What is Erectile Dysfunction? Definition and Overview

Erectile dysfunction, medically known as erectile dysfunction, is the inability of a man to achieve or maintain an erection sufficient for sexual intercourse. Erection is a result of increased blood flow to the penis during sexual stimulation. However, various physical and psychological factors can negatively affect this process.

Erectile dysfunction is a common condition affecting many men worldwide. Men of any age can experience this problem, but its frequency increases with age.

When diagnosing erectile dysfunction, specialists will usually assess the following factors:

• Physical Factors:
  • Heart diseases
  • Diabetes (diabetes)
  • High blood pressure
  • Cholesterol problems
  • Hormonal irregularities
  • Neurological diseases
  • Side effects of some medicines
• Psychological Factors:
  • Stress
  • Anxiety
  • Depression
  • Relational issues

This can lead to loss of self-confidence, depression and tensions in interpersonal relationships. The partners of people with erectile dysfunction may also be affected and sexual dissatisfaction may occur in the relationship.

Erectile dysfunction is usually diagnosed through self-reports, physical examination and sometimes blood tests or other medical tests. After the diagnosis, appropriate treatment options are worked out.

Medical treatments include oral medications, vacuum devices, hormone therapies and surgical procedures. In addition, in recent years a shock wave therapy called ED1000 has become a popular method of treating erectile dysfunction. This method sends low-intensity energy waves into the penile tissue, helping new blood vessels to grow and thus can contribute to improving erection.

Prevalence of Erectile Dysfunction in Men

Erectile dysfunction in men is a common sexual dysfunction and affects a certain percentage of men in different age groups. Erectile dysfunction (ED), also known medically as erectile dysfunction, is the inability of men to achieve or maintain sufficient erection for sexual intercourse.

• The prevalence of ED increases as men get older.
• 40 yaş üzeri erkeklerin yaklaşık %40’ında belirli bir derecede sertleşme problemi görülmektedir.
• 70 yaşına gelindiğinde, bu oran %70’e kadar çıkmaktadır.
• Chronic health conditions such as heart disease, diabetes, high blood pressure and obesity increase the risk of erectile dysfunction.
• Depending on age, physiological changes such as arteriosclerosis (atherosclerosis) and changes in hormone levels can also affect the prevalence of ED.

However, lifestyle factors also play an important role in ED. Adverse factors such as smoking, excessive alcohol consumption, insufficient physical activity and an unhealthy diet can increase the risk of erectile dysfunction in men. Psychological factors, such as stress, anxiety or depression, are also important factors that can lead to erectile dysfunction.

Academic literature shows that the prevalence of erectile dysfunction may vary according to geographical location, culture and socioeconomic status. The fact that it is a health problem that varies from country to country shows that this is a complex health problem on a global scale. Therefore, it is important to increase social awareness and develop accessible treatment options.

Psychological Effects of Erectile Dysfunction

While erectile dysfunction has a significant impact on men's sexual function, it can also have profound effects on psychological and emotional health. When men are faced with this condition, the following psychological effects are commonly observed:

• Lack of Self-Confidence: Men who have persistent erectile dysfunction may lose self-confidence. Since sexual performance is strongly associated with masculine identity, this kind of sexual dysfunction can make a person feel inadequate.
• Anxiety: Individuals with erectile dysfunction may experience increased levels of anxiety associated with fear of failure during or before sexual intercourse. This is known as performance anxiety and may contribute to the continuation of the problem.
• Depression Impaired sexual functioning can bring on symptoms of depression or aggravate an existing depressive state. Such a situation negatively affects the person's motivation, energy level and enjoyment of life.
• Relationship Problems: Erectile dysfunction can cause tension in the relationship with the partner. Lack of communication and conflict can exacerbate the problem, while lack of support and understanding between partners can increase emotional distance.

These psychological effects can be addressed through individual or couples therapy, which is an important part of the treatment process. While treatment methods such as the ED1000 can be effective in overcoming erectile dysfunction, additional support and interventions may be needed to improve the individual's psychological wellbeing. Restoring self-esteem, managing anxiety, combating depression and increasing communication skills are critical to addressing erectile dysfunction in a holistic manner.

