr. Joyce: In most cases, yes. I think a lot of people have chronic low back pain as well, but I think most of us tend to see a lot of acute low back pain, and particularly my primary care colleagues see tons of it.

Interviewer: And we're talking in this particular Q&A that we're doing together about acute back pain, which is back pain that you were just doing something and you hurt yourself, right? Is that kind of what we're talking about there?

Dr. Joyce: Yeah. And it doesn't even have to be doing anything in particular, but you wake up, you have back pain, and you don't know where it came from. Or you were lifting something and tweaked something, threw out their back is a common phrase that people will use, all of those count as what we're talking about today.

Interviewer: And technically, when you say "acute back pain," that's back pain that lasts less than four weeks, right, four weeks or less?

Dr. Joyce: Depending on which guidelines you use, some people say four weeks, some people say less than six weeks, but somewhere in that range.

Interviewer: All right. So, but if I hurt my back like one day, I don't know how long it's going to last. So is there a better way to kind of determine what type of back pain I have? I suppose if I was doing something, it's pretty obvious that, oh, well, I tweaked my back doing that. But like this wake up scenario, how could I tell that maybe that isn't a symptom of something bigger? Because a lot of times back pain is a symptom of other things, isn't it, you've got to kind of rule out?

Dr. Joyce: Yeah. Yeah. And so that's when we start looking at kind of these what we call red flags. So it's very common that people will hurt their back, and oftentimes the pain can be very severe and debilitating. Severity doesn't always correspond with something being necessarily worse. There's actually set of red flags that we look for to kind of try to triage and look for people who might be at risk for having other sources of back pain that warrant further investigation.

Interviewer: All right. So before we kind of get to then acute back pain, I think it's really important to hit those kind of red flags to somebody can make an informed decision that they need to see their healthcare provider sooner than later, or trying to take care over themselves. What are those red flags?

Dr. Joyce: Big ones are trauma. Obviously, if you were like in a car accident, that would factor in. If you have new fevers, numbness, tingling, weakness in your legs. If you have a history of cancer, if you're having any bowel or bladder changes, you use any blood thinners, have cancer, have IV drug use, all these things could put potentially be risk factors. And those were reasons that we'd want you to be evaluated more soon.

Interviewer: And if a patient doesn't believe that that's the case, if they truly just believe, oh, I must have slept funny, or I did something, what can a patient do on their own for acute back pain before they need to see a doctor? What are some recommendations you would have?

Dr. Joyce: Yeah. So the first thing we actually recommend is that you avoid bed rest. Fifty years ago, everyone got recommended, "Oh, just stay in bed, let yourself heal." And what we found is that we were actually giving people a lot of bad advice.

What we recommend now is actually that you try to stay as active as you can tolerate. For most people when they're having an acute back pain flare, they're pretty uncomfortable. So even simple things like getting up, showering, cooking a meal, eating can be somewhat uncomfortable, but our recommendations are to actually try to stay active because recovery is faster when you do that.

Interviewer: And is that because you're getting more blood to the area? What's going on there? Do we know?

Dr. Joyce: I'm not sure if we have exact answers on that. Some of it is that we're probably reducing some of the stiffness. When people have a lot of back pain, they don't move their muscles, they get really stiff and that can cause more pain.

I think we're also testing it. Some people with back pain are really afraid that they're going to do damage and so they don't do anything. And so then their muscles start getting weaker. Within a week, you can lose a large percentage of your overall muscle mass just by not moving and staying in bed. And so by keeping your muscle strong and keeping you moving, you help stretch and strengthen those muscles and help your body on the way to recovery.

Interviewer: And this extra moving, you're not going to hurt yourself most of the time. Is that correct?

Dr. Joyce: As long as you don't have one of those red flags, in most cases, you are able to go out and do whatever you need to do, knowing that there may still be some pain due to this flare-up. But it's safe to go out and be active. In fact, it's kind of the treatment of choice at that early stage.

Interviewer: All right. So get active or just be active as much as you can tolerate. What are some other things that a person could do before they go see a doctor?

Dr. Joyce: They can try over-the-counter medications. So nowadays, we have the Salonpas patches or other lidocaine patches that people can use. There are a variety of topical creams. There's Tylenol. There's oral anti-inflammatories that people can take. All of those are over-the-counter and are medications that patients can try out.

Additionally, this somewhat depends on your insurance plan, but sometimes you can get direct access to physical therapy without even needing to see a doctor in certain cases. And so that's often a reasonable place to start.

Interviewer: And then what amount of time doing those types of things should a patient wait until they start to see some relief or start to be concerned that, "Oh, maybe this isn't acute"?

Dr. Joyce: Yeah. So I would give it at least two weeks and see how you're feeling at that point. If at that point you're not getting better, that might be a good time to at least start scheduling an appointment with your doctor. Most patients with back pain will recover within two weeks.

The next set will kind of get better over the course of six weeks. And definitely if it's been over six weeks, it's probably worth seeing a physician to evaluate you.

Interviewer: And then when you come into your physician, you could go to a primary care physician, or could you come to an expert such as yourself at that point? What would you recommend there?

Dr. Joyce: If you have a good, established care with a primary care physician, I think that's a great place to start, and they will often be able to help you. If you have any concerns, or if for some reason you're not able to get in, or you don't have a primary care physician, we're always happy to see people and get people in from the ground up and make sure that they're getting treated appropriately.

Interviewer: All right. And then what types of things would you do at that point for a patient that has gone two to four weeks not necessarily seeing the kind of recovery that they'd like? What are you looking for at that point?

Dr. Joyce: Yeah. So, at that point, we likely would get some imaging, probably starting with an X-ray, just to check to see that the bony structures are intact and there's no new issues. And sometimes there are things on the X-rays that can clue us into other potential sources of pain that we might not otherwise be able to see just from our physical examination.

We'd prefer a full history and a physical examination to really get a better picture of the back pain and understand how it fits in with your other medical conditions and if there's any other rarer conditions that we really need to be looking at.

