Friday, April 11, 2014

Medical Scribes, an Evolving Threat to Patient Privacy

by Joel Sherman MD

Medical scribes are a burgeoning field with many institutions and practices exploring their use while the many commercial enterprises who lease out scribes are pushing for their widespread acceptance.  There is no accepted definition of what scribes do or what their background or training should be.  There is no mechanism for licensure of them in any state.  They are poorly defined medical assistants.  The field is in its infancy and its ultimate role in our healthcare system is unclear.

The usual use of a medical scribe is to follow a provider around in their clinical tasks for the purpose of data entry.  This may or may not involve being present for the history and physical exam.  Most commonly they are physically present in the room and witness the entire encounter.  The need they fill is a function of our ever increasing mandates for electronic medical records (EMR).   Before EMRs, the use of data processors in examining rooms was quite rare.  Thus federal mandates have created another whole class of employees who are placed in the middle of health care interactions increasing the potential cost and complexity for all.   Some practices will clearly be tempted to use the scribes for as many uses as possible including assisting with minor procedures which I’ve seen advertised and acting as chaperones, which I know happens. This can help to ameliorate some of the extra cost involved in their employment.

The background of scribes is not standardized.  The minimum requirement appears to be competent data entry ability which translates into typing speed at a terminal.  Some advertisements require applicants to have a high school diploma or a year or two of college.  Many make no mention of education at all.  Some commercial sites train the scribe for a period varying from a few weeks to months.  At the high end, some advertisers require an existing knowledge of medical terminology with the preferred candidate being a medical student or premed student.  This is more often the case when the scribes are being used by academic institutions that have much greater access to people with these qualifications.  The majority of practices will not have access to premed or med students.  The scribes are mostly young and it is likely that few will choose this as a permanent career.  Thus they constantly have to train new ones.  The advertised pay rates vary from a minimum wage of about $8/hr up to about $20-25/hr.  The work may be full time but often is part time.

The touted benefits of scribes are to increase the efficiency of the practice by allowing the physician to see more patients while having a more personal interaction as they are freed from data entry.   It is advertised as a money saving strategy though a practice I discussed this with wasn’t at all sure that it saved money in their practice.  Scribes are a possible solution to the imposition of EMRs whose benefit to the patient and practice are frequently unclear or negative to begin with.  The dangers to patient privacy are clear but not often emphasized.  How much of a concern this is depends on the practice.  My ophthalmologist uses them without difficulty.  Few would object to an assistant hearing your ophthalmological history.  But many patients of general practitioners or internists would be inhibited from giving an intimate history by the presence of an assistant.  A few have the assistant outside the room for this perhaps making the patient more comfortable.  The presence of scribes during intimate physical exams is a further situation where many patients would be uncomfortable.  One article by urologists studied this and found no problems with acceptance, but the study had many caveats which the authors document[1].  This took place in an academic setting with medical students used as scribes.  The majority of the scribes were in fact men.  The one female urologist in the practice with a predominately female following refused to be part of the study.  I think the results would have been different in a urology practice in a private non academic setting where scribes were predominately young women without a medical background.   The routine use of opposite gender scribes would certainly make many patients uncomfortable in a private urology practice.  The most common use of scribes to date is in emergency departments where there are certainly many issues of patient privacy.  But in emergency settings patients are less likely to be concerned about their privacy.

The accuracy of scribes has not been studied to my knowledge.  The results would depend greatly on the background and training of the personnel.  But I do not see how anyone with a high school background and a few months of training could possibly understand all the medical conditions covered in a general practice.  The physician is responsible for signing off all records of course, but if the record is full of errors, it would be of limited use.  If premed or med students are being used, the results should be better, but this is partially mitigated by the fact that there would be immense turn over and new people would always need to be trained.

In summary, the routine use of scribes in a general practice has many potential problems of privacy and accuracy.   I don’t see how scribes without a medical background could ever be competent to understand a general medical history.  It would be far more accurate to have patients fill out detailed questionnaires on the initial visit and then have data entry performed on this later by scribes.  This would also permit a far greater feeling of patient privacy.   Patients have always understood that their medical records may be processed for administrative purposes.  The presence of scribes during intimate histories and exams should be very limited and only done with the express permission of the patient.  They should not be used as chaperones or multipurpose medical assistants without further special training.  In the long run the use of scribes is likely to be a temporary answer to a cumbersome system of mandated EMR which can still cause as many problems as it solves.  There is no intrinsic reason why EMRs need be so intrusive that their use requires a staff of intermediaries.  This makes it increasingly impossible for solo physicians and small groups to stay in practice.