Physiological causes of erectile dysfunction

Erectile dysfunction (ED) is a common health problem in men and may develop due to various physiological factors. These physiological causes include the following conditions:

• Cardiovascular Diseases: The ability to have an erection is directly related to the pumping of sufficient blood into the penis. Problems in the cardiovascular system can lead to ED by affecting blood flow.
• Diabetes: High blood sugar levels cause a number of complications, including nerve damage (neuropathy) and atherosclerosis, which can affect blood flow to the penis.
• High blood pressure and cholesterol: These conditions can lead to hardening of the arteries (atherosclerosis), preventing enough blood from reaching the penis.
• Hormonal Disorders: Hormonal imbalances such as testosterone deficiency can also contribute to ED.
• Neurological Diseases: Diseases affecting the central nervous system, such as Parkinson's disease and multiple sclerosis, can have a negative effect on erectile ability.
• Pelvic or Spinal Injuries: Injuries to the pelvic region or spinal cord can damage the nerve pathways to the penis.
• Prostate Diseases and Treatment: Prostate surgery or radiation therapy can cause nerve damage that sometimes causes ED.

In addition to physiological factors, side effects of certain medications and lifestyle-related factors (smoking, overweight, lack of physical activity) can also play a role in erectile dysfunction. In order to make an accurate diagnosis, it is important to be assessed by a health professional and to undergo various medical tests. In this way, appropriate treatment methods can be decided.

Erectile Dysfunction and Cardiovascular Health

Erectile dysfunction (ED) is the name given to sexual dysfunction in men and occurs as inability to achieve or maintain sufficient hardness in the penis. ED may actually be an early warning signal of cardiovascular diseases. The relationship between cardiovascular health and this problem stems from the fact that both conditions are closely related to the condition of the blood vessels.

• Endothelial Dysfunction: Endothelial cells line the lining of blood vessels and keep them functioning properly. Endothelial dysfunction can lead to narrowing of the blood vessels and hardening problems as well as heart disease.
• Atherosclerosis: Plaque build-up in the blood vessels, i.e. atherosclerosis, can cause both erectile dysfunction and heart disease. If the blood vessels leading to the penis become narrowed or blocked, erectile dysfunction may occur.
• Hypertension and Hyperlipidaemia: High blood pressure and high cholesterol levels can cause arteriosclerosis and narrowing. These conditions increase the risk of ED and may predispose to cardiovascular diseases.

It is important that men with erectile dysfunction also have their cardiovascular health checked, as these two conditions can mutually trigger each other. If diagnosed and treated early, cardiovascular health can be protected and the effect of erectile dysfunction can be reduced. ED1000, developed for the treatment of ED, aims to repair damaged blood vessel tissues and improve blood flow by applying shock wave therapy. In this way, it can have positive effects on both erectile dysfunction and vascular health.

Lifestyle Factors Contributing to Erectile Dysfunction

Erectile dysfunction can be caused by a number of lifestyle factors. Awareness of these factors and changes that can be made to them can be important steps in overcoming the problem.

• Smoking: Nicotine can cause erectile dysfunction by restricting blood flow in the blood vessels. Smoking also contributes to arteriosclerosis (arteriosclerosis) and heart disease, negatively affecting general health.
• Alcohol Consumption: Excessive alcohol use may increase the risk of erectile dysfunction. Alcohol may have effects that weaken the sexual response by suppressing the central nervous system.
• Drug Abuse: Abuse of certain drugs, including illegal drugs, can adversely affect the ability to get an erection.
• Obesity and Sedentary Lifestyle: Obesity increases the risk of diabetes and cardiovascular diseases, which can lead to erectile dysfunction. Regular exercise improves blood circulation and can reduce the risk of ED.
• High Blood Pressure and Cholesterol: High blood pressure and cholesterol levels can narrow blood vessels and cause erectile dysfunction.
• Stress and Anxiety: Chronic stress and anxiety can have negative effects on the nervous system that provides hardening. As a result, sexual performance may decrease.
• Sleep Disorders: Problems such as insufficient sleep or sleep apnoea can affect sexual health and contribute to erectile dysfunction.

Depending on the individual situation and lifestyle, one or more of these factors may play a role in men with erectile dysfunction. It is possible to overcome these problems through lifestyle changes and treatment modalities. Innovative treatment methods such as ED1000 can help overcome erectile dysfunction, while adopting a healthy lifestyle can support this process.