At that point, then we make a decision, based on everything, on what the next treatment plan should be, whether it be a formal referral to physical therapy, whether it be more advanced imaging in preparation for certain procedures, and considering different injections.

Interviewer: What about surgery at that point, or when does that come into play?

Dr. Joyce: Most patients don't need surgery. And that's one of the great things. The natural history of these, which means how people do if we do nothing and just let people live their lives, is that most people recover with it over time. It just can be very debilitating during that time.

And so, in most cases, surgery isn't recommended. If you do have one of those red flags, I think it's worthwhile to get evaluated, and then we can see whether surgery makes sense. But in most cases, there's nonsurgical options that we will try first and see if we can help get this under control or get your pain better before having you meet with the surgeons.

Interviewer: And then how about you using opioid medications for back pain? Is that ever a good idea?

Dr. Joyce: In most cases, I would say probably not. There are always exceptions to the rule, so I don't want to say never. But in general, opioids aren't really a first-line treatment for back pain. And if you look at the CDC or you look at other organizations, such as the American Academy of Family Medicine, they don't recommend opioids. And part of the reason is that they've been shown to have higher risks, which we all know through the opioid epidemic, but also no significant benefit when compared to other over-the-counter medications. So Tylenol and Advil versus opioids, the studies show that they're roughly equal in terms of controlling the pain and the opioids carry a much greater risk. So, in most cases, we try our best to avoid opioids because we don't want to risk our patient's health.

Interviewer: And when you're talking about over-the-counter painkillers for back pain, do you just follow the directions on the boxes to what your dosage should be, or generally do you recommend to your patients a higher dosage?

Dr. Joyce: It depends on the medication, but, in general, I probably will recommend for Tylenol, you can take up to two Extra Strength Tylenols, and you can do that three times a day as kind of a high-level dose of Tylenol.

And then for the anti-inflammatories, the low doses of the medication tend to be more pain relievers. And at the higher doses, they tend to have a little bit more anti-inflammatory effect. And so sometimes, for a medication like Advil, we can recommend up to three tablets of regular Advil three times a day.

Any more than that, you should probably be seeing a doctor or checking in with them to make sure you're not using too much medication because that can have other side effects.

Interviewer: What should you do if you suspect your child is doing drugs? It's a scary moment for any parent. I mean, how do you know for sure? What's the best strategy for talking to them about it? How much can you do on your own and when should you see a professional?

I'm going to answer those questions with our expert today, Dr. Mary Steinmann. She's a psychiatrist who specializes in child and adolescent psychiatry.

Dr. Steinmann, let's start at the beginning here. We're going to cover a lot of ground today. But what is the first thing a parent should consider if they have a reason to believe that their child may be using some sort of a substance?

Dr. Steinmann: So I think there's definitely a difference between experimenting with substances and actually developing a substance use disorder. And so it can actually be fairly normative or expected behavior in children and adolescents to be curious about or experiment with substances. But we also know that using substances can really place individuals at risk of developing later substance use disorders. So it's something that we want to take very seriously and be able to help parents identify signs in their own children that may warrant additional questioning or additional evaluation or perhaps even getting additional help and support and resources.

Interviewer: Yeah. So if experimentation can be normal . . . I would imagine as a parent, as soon as I saw my kids or had the idea my kids were using drugs at all, I would be like, "Oh, they've got a problem." But you're saying that that's not always the case?

Dr. Steinmann: That's right. It's definitely concerning behavior. It's not something that parents need to be complacent with. I think it's important to actually dissuade substance use and to talk to kids about the dangers of substance use and the potential consequences of substance use, because there are a lot of them.

Kids don't tend to think about long-term risks very much. Their brains aren't hardwired to think about long-term consequences until, honestly, sometimes their 20s. And so that's where I think it's helpful for parents to kind of take a role of, "These are the rules in our house. This is what our views are. These are what our values are. Here's what's acceptable and unacceptable behavior for our house. But I am also here and open to answer questions or listen to what you have to say. Or if you find yourself in trouble, intentionally or unintentionally, I am here for you."

Interviewer: So I'm a little confused. If you suspect that your child is using a substance and maybe . . . I don't know. Do parents generally have a good idea if it's early on? When you said, "Don't be complacent," do you just kind of sit back until you start seeing a problem develop, or do you jump right in as soon as there's some sort of substance use and say, "I understand this is just a natural thing. If you ever want to talk about it, we should"? I mean, I don't quite understand that differentiation.

Dr. Steinmann: I think a lot of the differentiation depends on families, right? So there are some families where even alcohol use or smoking is not a practice in the home, and so there might be a different baseline for a family addressing substance use and experimentation and how they approach that topic in their children, versus maybe a family where there is recreational alcohol use, or occasional nicotine use, or what have you. And so there are some baseline cultural differences that I think go into play.

We certainly want to educate our kids up front about what the dangers are, and say, even if you're comfortable as a parent, "This is kind of my own experience with using substances," talking about responsible use, if that is a value in your home. And in other homes, that might not be acceptable at all.

But kind of laying down, "This is what our family values here, our baseline. I understand you may be tempted to experiment with things. Here are my concerns about that."

And then also knowing your child and knowing their baseline and being able to identify if they're starting to behave differently, if they're starting to hang out with a different peer group, knowing what their peer group is and who their friends are. Having those consistent expectations is really important, but then also providing that guidance, that education, "This is what we value in our family."

That may be no substance use whatsoever. That may be, "This is the concern I have about you using substances right now as an adolescent." And that's the stance I tend to take as a child and adolescent psychiatrist. It's, "I'm concerned about the effect that any substance has on your developing brain. I understand you might be tempted to use. I discourage that, but I am also here if you have questions," and not to shut down that conversation prematurely.

If curiosity develops, if they're like, "Well, I see you drink all the time. Why can't I?" being prepared to kind of have those discussions so that then that increases your chances of having your child actually be honest with you if and when they start down that path, and being available to support and guide and eventually seek help, if needed.