[1] Koshy S et al, J. Urol. Vol 184, 258-262, July 2010.

This article has been re-published on

Wednesday, May 1, 2013

Informed Consent for Urinary Catheterization
by Misty Roberts

Informed Patient Consent Is Missing From Urinary Catheters

A urinary catheter is a hollow flexible tube inserted into the bladder to drain urine. This catheter drains urine from your bladder into a bag outside your body. Common reasons for a urinary catheter include staff convenience, urine leakage (incontinence), urinary retention, certain surgeries such as prostatectomy, and surgery lasting more than three hours. Staff Convenience is a very common reason for the use of indwelling catheters, and one which is recommended against by many universities and government organization. There is the perception that it is more convenient for nurses to place a catheter rather than take the patient out of the bed several times a day to change bed sheets and clothing, to help him/her to use a bed pan or walk to the bathroom, and to change diapers. Nurses should never use those reasons to catheterize patients. Foley catheters are not appropriate as a treatment for incontinence.

Many people feel that urinary catheterizations are an invasion of their bodily privacy even if they are done by a nurse or doctor of the same gender especially when they are not really necessary. Patient modesty is not the only concern with urinary catheters. You easily get infections or injuries from urinary catheters. Urinary catheters are the number one cause of hospital-acquired infections. About 80% of hospital-acquired urinary tract infections are related to urinary catheters. About 10% to 30% of male urinary catheterizations result in urethral injury. Check out complications that can occur from urinary catheters.

While it is true that some hospitals and medical facilities have worked to decrease the number of urinary catheterizations on patients due to concerns about infections, many medical facilities in the United States continue to do many unnecessary urinary catheterizations. Outpatient Surgery clinics typically do less urinary catheterizations than hospitals.

Urinary catheter is standard for many surgeries that do not really require them at some medical facilities. One man who had a simple neck surgery in a Georgia hospital was very upset and embarrassed when he woke up and discovered that he had a urinary catheter. He was not even asked for consent to have the urinary catheter inserted. Urinary catheter is not necessary for a simple neck surgery. When his daughter asked the nurse why he had a Foley catheter, the nurse replied by saying he needed one because he could not walk. A patient’s inability to walk is not a reason for a urinary catheter. Unfortunately, what happened to this man is pretty common at some medical facilities.
Some patients have urinary catheters inserted when they go under anesthesia and then removed before they wake up so they are unaware that they had a catheter unless they find out from their records or had difficulty urinating or felt burning sensation as they urinated after they woke up from surgery.  I feel that this is very unethical.

Some medical facilities allow nursing students to practice inserting urinary catheters on patients under anesthesia without their consent. This is very unethical. This unethical practice violates a patient’s wishes for modesty and could cause complications such as blood infection, Urinary Tract Infection, urethral injury, etc. Because nursing students have limited experience, they are more likely to injure patients they catheterize. While it is true that nursing students need practice with urinary catheterizations before they graduate from nursing schools, nursing school students should only do urinary catheterizations that are absolutely necessary under supervision of an experienced nurse and with a patient’s consent. Nursing schools should have their students do urinary catheters on mannequins as much as possible. Every nursing school should have a urinary catheter simulator such as a male catheterization simulator.

When is urinary catheter medically necessary?
Neurogenic bladder, acute urinary retention that cannot be resolved, acute bladder outlet obstruction, oliguria due to hypotensive shock, end of life comfort care of a terminal patient, certain surgeries such as prostatectomy and hysterectomy, prolonged surgical procedure (not a few hours) with general or spinal anesthesia. Most surgeries are less than 3 hours long so most surgery patients should not be catheterized at all.

Different types of anesthesia and effects on bladder functions:

Local Anesthesia – This type of anesthesia has no effect on bladder function at all so there is no need for a urinary catheter if you have local anesthesia. You should strive to have surgeries such as hand, wrist, etc. with local anesthesia if possible. Even knee surgeries can be done with local anesthesia now.
General Anesthesia – In short surgeries that are not longer than 3 hours, there is usually no effect on the bladder. The bladder will become distended in longer cases and the patient could become incontinent over time.