Medical Diagnostic Processes for Erectile Dysfunction

Diagnosis of erectile dysfunction (ED) helps to understand the root causes and to formulate an appropriate treatment plan. This process usually consists of the following steps:

• Review of the patient's medical history:
  • The patient's current health status, previous surgeries, medications and lifestyle habits are evaluated in detail.
• Physical Examination:
  • A thorough examination of the genital area is performed. The cardiovascular system and neurological functions are also checked.
• Laboratory Tests:
  • Various blood tests such as complete blood count, lipid profile, liver and kidney function tests may be performed.
  • The blood sugar level is analysed for diabetes.
  • A hormone profile analysis is important, especially with regard to testosterone levels.
• Psychological Assessment:
  • Psychological factors such as anxiety and depression are evaluated to determine whether ED is of psychological origin.
• Penile Doppler Ultrasonography:
  • It is performed using Doppler ultrasound to assess the blood flow to the penis and helps to detect vascular problems.
• Nocturnal Penile Tumescence Test (NPT):
  • This test measures spontaneous erections that occur during the night. It is used to find out if a man experiences normal erections during REM sleep.
• Intracavernous Injection and Penile Erectile Testing:
  • Medication is injected into the penile tissue to create an artificial erection. This provides information about the duration and quality of the erection.

In addition to identifying the underlying cause of ED, these diagnostic methods also play a key role in selecting appropriate treatment options. The results of these tests are important in determining treatment options such as the ED1000.

Erectile Dysfunction Drug Treatment and Side Effects

Medication treatments for erectile dysfunction include a class of drugs known as phosphodiesterase type 5 inhibitors (PDE5 inhibitors). These medicines include sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Stendra). The medicines work by helping the smooth muscles in the penis to relax so that blood can flow more easily into the penis. This process is necessary for a healthy erection to occur.

Medication is usually effective, but it also has a number of side effects. Possible side effects may include:

• Headaches
• Flushing of the face
• Digestive system problems
• Blurred vision or changes in vision
• Nasal congestion
• Back pain

In rare cases, serious side effects may occur, for example

• Hearing loss
• Prolonged and painful erection (priapism)
• Chest pain or heart problems

These medications may also be unsuitable for people with certain health conditions and may interact with certain other medications such as nitrate medications. Therefore, before starting any erectile dysfunction drug treatment, one's health history should be reported to his or her doctor and the doctor's recommended dosage instructions should be strictly followed.

Furthermore, medication may not always help with erectile dysfunction caused by psychological or emotional factors. In such cases, concomitant psychological counselling or therapy may be helpful. In order to achieve an effective result, drug treatment should often be supported by healthy lifestyle changes and regular follow-up appointments.

Surgical Methods in Erectile Dysfunction

For patients struggling with erectile dysfunction, there are surgical options as well as lifestyle changes, medications or devices. These methods may be suitable for individuals who do not get results from noninvasive treatments or do not respond to medical treatments.

• Penile Prosthesis Implantation: In men with severe erectile dysfunction, flexible or inflatable devices can be implanted in the penis. The prostheses mimic a natural hardness for sexual intercourse and maintain this hardness for the desired duration.
• Vascular Surgery: If erectile dysfunction is the result of vascular damage affecting the blood supply to the penis, it may be possible to repair the vessels with surgery. This method is usually suitable for younger patients and should have a strong volume and effectiveness.
• Venous Leakage Surgery: In cases where erection cannot be maintained as a result of too rapid escape of blood from the penis, surgical procedures that eliminate venous leakage can be applied.

Prior to treatment, the potential risks and complications of surgical intervention should be well understood. Since surgical procedures can be permanent, patients should be informed in detail about their expectations and possible changes after surgery. In addition, the costs of these surgical procedures and whether they are covered by insurance policies should also be considered.

Such surgeries are usually conducted by urologists and performed in clinics specialising in male sexual health. The success of surgical methods may vary depending on the general health of the patient and the degree of erectile function before surgery.

Introduction of the ED1000 Treatment Method

Erectile dysfunction is a health problem that affects many men and significantly reduces the quality of life. Developed as an alternative to traditional treatment options, ED1000 treatment method is a promising technology especially for patients with vascular-induced erectile dysfunction. ED1000 is used to improve blood flow in the penis based on shock wave therapy.