Interviewer: So it sounds like if you suspect your child is using substances, and maybe they're just at the point where they're just kind of experimenting, that's a great invitation to have a conversation at that point?

Dr. Steinmann: Exactly. And even before use. I think sometimes we overestimate the age at which kids may actually be exposed to substances in schools, but we may be having these conversations too late sometimes and setting those expectations too late sometimes.

And so being aware that a lot of times, by middle school, kids are already exposed to peer groups or other folks who use, and maybe thinking about this for themselves. We may be wanting to even have those conversations earlier, depending on the environments in which our kids socialize.

Interviewer: And it sounds like a parent's kind of mindset is super important for this first conversation from the standpoint that I think . . . Well, first of all, what are some of the reactions that you see parents have when they find out their kids are using drugs? I can imagine there could be some anger that is probably born out of fear, because drugs can be detrimental to somebody's life. There's probably the thought that only bad kids do drugs. Are there some other reactions you see? Or what do you see?

Dr. Steinmann: Fear is a big one. And I love what you just said as far as anger often being born out of fear. Anger is a very reactive emotion. We all get angry over a lot of things. But if we dig deep, a lot of times it does come from that fear, either because we're terrified of . . . We just want the best for our child. We want them to grow up to be the best version of themselves that they can be, and there are serious consequences to problematic and ongoing substance use. There can be dangers to even intermittent substance use. And so fear is a very, very common and normal response to parents.

Also, that anger component of fear or fear that gets manifested as anger tends to be the emotion that then puts our kids on the defensive and shuts them down.

And so even though it's a completely valid emotion and an understandable one as a knee-jerk response on the parents' end, it may be the one that we want to kind of work on our own response to continue to invite that conversation instead of making the child feel that they're a bad kid because they thought of going to a party with their friends or even tried to ask a question or to get clarification for themselves or to seek help. Very often it's that fear of anger and punishment that keeps kids from seeking help.

Other common responses I get are often, "Only bad kids do that." And I think probably what parents often mean by that is the behavior is certainly concerning and undesirable, but that doesn't mean our child is a bad kid. There's a difference between the behavior and who someone is as a person, and sometimes kids can overly internalize that.

And so, if a parent's response is, "Well, only bad kids do that," or, "My kid possibly can't do that," that's a form of denial that probably needs to be addressed, especially if you're starting to see telltale signs of substance use or behavior changes. And we can talk about that in a little bit.

Or it can be, "Well, why are you judging my friends? They're not bad people. I know who they are. You don't," which can also raise defensiveness and unwillingness on the part of the child to engage more in that conversation.

Interviewer: Let's say a parent has suspected that their child is using a substance. They've had the conversation, they followed your advice, but then they start noticing, like you mentioned, some personality changes or they start becoming more concerned that it is escalating to a different level. Is that the point that you would get your child help, or is there another intervention that a parent would do first?

Dr. Steinmann: I think there are a couple different routes to go. So we have that conversation. Maybe we were lucky enough to have that conversation upfront before use even started, and the conversation had exactly the effect that we intended to have, which is to deter use. That's kind of the best possible scenario. "Hey, let's talk about the dangers of this." The kid acknowledges, "Yep, that's not a behavior that is good for me," and we move on.

Maybe experimentation happened, and then I think it's important to have the conversation potentially of, "What was that like for you?"

Understand what drives a behavior. We don't tend, as human beings, to engage in behaviors that don't work for us, especially in the short term in teenagers.

And so some may admit, "Hey, I've been really stressed out and I tried alcohol," for example, "and it helped me to feel better." Wow. As a parent, I would want to know, "Well, what's been stressing you out? Is there something else that's healthier that we can kind of engage in? Because, once again, I have my concerns about kind of going this route to address stress and manage stress. Are there different things that we can work together on to help you out with?" and seeing if we can get to the underlying driver of that behavior.

If the behavior continues despite, "Hey, we have a house rule we don't smoke, we don't engage in underage drinking, we don't engage in any forms of substance use" . . . which again is my stance, really, as a physician, because I'm concerned about that brain development . . . and the use continues, then we might need to consider additional types of interventions and understanding what's underlying that continued substance use.

I'm also going to be keeping a close eye on function. Function is really, in psychiatry and in medicine and mental health, what we look for to really start to make that distinction of, "What's the difference between substance use and a substance use disorder?"

And when we say the word "disorder," what we really mean is there is some impairment in academic functioning, in relationships, and that could be friends, family, etc. Are we engaging in additional risk-taking behaviors? Are we putting ourselves in safety risk by result of use? Are there legal consequences? Are we carrying vape to school, for example? All of those things would be red flags for more serious problematic use and possible disorder that might warrant additional treatment.

Interviewer: When a child is using a substance, is there generally some other underlying cause? Is it really truly just kind of a symptom of something else going on? I mean, either experimentation out of curiosity or an underlying condition, or are there other reasons?

Dr. Steinmann: It can be all of the above, honestly. What can start as experimentation can then kind of just spiral out into use for other reasons.

Some people may never engage in use but may find themselves starting with symptoms of anxiety or depression and then are just trying to find a way out of feeling that way. And they may have tried other things or talking to friends or things like that, or hear that, "Well, taking this has helped for me. Maybe it would help you too." And so it can sometimes be a chicken-and-the-egg type of scenario, honestly.

Interviewer: All right. Sounds like we have two steps so far. A parent suspects their child is using a substance, they have a conversation because it's just experimentation. Then that behavior continues, they have another conversation again asking this time, "Is there something else going on?" or, "Why are you using it?" or, "How does it make you feel?" reiterating the rules or the policies in the household. What would be the third step if it continues on past that point?

Dr. Steinmann: I would say then it's probably time to get some external support and some help. And honestly, it's never too early to get external help and support. Again, if this is just a conversation that, for any reason, a parent might struggle to have with their child or not know how to approach it, it is perfectly fine to seek out professional help to help learn how to have that conversation.

And there are a lot of other internet resources that are available if you don't have the ability to talk to somebody.