Spinal Anesthesia - Spinal anesthetics block activity along the nerve fibers that travel between the nerve centers of the brain and the bladder. Patients lose the sensation to void about 1 minute after being injected with spinal anesthesia, but will continue to feel dull pressure as the bladder reaches full capacity. In addition, the ability to contract the detrusor muscle is lost 2 to 5 minutes following the injection of local anesthetics and still persists even after bladder sensation is fully recovered. Spinal anesthesia with long-acting local anesthetic therefore contributes more to POUR (Post Operative Urinary Retention) than spinal anesthesia with short-acting local anesthetic, since the inhibitory effect of spinal blockade on bladder function lasts longer. Patients receiving spinal anesthesia with short-acting local anesthetic are often able to void shortly after outpatient surgery and are ready to leave the PACU quickly. (Source: What Do You Know About Post-Op Urinary Retention? - Outpatient Surgery) If you have spinal anesthesia, you should request spinal anesthesia with short-acting local anesthesia to reduce your chances of urinary retention.
Any bladder issues after surgery are most likely due to narcotics used for pain control.
Every patient should use the bathroom before surgery takes place. Most surgery patients are asked to not drink anything for at least 6 hours before surgery so their bladders are empty.

Patients who might become incontinent should be given the option of wearing disposable waterproof underwear or boxer shorts. You can buy them before you come to the hospital.

Why is there no informed consent for urinary catheters?
No informed consent is required for urinary catheterization. Despite the common use of urinary catheters and the well-known risks of complications associated with urinary catheters, patients are not asked to sign a written consent that discloses the advantages and disadvantages of urinary catheters. Rarely are patients informed verbally of the risks of urinary catheters. Another concern is that many patients care deeply about their modesty and would not want a urinary catheter to be inserted by an opposite sex medical provider.

John Fisher, a medical malpractice lawyer in New York shares in his article (Why Consent For Urinary Catheters Should Be Mandatory) that in evaluating hospital care throughout New York, he has not seen a single consent form for urinary catheters. Since patients with urinary catheters have a much higher chance of getting a urinary tract infection than those who do not have a catheter, the question must be posed: why is there no informed consent for urinary catheters?
Do patients really give “implied consent” to urinary catheterization?

Physicians and nurses will explain the patients give “implied consent” to urinary catheterization based on the theory that urinary catheterization is a common and routine part of hospital treatment. However, informed consent is important for urinary catheters for the following reasons.
  • Urinary catheter complications pose such a common and significant risk to patients.

  • Urinary catheterization is an invasive procedure and embarrassing for many patients who value their modesty. Every patient should be given the option of having a same gender nurse or doctor for the catheter insertion if it is absolutely necessary. Check out how male urinary catheterization and female urinary catheterization are done.
Once given information about the risks and benefits of urinary catheterization, the patient can make a fully informed decision whether they wish to accept the risk and if they want a same gender nurse or doctor to insert the catheter.

What is the downside of consent for urinary catheterizations? A little more paperwork and time for hospital nurses, but isn’t a fully informed patient worth this minor sacrifice? Patients should be informed that urinary catheter insertion involves the risk of complications, facts about how invasive the procedure is & their option for same gender nurse, and a specific consent relating to the pros and cons of a urinary catheter should be signed by the patient.
If the patient is incapable of making decision about urinary catheter, a family member should be asked for consent.
How to Refuse a Urinary Catheter?

Because there is no informed consent for urinary catheters and urinary catheter is standard for many surgeries and sick patients who cannot move at some hospitals, patients and their families must speak up and take steps to ensure that a urinary catheter is not inserted. Keep in mind that the inability to walk is not a reason to insert a urinary catheter.

Steps To Ensure That No Urinary Catheter Is Inserted:

1.) Request that no urinary catheter be inserted in writing. Write all over your surgical consent form that you do not consent to urinary catheter and that your underwear may not be removed at all for surgeries that do not involve the genitals. Try to get the consent form the day before surgery if possible.
2.) Talk to the surgeon, nurses, and everyone that will be involved in your care about how you do not permit a urinary catheter to be inserted and that your underwear must stay on.
3.) Type up a document saying that you do not consent to a urinary catheter and make several copies to give to everyone involved in your care.

Misty Roberts is the president / founder of Medical Patient Modesty (, a 501c3 non-profit organization that works to improve patient modesty.

Monday, April 1, 2013

Inappropriate Touching in the Doctors Office

How Good Intentions Turn into Bad Actions

By Peter A. Ubel, M.D.