The main features of the ED1000 method are as follows:

• Low Intensity Shock Wave Therapy (LI-ESWT): The ED1000 sends low-intensity shock waves into the penile tissue. This treatment promotes the development and healing of blood vessels, thus increasing blood flow to the penis.
• Non-invasive Treatment: ED1000 treatment is applied without surgical intervention. It is a painless and comfortable treatment option for patients.
• Short Duration Sessions: The treatment consists of short sessions, usually several times a week, lasting approximately 15-20 minutes.
• Long Lasting Effects: ED1000 treatment offers long-term results. In many patients, post-treatment effects can last for months or even years.
• Can be Combined with Medication: ED1000 can be used in conjunction with existing drug therapies, although it may also be effective as a stand-alone treatment for some patients.
• Wide Disease Spectrum: Suitable for a broad population of men, including patients with underlying health conditions such as diabetes, hypertension.

ED1000 is a treatment with proven efficacy and safety in clinical trials. However, like any treatment, ED1000 should be recommended under the supervision of a doctor and for appropriate patients.

Biomedical Principle of Treatment with ED1000

ED1000, which is used in the treatment of erectile dysfunction (ED), is a method known in the biomedical field as shock wave therapy. The basis of this treatment principle is to increase blood flow and promote new blood vessel formation (neovascularisation) by applying low intensity shock waves to the tissues in the penis. The method is particularly recommended for patients with erectile dysfunction of vascular origin.

• Tissue Repair and Regeneration: ED1000 treatment supports the repair of damaged endothelial cells in the penis and the formation of new blood vessels. As a result of this process, blood flow in the arteries carrying blood to the penis improves and a healthier erectile function is provided.
• Transformation of Collagen Structure: The treatment affects the hard collagen structure that loses the elasticity of the tissue in the penis and facilitates the transformation into a softer tissue. Thus, the penis tissue that gains flexibility allows for a better erection.
• Neural Stimulation: The creation of a stimulus to the nerve tissue in the area where shock waves are applied contributes to the improvement of neural functions. This is an important factor for the improvement of erectile function.

The course of treatment is usually administered once or twice a week for several weeks, and these adjustments can be personalised according to the patient's condition and response to treatment. The use of the ED1000 is usually painless and no anaesthesia or surgical intervention is required. Patients can return to their daily activities immediately, as there is no need for any recovery period after treatment.

However, the success rate of treatment with the ED1000 can vary depending on the severity of the erectile dysfunction and the general health of the patient. Therefore, it is important to carry out a detailed health assessment before starting treatment.

Application Process in ED1000 Treatment

Erectile dysfunction is a condition that negatively affects the quality of life of many men. ED1000 is a state-of-the-art treatment method with a high success rate in this regard. The application process of ED1000 treatment should be carried out carefully and step by step.

1. Preliminary Interview and Evaluation:
   • A comprehensive preliminary interview is conducted about the patient's medical history and current health status.
   • The underlying causes of erectile dysfunction are tried to be determined.
   • It is decided whether the patient is suitable for treatment.
2. Determination of Treatment Protocol:
   • A special treatment plan is created for each patient.
   • The frequency and duration of treatment are adjusted according to the patient's needs.
3. ED1000 Treatment Application:
   • Patients are usually informed that no preparation is required before the procedure.
   • The ED1000 device is designed to improve blood flow in the penis by sending low-intensity shock waves.
   • The procedure is carried out by means of a cap that is inserted towards the penis.
   • Pain or discomfort during the treatment is minimal and anaesthesia is not required.
   • Sessions last about 15-20 minutes and are usually applied several times a week.
4. Follow-up and Monitoring:
   • Regular follow-ups are performed to evaluate the effectiveness of the treatment.
   • Patients' progress is monitored and assessed for any side effects or complications.
5. After and Maintenance:
   • After the ED1000 treatment has been completed, additional recommendations, such as lifestyle changes, are made to prevent the erectile dysfunction from recurring.
   • For long-term success, patients are encouraged to adopt healthy habits and attend regular medical check-ups.

ED1000 Treatment and Comparison with Other Treatment Methods

Erectile dysfunction (ED) is a common problem among sexual dysfunctions in men. ED1000 treatment is a new generation treatment method developed to overcome erectile dysfunction. This method is based on Low-Intensity Shockwave Therapy (LISWT). ED1000 aims to improve blood flow to the penis so that a natural erection can be achieved.