But I would seriously then consider looking at other resources, including a therapist or a primary care physician.

Not all cases of substance use disorder have to go directly to a psychiatrist, just like not all cases of depression and anxiety need to go to a psychiatrist. Sometimes talking with external supports, such as your child's pediatrician or primary care provider, someone that has an established relationship with them and knows them, can be a good middle-ground next step to get additional support before jumping into subspecialty options, although those are definitely certainly available.

Interviewer: Is there a negative message given to a child when you say . . . because there's a certain weight to saying, "All right. We've got to go to the psychiatrist now." You know what I'm saying? For this problem. That comes with a whole bunch of other stigmas.

Dr. Steinmann: It can. And unfortunately, getting mental health care and having mental illness needs is still really stigmatized in our society. I think that's why I generally recommend starting out with primary care if someone is having questions.

Now, granted, there are times where you would want to bypass primary care. For example, if your child has been absolutely refusing to go to school or you're noticing that they're skipping school a lot or they're getting suspended or even expelled for issues related to substance use, or you're concerned that there's an imminent safety risk, such as heavy use or heavy binge use or physical consequences from that, or you suspect a really severe underlying driver for substance use, including depression or anxiety, perhaps even things like suicidal thoughts, or if you suspect another serious mental illness, those would be things that would be quite appropriate to go up to a higher, more specialized level of care.

It can take a while to access the mental health system as well, and you don't want to get stuck in the lurch while your child is really struggling, especially if their imminent safety is on the line.

Interviewer: When you talk about substances, drug use, what does that entail for you as a physician and a psychiatrist?

Dr. Steinmann: That's a great question. I think a lot of times, when we talk about substance use, our minds automatically go to the hard stuff like heroin or cocaine or methamphetamine. We also think about alcohol and nicotine and marijuana, which are a little more readily available.

But there are also, especially with teenagers . . . Think about access and what you're more likely to be able to get a hold of or afford. Or what are the underlying concerns that might be problematic in teenagers, such as anxiety or depression?

This is another great example of a misperception, actually. Sometimes we think, "Well, my child is very high functioning and they do great in school. They can't possibly have issues with substance use." But I work with a lot of teenagers and young adults who may have some mild ADHD or anxiety who are very high performers and may feel compelled to be even higher performing. And so they may actually get wrapped up in overuse or misuse of cognitive enhancers, like caffeine or prescription stimulant medication.

And so having an idea of kind of the breadth of things that can be misused or abused is important.

It's scary and it can be overwhelming to think about, but it's important to, again, think about those underlying drivers of behavior and the type of direction that might lead even into substances we might not typically think about as being abusable.

Interviewer: And some of these ways of talking to the children about substance abuse might be kind of against a particular parent's parenting philosophy. We are all raised in our own ways by our own parents, and a lot of times, that's the way we raise our children. Is this evidence-backed stuff? Should somebody just go ahead and use their instincts instead going into this conversation? What are your thoughts on that?

Dr. Steinmann: I think that parents are the experts on their children, and so using your instinct can be a very powerful tool.

If you are noticing that your child is not acting like themselves, I do think it's important to ask more questions and probe. And again, by asking, you're kind of almost opening the door to, "I'm interested, I'm curious about you. I care about you."

Sometimes the hardest thing we can do, as parents, is to open the door to conversations that we might not be comfortable having, but by doing that, we're actually modeling for our kids that it's okay to talk about these things, that maybe their assumption that we're going to blow our stack or over-assume might be unfounded, that we want to be and try to be safe people to talk to because we have their well-being at hand.

I liken it in some ways to talking about suicide, for example, and suicide prevention. There's significant data that shows that simply asking about suicide does not increase the risk of suicidal behavior. And I think the same is very true for substance use.

Just because you're asking doesn't mean that you are giving permission or suggesting that they should engage in that behavior. All asking does is signaling your child that, "Hey, I'm aware that this is a problem and I want to be a person that you can rely on and trust to talk to about it."

Interviewer: For a parent listening to this interview that wants to go on to get some more information, what are some good reliable sources that they could go to online to get some help framing this or figuring out the approach or whether or not they should be concerned at this point? What do you recommend?

Dr. Steinmann: For reputable sources on the internet . . . because you're right, there are a lot out there and it can be really overwhelming to kind of weed through and find the best sort of reputable information. I really like the Substance Use Resource Center through the American Academy of Child and Adolescent Psychiatry. The Substance Abuse and Mental Health Administration, or SAMHSA, also has a lot of good resources.

And something that I found fairly recently as a resource, that I thought was very parent-friendly type of language, is through the Child Mind Institute. And they have various questions about how to talk to your teen about substance use for parents who may not be sure on how to start that conversation.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: Welcome to "Who Cares About Men's Health." It's a Men's Health Essentials episode. A weak stream, is that something that you should have a doctor look at? That's what we're going to talk about.

My name is Scot Singpiel. I am the manager of thescoperadio.com. I provide the BS. That's what I do. The MD to my BS is Dr. Troy Madsen.

Troy: Hey, Scot. It's me, and I have to say I am so excited to be joining you today on the number two rated podcast in the world.

Scot: What?

Troy: Men's health podcast. Let me clarify that. The number two rated men's health podcast in the world. It's my honor to be here.

Scot: Tell me about that. We're number two?

Troy: We are number two. I did a search. I just searched on Google "top men's health podcast." The first site that came up ranks them by multiple factors. We are number two, behind "Men's Health" magazine's podcast. It's pretty cool.

Scot: All right. Wow.

Troy: We'll take it.

Scot: Yeah, I don't know if . . .

Mitch: We will take it.

Scot: . . . that's cool or that's more pressure. And joining us as always, Producer Mitch is in the mix.

Mitch: Hey, there.

Scot: And going to help us with our weak streams if any of us have weak streams . . . I think I might have a weak stream. I don't know. We're going to find out. Urologist Dr. John Smith, welcome.

Dr. Smith: Hey, thank you.

Scot: So weak stream. Hey, Troy or Mitch, how is your stream? Everything okay with the stream? You feeling pretty good about it?