This article – presented here with the author’s permission -- was first published in Critical Decisions on August 9, 2012. Dr. Ubel Is a physician and behavioral scientist, and Professor of Business and Public Policy at Duke University.  His research and writing explores the quirks in human nature that influence our lives - the mixture of rational and irrational forces that affect our health, our happiness and the way our society functions. It also explores controversial issues about the role of values and preferences in health care decision making, from decisions at the bedside to policy decisions. He uses the tools of decision psychology and behavioral economics to explore topics like informed consent, shared decision making and health care rationing. In his spare time, he enjoys classical piano, sports (playing and coaching!), chili peppers and raising two very active boys.  His most recent book, Critical Decisions, came out in the fall of 2012.

I felt a woman’s uterus without her permission. How this happened, and why I thought I had done the right thing at the time, tells us something important about medical education and shows us why doctor/patient interactions often play out like conversations between earthlings and aliens.

To understand my inappropriate actions, you need to know something about the physical exams that we physicians conduct on our patients. More specifically, about the pelvic exams we perform to assess whether a woman’s uterus or ovaries are potentially diseased.

Almost no one enters medical school with any skills at examining patients’ bodies. Consequently, the first time medical students listen to their patients’ hearts, they are lucky to distinguish the proverbial “lub” from the “dub”—what in technical terms we call the S1 and S2 heart sounds. It takes dozens of listenings before medical students are able to recognize the existence of a significant heart murmur, and hundreds more before developing any true expertise and recognizing subtler abnormalities.

And yet, listening to heart sounds pales in comparison to the difficulties of performing expert pelvic examinations. For starters, when a medical student listens to a patient’s heart through a stethoscope, the worst outcome for the patient is the feeling of cold plastic on their chest. An inexpert pelvic examination, on the other hand, can be painful for patients. Add to that the sheer uncomfortableness of an even expertly conducted pelvic exam—this is after all a very private body part being palpated in a manner that even under experienced hands is usually embarrassing and unpleasant—and the very act of practicing a pelvic examination feels like a major intrusion. Any woman willing to let a medical student examine her (before the more experienced doctors inevitably repeat the examination) is doing the medical profession a big favor. 

Pelvic examinations differ from heart exams in another important way: they are much more difficult for medical students to glean information from. An experienced physician conducting a pelvic examination can discern whether a woman’s uterus is mal-rotated; whether either of her ovaries is enlarged; and whether palpation of the uterus causes a woman to experience disproportionate discomfort, a reaction that could signal underlying pathology. Yet as the female obstetrician who supervised me during medical school put it to me: “The first dozen pelvic examinations you perform, you won’t feel a uterus, and you definitely won’t feel any ovaries; you will just feel warm.” 

Indeed, the pelvic examination can be an acutely uncomfortable portion of the medical encounter for students to learn. We feel nervous probing women’s private parts; we feel embarrassed at failing to glean any information from the exam after patients have been kind enough to let us practice on them. 

But we know that we must overcome our nerves and practice. I certainly knew of my need to practice when I walked into the operating room that day, in 1987, gowned and gloved and prepared to assist the surgeon in any way possible, assistance that given my almost complete ignorance of gynecologic surgery largely would amount to holding a retractor during the procedure. (A retractor is a medical instrument used to hold back, say, folds of skin and muscle from the underlying tissues being surgically treated.)

“Student, come over here right now,” the surgeon said. “We need to start the operation, but you need to examine the patient first.” 

I needed to examine her? I couldn’t see how that would help anyone. I had never met the patient before, but instead had simply been told to head over to surgical suite number three, or whatever number suite it was, to assist in the operation. I hesitated, which only prompted more urgent beckonings from the surgeon:

“Come over and feel her uterus,” she told me. “She has a large uterine mass. You need to know how to recognize this kind of mass on a pelvic exam.”

My confusion was obvious to see, despite the surgical mask covering the lower half of my face. 

“Don’t worry,” the surgeon continued. “She’s anesthetized and won’t feel a thing. Plus, her muscles are totally relaxed from the anesthetics, so you will have a much easier time feeling the anatomy.”

I inserted two fingers from my right hand into her vagina, pressed gently on her abdomen with my left, her uterus now squeezed between my two hands. Yep.  Definite mass. My physical examination skills were now inching towards expertise. My surgical supervisor had helped me develop as a physician. 

But of course, she’d also shaped my moral development. I had examined the woman, after all, without her permission. How could the surgeon and I have thought that it was acceptable to do this?  I could only speak for myself. To begin with, I was frantically obsessed with learning my new trade.  In addition, I wanted to impress the surgeon and get a good grade on the rotation. So when I stood there in the O.R. that day, presumably facing a moral dilemma, I barely gave the situation a second thought.