Compared with other methods of treatment:

• Oral Medications (PDE5 inhibitors): Oral medications such as Viagra, Cialis and Levitra are commonly used to treat ED. These drugs work by increasing blood flow to the penis. However, these drugs can have side effects and may not be suitable for some men.
• Injection into the penis: This treatment involves injecting medication directly into the penis. The erection achieved with the medication is usually quick and effective, but the procedure can be uncomfortable for some men.
• Penis Pumps: Penis pumps, which are vacuum devices, promote hardening by accumulating blood in the penis. Although it is a practical and drug-free method, it is not preferred by everyone.
• Penile Implants: These implants, which are inserted into the penis through a surgical procedure, provide a guaranteed erection. However, the risks and costs of surgery should be considered.

ED1000 treatment stands out as a non-invasive, painless and drug-free method. Side effects are minimal and it can offer long-term solutions. However, the effectiveness of ED1000 treatment may vary according to underlying health conditions and individual response. Patients should evaluate the advantages and limitations of ED1000 together with other alternative treatment modalities and decide on the most appropriate treatment option.

Long Term Effects of ED1000 Treatment

ED1000, which is used in the treatment of erectile dysfunction, is known as state-of-the-art shock wave therapy. Clinical studies on the long-term effects of this treatment on erectile dysfunction show positive results. When the long-term effects are examined, they can be grouped under the following headings:

• Lasting Improvement: It has been observed that the improvement in erectile function obtained after ED1000 treatment continues for a long time. In some patients, the response period to the treatment may continue for months and sometimes years.
• Improvement of Vascular Health: Shock wave therapy increases blood flow by dilating the blood vessels in the penis. This improves vascular health in the penis and strengthens the ability to harden, and this effect can be long-lasting.
• Reduced Drug Dependence: ED1000 treatment can reduce or completely eliminate the need for medications that some patients use for erectile dysfunction. This improvement helps reduce drug-related side effects by enabling patients to use less medication.
• Psychological Effects: Erectile dysfunction can have serious psychological effects. Successful results of ED1000 treatment can lead to a marked increase in patients' self-confidence and quality of sexual life.
• Low Risk of Side Effects: ED1000 treatment has almost no side effects. This allows patients to accept the treatment more easily and does not cause long-term treatment-related negativities.

These findings suggest that ED1000 treatment may offer an effective and long-lasting solution for men with erectile dysfunction. However, it should be remembered that ED1000, like all medical treatments, may have different results from person to person. Each patient's medical history, lifestyle and individual response to treatment may differ. Therefore, regular medical check-up and follow-up before and after treatment is important.

Expected Results and Patient Satisfaction after Treatment with ED1000

ED1000 is a shock wave therapy based treatment developed for patients with erectile dysfunction. This method aims to help make healthier and longer lasting erections possible by improving blood flow in the penis.

Expected Results

• Improved Circulation: With ED1000 treatment, the blood vessels in the penis dilate and blood circulation increases. This is an indication of how it can contribute to the reduction and sometimes complete cure of erectile dysfunction.
• Painless Treatment Process: No pain is felt during the treatment and the procedure is very comfortable.
• A Drug-Free Method: ED1000 is suitable for patients who do not want to or cannot use medication, because the treatment is carried out without medication.
• Low Risk of Side Effects: Compared to drug treatments, the risk of side effects is lower, thus increasing patient safety.

Patient Satisfaction

Patient satisfaction is often linked to treatment outcomes and improvement in patients' quality of life. In the majority of patients treated with ED1000, a significant improvement in sexual function is observed. Patients express their satisfaction after treatment in the following ways:

1. Improvement in Erection Quality: Patients observe more solid erections and prolonged duration of sexual intercourse.
2. Satisfaction in Relationship with Partner: Patients and their partners give positive feedback about increased satisfaction and performance during sexual intercourse.
3. Psychological Benefits: Decrease in stress and anxiety levels due to erectile dysfunction is one of the important factors that increase patient satisfaction.
4. Strengthening Relationships: Treatment supports relationships by increasing sexual satisfaction and enhancing sexual communication between couples.