Troy: The problem with a question about the stream, Scot, is I don't know what to compare it to. Should I be looking at guys in the airport in the urinals without the barrier there and just look at their stream? I don't know. I think my stream is good.

Scot: Yeah, or sometimes you listen, and it's like, "Oh, my gosh, what's that? About a gallon a minute coming out of there?"

Troy: Oh, yeah. Some guys are just like, "Wow." Yeah, it's something else. I feel like I've got a good strong stream, but I don't know.

Scot: All right. Mitch, do you want to comment or do you want to abstain?

Mitch: No. I know for a fact that I have an average or above-average stream because I've actually talked to a urologist.

Scot: Oh, you have?

Mitch: Yes, I have, about this very concern.

Troy: And you've measured it?

Mitch: They measured it. It's not like I measured it myself. There was a science to it that I'm sure Dr. Smith will be able to tell us all about.

Dr. Smith: So you objectively know you've got a good stream, it sounds like.

Mitch: I'm going to see if I can't pull up the graph. You guys might find that interesting, or gross. I don't know. Hold on. Keep going.

Scot: Dr. Smith, that's what we're here to talk about. I feel like perhaps as I've aged, maybe I've lost a little stream power. Maybe. I don't know. It varies. Some days I'm like, "Huh, this isn't coming out very fast." And then other days, things seem to be fine. So we're going to get into all of that. First of all, is stream something that we should be worried about as guys?

Dr. Smith: I think you should be at some point. I usually ask gentlemen about their stream and I ask them, "Do you hit the back of the bowl, the middle of the bowl, the front of the bowl, or your shoes?" But I think if you're a front of the bowl or shoes guy, we definitely should be having a conversation.

Scot: Okay. Has that been proven by research, that little method that you just told us about?

Dr. Smith: It's anecdotal, but it gives me a lot of information right up front without having to put them on a machine like Mitch.

Scot: Okay. All right.

Troy: So you're saying that for some men, full force, they're hitting their shoes?

Dr. Smith: Well, they shouldn't hit their shoes. That usually means they've got a problem.

Troy: Yeah.

Scot: And is this they're trying to actually actively push out, or should the urine just be coming out? Is that how you would measure the ideal stream measurement?

Dr. Smith: I'll answer that with talking about Mitch's machine. So we do have a machine. It's called the uroflowtometer. It sounds really, really cool. We shorten it to uroflow just to make things easier.

And they actually have one of these that you can get at home now. There's a company where you can get one of these at home. It's called the Stream Dx, and your doctor could actually send one home with you.

What this machine does is when you urinate, it takes the amount of urine that you're putting out over time, and then it'll also show us if you're actually straining to urinate and you're using your abdominal muscles to urinate, because you really shouldn't need to do that. You should be able to just open things up and let things go.

And some men notice as they age, they have to push a little bit more. The urine stream is not as strong as it used to be. Some younger men may notice that they had an abrupt change in their stream. And those can both be issues that need a little bit of attention.

Scot: Is it normally an abrupt change, or is it over time, or is it both really?

Dr. Smith: So, depending on what's going on, the thing that is the problem depends on whether it's more of a sudden thing.

So an abrupt change in stream is something where you want to get it checked out because it could be a narrowing of the urine channel or the urethra, anywhere from the bladder all the way down. That usually happens in a rather quick fashion, and that's something that can cause a problem.

A urethral stricture is usually the most common thing that we see in younger men who come in with an abrupt change in their stream. And that's a narrowing in the urine channel as a result of a traumatic event, or even just sometimes what we call idiopathic, meaning it happened and we have no idea why.

Troy: You talked about the abrupt change, suddenly something happens, but it sounds like probably what you see more commonly would be stuff that just gradually decreases over time.

Dr. Smith: Yeah. So the decrease over time thing generally happens with men as they age, and that tends to be more of a prostate-related issue. And that's the slowing down of the stream where you go to the restroom in the airport, or you go to the Jazz game, or you go somewhere and you're standing next to somebody and you go, "Man, that doesn't sound like what I've got over here."

And so that can be due to age-related changes in the prostate. The prostate is like your ears and your nose. It continues to grow until the day that you die.

Scot: I feel like this is a stupid question. What about kidney stones? Could that result in a reduced stream?

Dr. Smith: It can if it's lodged within the urethra. Usually, kidney stones that are in the tubes coming down the ureters from the kidney to the bladder don't usually slow your flow down. They just cause pain and make you miserable.

Mitch: You'll know if you have a kidney stone, and that's what's blocking things, right?

Dr. Smith: Usually, if you know you're passing a kidney stone and then you have a urinary flow change, you could have it stuck in the urethra, but it's less likely to happen because the tube coming from the kidney down to the bladder is very, very small. And compared to the urethra, that's very, very large in comparison. It'd be like taking a coffee straw and then a Boba straw.

Scot: Good reference.

Mitch: All right. Okay.

Scot: You're very topical, aren't you? So is it really only two things that might cause a weak stream, the narrowing of the urethra or a prostate issue?

Dr. Smith: No. There are other things too, but those are the most common things that I see in younger and older age groups.

Another thing that I see commonly across all age groups is something called pelvic floor dysfunction. There's also dietary things that can make urination more difficult. The big three that I always talk to folks about are caffeine, alcohol, and spicy foods, three things that can definitely make urination more difficult or problematic.

Scot: Back to that machine that measures stream pressure, do I have to stand up when I do that, or is that a sit-down deal?

Dr. Smith: Either one. So usually, you can stand up to do it if you're comfortable that way, but you can also sit down.

It's kind of a crude measurement. It pretty much measures the urine as far as a volume . . . actually, excuse me, as a weight of urine as it comes out. It measures how much weight is being added to this scale over time. And so initially, you're going to be adding less weight, the weight of the urine to this flowtometer. And as you build up speed and you reach your maximum flow, you're putting that weight in at a rate and then it graphs that in a curve.