The result of that was that I began thinking that this kind of action was ok. The surgeon, after all, was a wonderful person, committed to medical education and patient care. And I knew that I had nothing but good intentions in examining this patient. There was nothing prurient in my behavior.  I simply wanted to become a better clinician. 

But I’m sure if we had woken up that woman and told her what happened, she would have been horrified. The women I have surveyed on this topic say that, while they’d be willing to give permission for medical students to practice pelvic examinations on them, they would feel violated if such practice occurred without their permission. 

Moral attitudes are often a function more of our experience than of our training. When some colleagues and I surveyed medical students and asked them how important it was to ask permission before conducting a pelvic exam on an anesthetized woman, brand new medical students almost universally stated that permission was vital but by the time the students finished their OB/GYN rotations three years later, they didn’t see permission as being important anymore. Despite the lectures they’d received about “informed consent” during the first two years of medical school, six weeks of an OB/GYN rotation was enough to change their moral attitudes.

How can an ethics lecture compete with a palpable uterine mass? 

Friday, March 15, 2013

You Can Make a Difference
by Doug Capra and Joel Sherman

Saturday, July 21, 2012

(This article crashed and had to be reposted so it is out of order and comments were lost.)

A Follow Up on ‘Juicy Nurse’
         Activism works. Especially in patient modesty and privacy violation where most people are passive and don’t complain.
         Why? Perhaps because offenders are not used to people complaining and are caught by surprise. Some may not even realize the seriousness of their insensitivity. Others certainly know these kinds of violations exist but, over the years, have convinced themselves that the events are not that important because – after all – no one seems to care.  No one complains.
            In January 2011, we published an article that described blatant patient privacy and modesty violations written by two nurses in their separate blogs. In essence, we chastised the nurses for what we consider their immaturity, insensitivity and lack of ethics regarding respecting the dignity of their patients and their profession. Before readers go any further with this article, we would ask that you read the above article we wrote and the excerpts from the now deleted blog of ‘juicynurse’ which are appended at the end of this article. 
            As we mentioned in our article, we did not know the identity of the apparent nurses authoring these blogs.  Fortunately, one of our readers, who prefers to stay anonymous on this blog read our article and was able to positively identify the nurse involved by the email address she provided on her site.  The nurse also gave her name in another section of the blog for a poem she wanted credit for.  With this information he was able to find her present site of employment where she has worked for years , nearly all of her professional career, as that of a large Miami hospital which we have previously identified.  He then wrote to the hospital informing them of this nurse’s online activities.  A few days later the blog was deleted.  The hospital through their public relations department thanked our reader and assured him that the problem was being taken care of, but would give no details claiming that all employment information was confidential.  We do not know the legal status of that claim, but it is commonly made.    With our reader’s permission, I also wrote the hospital and received a similar response.  They guarantee that action has and will be taken, but give no specifics.  In short, ‘juicy nurse’ has been identified and likely chastised by her employer, though we have no assurance that she is not still involved in patient care cataloging all the intimate details she has seen.  If we were patients at the hospital, we would refuse care from this nurse.   In our opinion a nurse so obsessed with the sordid and intimate details of patient care should not be involved with patients, probably not with nursing at all. 
                  We went beyond this by also sending a complaint to the Florida Department of Health.  We ultimately received a reply that the conduct of juicy nurse was not covered by their regulations and they would take no action.  They based this on the fact that no names are given in the article and thus no violations of privacy in their point of view.  This is surprising to us as enough detail is given that several patients the nurse describes could recognize themselves by her description.  A particularly horrible anecdote concerns a fully described disabled obese elderly woman who ‘juicynurse’ discusses in the crudest terms possible.    We believe revealing potentially identifiable data is prohibited under HIPAA.
                                   In a recent KevinMD article, Dr. Chris Gibbons, associate director of the John Hopkins Urban Health Institute and director of the John Hopkins Center for Community Health, wrote:
     "If you are serious about change you must be willing to endure a lot of discomfort. While this is no doubt true, I would take things one or maybe two steps further and say, 'Disruptive change will only happen when you become uncomfortable with being comfortable!'”

     He's speaking from inside the health care community, talking about making changes from within. The same may also be true for patients working from the outside. But not always.  In the case we've described, neither we nor our activist poster had to go through discomfort to get the attention of this hospital and this blog removed.