Positive results and patient testimonials attest to the efficacy and patient satisfaction with the ED1000 treatment for erectile dysfunction. However, as each patient's situation is different, the level of response to treatment may vary individually and a treatment plan specific to each patient may be required.

Coping with Erectile Dysfunction: Lifestyle Changes and Supportive Therapies

Erectile dysfunction can be affected by many physical and psychological factors. Individuals struggling with this problem can improve the situation with lifestyle changes instead of relying only on medical treatments. Supportive therapies also play an important role in this process.

Lifestyle Changes:

• Healthy Diet: A balanced and healthy diet helps to control body weight and improve heart health. Especially foods low in saturated fats and rich in fibre should be preferred.
• Regular Exercise: Moderate aerobic exercise for at least 150 minutes a week can improve erection quality and reduce stress by increasing blood flow.
• Avoiding Alcohol and Smoking: Alcohol and cigarette consumption are factors contributing to erection problems. It is recommended to reduce or stop consumption.
• Stress Management: Stress is one of the biggest causes of erection problems. Relaxation techniques such as meditation, yoga or regular walks can help reduce stress.

Supportive Therapies:

1. Psychological counselling: It can help individuals overcome the psychological barriers they face.
2. Couple Therapy: Therapy to be taken together with the partner can support finding a solution to the problem by strengthening communication.
3. Acupuncture or Reflexology: These therapies, which are considered traditional treatment methods, can help those who have erection problems by balancing the energy flow in the body.

Lifestyle changes and supportive therapies can help people with erectile dysfunction to recover both physically and emotionally. When applied together with medical treatments, these methods can increase the effectiveness and improve the quality of life of the person.

Effectiveness and Safety of ED1000 Treatment in Studies

Erectile dysfunction is one of the leading sexual dysfunctions in men and many treatment methods are aimed at improving this condition. ED1000 is an innovative treatment method that has attracted attention recently and is applied to the penis using sound waves. This method helps to stimulate the formation of new vessels in the penis and thus contributes to the improvement of sexual functions in patients with erectile dysfunction.

• Several clinical studies have been conducted on the effectiveness of ED1000 treatment. The results of these studies have generally been reported as favourable. The majority of patients reported significant improvement in erectile quality after treatment.
• In terms of safety, ED1000 treatment has been observed to have a high safety profile. Serious side effects during and after treatment were very rarely observed.
• Ease of use is another aspect appreciated by patients. Treatment sessions are usually short and do not require hospitalisation.

Despite these positive findings, however, some critics have called for more data on the long-term effects of the treatment and its efficacy in large patient populations. In addition, the number of studies comparing ED1000 therapy with conventional treatment modalities is increasing, providing important information on where to position the treatment and its integration into standard treatment protocols.

In conclusion, in the light of the available data, it can be said that ED1000 treatment is an effective and safe method in the treatment of erectile dysfunction, but further research is needed. The treatment needs to be evaluated by patients and physicians regarding personal tolerance, side effect profile and long-term benefits. This treatment approach is expected to have an important place in the field of male sexual health.

The effect of treatment with ED1000 on erectile dysfunction

Erectile dysfunction (ED) is a condition that affects many men and reduces their quality of life. In addition to traditional treatment methods such as drugs, vacuum devices and surgical interventions, the effectiveness of a treatment method called ED1000 has been discussed in recent years. ED1000 is an innovative treatment method based on low intensity shock wave therapy (LI-ESWT).

• The ED1000 treatment is designed to improve blood flow to the penis.
• This treatment promotes the formation of new blood vessels in the tissues of the penis, so it can increase the ability to erect.
• The ED1000 offers a promising alternative, especially for patients who do not respond to drug therapy or do not favour surgical intervention.

Several clinical studies have shown that ED1000 treatment can be effective in overcoming erectile dysfunction in men. For example

• Many patients have reported significant improvement in erection quality after the course of treatment.
• Studies emphasise that the efficacy of the treatment can occur within the first few weeks after administration and can persist for several months.
• The side effects of the treatment are usually minimal and the majority of patients considered the procedure painless.

However, it should be noted that ED1000 treatment may not be suitable for all individuals and its effectiveness may vary between individuals. It is important to consult a health professional and to have a comprehensive assessment before starting treatment. In conclusion, the positive effects of ED1000 treatment on erectile dysfunction should be studied on an individual basis and under the supervision of a doctor.