And the normal curve looks like a bell curve that you would have in school when they would grade you and give half the kids Fs that are on that one end, and the other kids get As and everybody else is in the middle. That's what the uroflow, a normal one, would look like.

Scot: Hey, in the chat, click on . . . Mitch sent us this. Is this what we're talking about here?

Mitch: Yeah. Those are two examples of the machines.

Scot: The very first one?

Dr. Smith: I don't know how to get into the chat. Let me check and see.

Mitch: Yeah. I had something similar to the first one.

Dr. Smith: Yeah. That's exactly what it is. Did you order one of those on Alibaba?

Mitch: We are $500 away from knowing exactly how everyone's flow is going.

Scot: I know.

Dr. Smith: It's less than that if you just get your doctor to prescribe you a Stream Dx.

Mitch: You could probably DIY this. It looks like you could maybe do a bucket, a funnel, and . . .

Dr. Smith: One hundred percent you could DIY this.

Troy: It's just a funnel and some sort of measuring . . . Yeah.

Mitch: A scale.

Troy: A scale. That's right.

Dr. Smith: It really is. Then you've just got to be able to graph it over time and have that amount of stuff come in. But yeah, those are the normal graphs. If you look at that flow curve, you'll see what we see. That normal bell curve is pretty normal. And then the guy that has multiple different curves, they have an interrupted flow, that start, stop, start, stop that a lot of guys will talk about that have a slow flow.

Scot: What's up with this dysfunctional voiding curve? It goes way up and way down.

Dr. Smith: So usually, that's due . . . When they say a detrusor overactivity, the detrusor is the muscle that's in the bladder wall. And when that muscle is overactive, it has a spasm and just pushes with a high amount of pressure, and that's why you see the flow and the pressure go up.

Troy: Interesting.

Mitch: So you completely void the bladder in the first few seconds. That's why we're seeing such a high curve. I'm trying to make sure for listeners who can't see graphs . . .

Dr. Smith: Yes.

Mitch: Yes. Okay. Interesting.

Troy: I guess as I'm hearing this, though . . . I don't know if I have a weak stream. Maybe you go to a Jazz game or a sporting event or something, you hear other guys and it sounds like they just opened up a garden hose over there or something. I don't know. But the question is, does it matter? Do I need to buy the uroflowmeter and check out my flow, or what's the downside of having a weak stream?

Dr. Smith: So to a certain extent, it's not an issue. It can be and it is as people age. The big thing you want to make sure of is that you're emptying your bladder.

Now, the thing I always tell my patients is the urinary system, the bladder on out, is meant to be a low-pressure system. The sphincter that keeps the urine in your bladder and out of your pants opens up, your bladder squeezes, the urine goes out into the toilet, and nobody is the wiser. And that's supposed to be done in a low-pressure setting.

As we age, the prostate gets bigger and closes down the opening of the prostatic portion of the urethra, making it a higher-pressure system. Now, that's not a problem until it becomes a problem.

I know that's very specific, and so what I usually tell people is there's a certain point where that pressure builds up and the bladder can't keep up with it and you start to have residual amounts of urine where your body is not emptying the bladder completely. That can cause a problem, increase your risk for infection.

But also, as your bladder increases the pressure, it can also push pressure back up the ureters towards the kidneys, and long-term can cause kidney damage. And so that's the reason where if you think there's a problem, you should probably have somebody take a peek at it.

Troy: Would you have other signs also that would maybe suggest that there was an issue there?

Dr. Smith: Yeah. So normally, we call these lower urinary tract symptoms. Some doctors will just say LUTS. That's the lazy way to say it. But it's pretty much a non-specific group of things like going to the bathroom more frequently, having increased urgency to get to the bathroom. When you have to go, you have to go now. I call it the "gotta-gos." You can have urinary hesitancy, difficulty getting things started. You can have nocturia, which is waking up multiple times at night to go to the restroom.

Those are all considered lower urinary tract symptoms. And there are a few others that are involved there that make the rounds.

And so again, those are the things that you may also experience in addition to a slowed urinary flow. People may also say, "I don't feel like I'm emptying. I just feel like after I'm done, there's more there."

Scot: You probably already explained this, but I just want to be clear. So first of all, I thought a weak stream was indicative of maybe some health problem. But other than the fact that you might not be getting all the urine out and over time that can cause an issue, a weak stream in of itself isn't necessarily a bad thing.

Dr. Smith: Not necessarily. It does depend on how weak the stream is and what's going on upstream. Some people have intermittent weak stream, like you were saying. Some days, it seems like it's weaker than others. Usually, that's due to caffeine, alcohol, spicy foods, things like that, where people notice, "Oh, if I drink four cups of coffee, I tend to go more frequently and have urgency and may not feel like I empty well," or whatnot that way.

Mitch: So the reason I got tested was I was urinating a lot more frequently last year, and it was enough that I was worried to go to the doctor. They had me use the uroflow, test everything out, and then come to find out I was just drinking a pot of coffee a day because of the two jobs I was working. So it was a whole thing.

Dr. Smith: Yeah, you're not uncommon. A lot of times when people come in, I usually check for lifestyle things. Guys that go to Buffalo Wild Wings and they have a couple of beers and then they go home and they notice that their urinary system or their urinary function is more frequent, less frequent, those types of things, I tell them, "If you know that's happening to you, then it's self-inflicted and you know how to change it."

Or the guy that drinks a pot of coffee and I say, "Hey, you just need to drink less caffeine or no caffeine to make your life easier and make your urinary system better."

Troy: I guess hearing this, too, it makes me wonder, and hearing Mitch's experience, do you find that people think their stream is too weak and they overreact and so you see a lot of these cases where, "Hey, your stream is fine"? Or do you find that a lot of guys just put this off and ignore it and then come in when they have a really weak stream?

Dr. Mitch: So I see both ends of that spectrum. I have the guys who when something seems to go wrong from the waist to the knees, they immediately are in your office, and the other guys that don't think it's a problem and come in once their bladder is no longer functioning and they have a liter and a half of urine in their bladder and don't know it.