     Dr. Gibbons also wrote:
     "Whether the goal is personal weight loss, professional achievement, disparities elimination, patient access to personal health data, societal health improvement, or global peace, resist the logical, evidence based tendency to be satisfied with “change,” and release yourself to achieve what others think impossible by first becoming uncomfortable with being comfortable."

     We urge our readers to get involved. Be proactive. Don't be afraid to make civil complaints and provide solutions. And if you are ignored, don't give up. Resend those letters with copies to the media, if necessary.  As Dr. Gibbons suggests, don't be comfortable with an unfair status quo. Be uncomfortable with it. And do something.
The following are copied from which was deleted several days after our astute reader filed a complaint with BHSF.  There were also other posts which in my opinion are worse than the ones we’ve reprinted in that they are so graphic patients could likely identify themselves:
Monday, September 7, 2009

I have to talk about this! I know the men followers will probably not enjoy this, but it needs to be discussed. I have seen so much PENIS in the last 8 years! I did not realize in nursing school the variety of PENIS that I would be exposed to, I mean in the text books......a penis is a penis, but in the real word the PENIS is always an interesting surprise!

I have seen big penis, small penis, hidden by huge bush penis, "that's it?" penis, peek-a-boo penis, smelly penis, dirty penis,oozing penis, uncircumcised penis, young penis, old penis, swollen penis, uncomfortably hard every time I walk in the room penis, paralyzed penis, white penis, Jewish penis, Asian penis (not good), I can't find your penis because you are tooo fat penis, famous penis, HOLY SHIT that's a large penis, penis, and the SURPRISE, I am a white man from the waist up and a black man from the waste down penis!

It is true what they say about the black man.  I have seen A LOT of black man penis and it is NEVER small.  From the time these penis's enter the world they are HUGE.  It is UNBELIEVABLE!  The little black babies have penis's that actually flop up over their belly buttons. When I worked in pediatrics, I was shocked at the head start that these little black babies get....they are ahead of the game from day 1!

I once had to take care of a famous Miami coach.  In between juggling his girlfriend and wife, we would chat here and there.  He asked me to get him some pain medicine and when I did and came back to the room, I opened the door and I saw him standing up with the urinal in between his knees.  I quickly thought to myself, "that's weird....why is he holding the urinal in between his knees?"  Then I realized, "HOLY SHIT THAT IS HIS PENIS ALL THE WAY DOWN THERE"  It is TRULY AMAZING!  I have never seen anything like it and instead of quickly closing the curtain or running out of the room, I stood there like a little girl seeing a penis for the first time.  I was truly shocked and I eventually stuttered my way out of the room, dropping the medicine, staring at the penis and walking out of the room backwards like an AWKWARD mess!

I guess in nursing school they just figure that a penis is a penis!  They do not warn us of all of the interesting penis that we will encounter in our careers for fear that we will giggle our way through nursing school.  Sometimes we find a nice surprise, sometimes it is small, sometimes it is smelly and sometimes it is truly freakishly large......they all work the same way but at the end of the day.....NURSE'S LOVE A GREAT PENIS STORY!

Posted by at 8:34 AM
Sunday, June 14, 2009
Well, I guess I can not leave the women out! After the Penis post.....that would not be fair!

Ladies......your junk is disgusting! For god sakes.....TAKE CARE OF YOURSELF!

I am up in everyone's business ALL of the time and I have to tell you, it is AWFUL! I have actually offered to PAY someone to put a Foley catheter in a women for me! I HATE IT!   Where is the freaking hole man? wonder men are so confused! Don't get me wrong, I KNOW anatomy! I know where things are SUPPOSED to be.......but the older and fatter you get the more FREAKING CONFUSING it is! There is NO text book urethra for a women! "Why isn't any urine coming out?", we wonder......."oh, i know......BECAUSE YOUR IN THE FING VAGINA!"

It is the most disgusting.........I don't mean to offend anyone, but the thinner you are the easier it is, not much, but a bit easier. We do not have stirrups when we(nurses) do this.......we HAVE to be able to hold the legs back, maintain sterile technique and insert the Foley catheter........if you are not able to help us at all, it makes it very difficult.......smelly.......and sweaty......!

Like I said, I would rather pay someone.......does that mean I am prostituting my services?

Wasn't it the grandmothers of the world that said, "make sure you have clean underwear on when you leave the house because you never know!"
Illustration from another article from about a fat woman blowing farts