So those are kind of the extremes, but I do see both angles where people are very worried about their current urinary flow, and then others that are like, "Oh, yeah. It's been like this for 15 years," and they don't do anything about it.

Troy: Yeah. See, John, I'm just worried I'm going to be the guy with a liter and a half in my bladder. I'm going to finally show up and be like, "Something is wrong here."

But again, it's hard to tell. Now that we're talking about all this stuff, I'm thinking, "Yeah, I do get up two or three times a night," and, "Yeah, sometimes I really have to go." So it makes me wonder. I don't know. Maybe I need to get checked out.

Dr. Smith: Well, Troy, I'm not going to age you at all, but I'll just give what I tell people. Over the age of 50 to 55, everybody, both men and women, gets up once a night. It's pretty normal. So once a night is not a huge issue.

When you start getting up two and three times a night, that tends to be a little bit more pathological where you may want to even just get it checked out.

Troy: I might need to. I do drink a lot of water. We've talked about that before. So I don't know if that's part of it. Hearing Mitch's experience, it sounds like there was a lot of coffee consumption going on and a lot of caffeine. I just drink a ton of water. So I've always chalked it up to that, but I don't know. Yeah, it sounds like maybe I should get checked out.

Dr. Smith: Well, some homework you could do too is if you cut the liquids off a couple hours before you go to bed and then you notice that you don't wake up as much.

I have plenty of patients who come in and they're like, "Yeah, I drink two glasses of water before I go to bed and I wake up two or three times." I said, "Yeah, go figure."

Mitch: That's how I felt after we had done all this testing and everything and he's like, "You're drinking how much coffee a day?" And I'm like, "Yeah, it's about a pot of coffee a day. Of course, I'm urinating more. No duh."

Troy: Exactly.

Dr. Smith: You're putting eight cups of a diuretic into your system and then drinking a liter and a half water. You're going to be going to the bathroom. And the same thing, if you drink 32 ounces of water before you go to bed, you're going to wake up to go to the bathroom.

Troy: Yeah. That is true.

Scot: I feel like this conversation has expanded beyond weak stream. We're talking about going often or going in the middle of the night. Is it all really related?

Dr. Smith: Yes. When it comes down to a lot of that, a lot of times people come in and once you ask them those more probing questions, "Do you have increased frequency, urgency, your stream is weak? Do you feel like you're emptying well? Do you have hesitancy? Do you start and stop your flow?" those types of things, usually it's not just, "Oh, I thought my flow was weak," and that's it. There's usually a yes to multiple of those other questions.

Scot: Okay. And then how do you avoid being the person that's in your office when anything goes wrong between the pelvis and the knees, you said?

Dr. Smith: Yeah, the waist and the knees.

Scot: Yeah, and being the person that should have been there two years ago. How does a guy that's listening figure that out? I think a lot of us guys don't go to the doctor because we're like, "Oh, it's probably nothing," or we don't want to be a bother, or it can be a hassle, or whatever. So how does a guy figure that out?

Dr. Smith: I think you use your best judgment if you think it's slowed down enough that you want to get it checked out. But other things you can do are just lifestyle modifications. Mitch could have probably cut the coffee down before he went into the urologist and seen if there was a difference. Troy can cut water off before he goes to bed, and see if that makes a difference.

You can do lifestyle modifications where you decrease the amount of caffeine you intake, alcohol, spicy foods, see if there's anything dietary related. Then you can also watch your intake before bed. Make sure that you're putting yourself in the best position possible to see how your urinary system functions without any of those additives that may make your life worse.

Troy: And what about the person who's listening right now, just like me listening to this, and just thinking, "I've wondered if there's an issue"? Would it be a simple test to just say, "Okay. I've got to go urinate right now"? You go and you urinate, and your stream is hitting the back of the bowl without a lot of effort. Are you good?

Dr. Smith: That's the reason that I ask that question, because it lets me know how worried I should be about those folks.

The other thing is to go ask those questions to . . . If you've got a significant other, that's my favorite when the patient comes in with their spouse.

Scot: Oh, no.

Dr. Smith: I go, "Is your stream weak?" He's like, "No. It's good." And you just look over their shoulder and their significant other that's with them is just shaking their head like, "He's totally lying."

Scot: Is that because they're the one that cleans the toilet? Is that what's going on there?

Dr. Smith: Guaranteed. Yeah. Or washes the shoes.

Troy: You're just a poor aim, or what?

Dr. Smith: But you'll see a lot of them like, "Oh, do you wake up much at night to go to the bathroom?" They're like, "No. I maybe wake up once," and their partner looks over at them like, "No, he wakes up like four times at night." So they'll keep you honest a lot of times.

Scot: Yeah. It sounds like that's something to watch out for as a guy, is just that sometimes maybe we disillusion ourselves a little bit. We need to take an honest look at these types of things.

Dr. Smith: Absolutely.

Troy: Again, just for my own peace of mind, it sounds like if you do go to the bathroom and you are hitting the back of the bowl without a lot of effort, you're probably okay.

Dr. Smith: Yes. I would say that's a pretty good idea. If you're not forcing the urine out and your flow is coming out pretty robustly, you're okay.

Now, if you have any questions, Troy, you just give me a buzz. We'll get you into the office.

Troy: Okay. I'm a little nervous now because the whole night thing, that's got me thinking, "Maybe I need to get things checked out." Anyway, I'm feeling okay about things.

Scot: But there are not other symptoms, though, really. Are there?

Troy: Sometimes, like John said, the whole gotta-gos things, sometimes I'm just like, "I've got to go." But again, I've always just attributed it to I drink a lot of water. So maybe I'll cut back on the water a little and see what happens.

Scot: Hey, if you guys want . . . Hey, Dr. Smith, can you write us a prescription for that thing? Do you guys want to have a little competition?

Mitch: There's no need to make this a competition.

Dr. Smith: I'm sure we could figure that out. Not that we need to make this a competition, but I think we could probably figure that out.

Mitch: I'm worried this is going to be like the pushup competition where it's going to be a recorded thing and John is going to be the referee watching and like, "Okay. Go for it, Mitch. Let's see what you can score."

Dr. Smith: Well, I don't have to watch. I have the machine give me a printout, so it makes it much less awkward.

Troy: That's good.

Scot: And then that's a little souvenir for all of us. We can each have our own little printout when we're done. So that'll be fun. Put that up in the office next to the diploma or whatever.

Mitch: Man.

Troy: Yeah. Exactly.

Dr. Smith: You can do that live on . . . not a podcast. You can make a vlog and throw that up.

Troy: Yeah, just like, "Here we go." This is University of Utah Health at its finest.

Scot: Any final thoughts, Dr. Smith? Anything that you feel compelled to say? Anything we should have hit or should have mentioned, or a wrap-up that you'd like to give a guy?

Dr. Smith: No. I think if you're worried about your stream and you do have any questions or concerns, getting in sooner rather than later is definitely better for you. So if you do have concerns, just pick up the phone, make a phone call. It's a pretty easy visit. It's nothing to be overly concerned about. You can check things out pretty quick and get some good objective answers and give yourself a lot of peace of mind.

Scot: And is that a urologist you're going to go to, or would your primary care physician have this equipment to do this?

Dr. Smith: If your primary care has this equipment, I would be very, very surprised. You want to call a specialist like a urologist, yeah.

Scot: Okay. Great. Well, Dr. Smith, as always, it's great having you on the show. Thanks for being a part of it, and thanks for caring about men's health.

Dr. Smith: Hey, pleasure is mine, guys. Thanks for having me. It's always great to be with you.

Interviewer: Now, if your child is complaining of leg pains, could it be growing pains, or is it something more serious?

Dr. Julia Rawlings is a nonoperative sports medicine physician here at University of Utah Health. And let's start with the type of leg pain I think just about every kid, at some point, experiences. One point or another, it seems pretty benign. What exactly is growing pain? What are growing pains, I guess?

Dr. Rawlings: Yeah. So growing pains, the name came kind of early in the 1930s and 1940s when people thought that growth was related to these pains that children get, usually later in the afternoon, evening, or maybe even wakes them up at night. But we know now that it's not related to growth, but it's more likely just related to children being very active during the day. So it's just these pains that come on later in the day or at night, mostly from kind of overuse of muscles.

Interviewer: But it's not like the bones are stretching or anything like that. It's just . . .

Dr. Rawlings: No, it doesn't have anything to do with growing. It does happen in children, but it doesn't affect their growth. It's not directly related to growing.

Interviewer: My understanding is it's pretty normal for kids to be having this and just as part of, like, I guess being active and running around.

Dr. Rawlings: It's very common. And the places where it's most common, usually it happens in the calf, the thigh, or the back of the knee. So those are some of the spots that we look at.

Interviewer: Okay. And it's like an aching or just like . . . I guess, how do we know that it's like that kind of pain?

Dr. Rawlings: Yeah, it's like an aching or a throbbing pain. Sometimes children will grab the back of their legs or grab their thighs or just be more cranky. It's usually at the end of the day. It can wake them up at night though.

Interviewer: And so your child's complaining of pain. I guess, as a parent, if you're worried, you know, what should you be on the lookout for to find out if it's something more than just typical growing pains?

Dr. Rawlings: Yeah. So growing pains usually happen intermittently. So it can happen every night, but that's a little less common. So growing pains typically are intermittent. They're usually in both legs, not necessarily at the same time. And the child usually wakes up in the morning completely fine and running around like there's nothing wrong. Those are all very typical for growing pains.

Interviewer: So say a kid is, you know, maybe continually complaining about leg pain or maybe they're getting it through the day. As a parent, what are some of the signs and symptoms that you should be on the lookout for to kind of let you know this isn't growing pains, it's something more serious?

Dr. Rawlings: Yeah, great question. So if your child is complaining of pain, particularly during the day, if they are complaining of pain in the same leg, if the pain stops them from participating in sports activities or from running with their friends, if they are limping with the pain during the day, or if you see anything else that seems abnormal, so swelling of the leg, redness of the leg, if they're getting fevers with it, all of that is something besides growing pains, and you should be seen for that.

Interviewer: And not to, say, worry parents, you know, prematurely, but what could be going on with their child?

Dr. Rawlings: So it could be something as simple as an overuse injury. Lots of times, in children that play sports, we see overuse injury at the growth plates actually. That's probably one of the more common things. If they're very active, say a teenager running, they could get a stress injury. They could just have tight muscles, and stretching could be helpful. All the way up to the more serious things that are very rare and uncommon, like childhood arthritis or bone cancer.

Interviewer: If your child is, say, showing some of these symptoms, what kind of doctor should you be going to, to, you know, treat the leg? Is it a primary care pediatrician? Is it a sports medicine specialist?

Dr. Rawlings: I think, initially, if your pain is kind of vague and you're not sure what's going on, starting with the pediatrician is a great place. If it's something more serious, like they're not limping, they can't get into the pediatrician, it is reasonable to go to an urgent care or the emergency department, particularly if they won't walk at all. We need to see what's happening. There are . . . sometimes toddlers will have a small fall and twist their leg, and they won't walk, and they'll have a little fracture that you won't even pick up on. And so that's one of the more common reasons we'll see toddlers stop walking, and that's something that can be taken care of either by a pediatrician, a nonoperative sports medicine provider, or in an urgent care emergency medicine setting.

Interviewer: And is there anything, maybe a home remedy, something they could try at home before they, say, take them into a doctor to maybe alleviate any of the pain that they're experiencing?

Dr. Rawlings: Yeah. So if they're experiencing more of these growing pains, kind of intermittent pains in the evening or at night, you can do things like massage the legs, massage the muscles. Warm packs, heating pads are helpful. If it's severe, you can try some acetaminophen, Tylenol, or ibuprofen. And sometimes if it's pretty frequent, you can have them do some stretching during the day and see if that helps as well.