At one of the more than 10,000 medical spas that dot the American landscape, you are likely to find a relaxing, inviting atmosphere that caters to the desire for calm, serenity and renewal. What you are unlikely to encounter, however, is a physician.
Despite being termed “medical spas,” only 37% of such facilities were owned by a physician as of 2022, according to an AMA issue brief on the need to protect patients with physician-led care at medical spas (PDF). Moreover, 70% of medical spas lack any affiliation with a physician practice.
And patient protection is sorely needed. Many of the procedures offered in medical spas constitute the practice of medicine, yet they are often provided by inadequately trained or unsupervised practitioners. This, in turn, can lead to patient harm.
In Florida, a technician without a license was arrested after a client developed a necrotic wound on her face. At locations in North Carolina and Arizona, several young women died during a laser hair removal treatment after toxic levels of pharmacy-compounded topical gels were applied.
Meanwhile, the AMA issue brief notes that 80% of cosmetic medical procedure lawsuits between 2008 and 2011 involved procedures performed in medical spas by nonphysicians. Moreover, of cases that resulted in injury from laser surgery between 2012 and 2020, 71% were performed by nonphysicians.
Medical spas often provide cosmetic medical procedures outside of a physician’s office. Though the industry has grown sixfold since 2010 and generates more than $20 billion in revenue, med spa locations are typically regulated as businesses and not as medical facilities. States also vary on the types of delegation and supervision they allow for cosmetic medical procedures.
Some states do require an initial consultation with a physician or a nonphysician provider prior to receiving medical care, while other states have no regulations at all. As a result, “there can be less oversight in these medical spas,” said M. Laurin Council, MD, president of the American Society for Dermatologic Surgery Association (ASDSA) and director of dermatologic surgery at Washington University School of Medicine in St. Louis.
ASDSA has been a leader on this issue and has created a comprehensive overview of medical spa safety. In addition, their microsite contains recent research, state regulation and news coverage. The ADSA also has put forward a med spa safety model bill to help policymakers and patients become better informed on this important patient-safety issue.
Why people seek out medical spas
Patients could go to a board-certified dermatologist or another physician with specialized medical training for these medical procedures, but medical spas have broad consumer appeal.
“They can be easier to get into, make appointments. It is not something where you must have referrals or insurance coverage like other medical procedures,” explained Dr. Council, an AMA member. It is often more affordable for patients to visit a medical spa that does not have to shoulder the cost of physician oversight.
Social media also drives this trend, as celebrities boasting of positive med spa results are splashed all over Instagram.
The importance of on-site physicians
Physician oversight at medical spas varies widely, Dr. Council said.
“Some med spas have a physician who is there and present overseeing the medical procedures. Some do not. Some have a physician who is listed as the medical director, but it may be a physician who is not a board-certified dermatologist, plastic surgeon or facial plastic surgeon. It may be someone who had less training in the medical procedure being offered,” Dr. Council said.
Having a physician on site who is appropriately trained in these procedures and immediately available to address any problems is more ideal for patient safety and efficacy, she added.
To protect patient safety, the AMA issue brief says that states should enact medical spa safety laws that:
- Ensure a supervising physician is present at the site, can immediately be able to respond in-person as needed, and is trained in the indications for, and performance of, any cosmetic medical procedure performed.
- Require a supervising physician to perform initial patient assessments, develop a written treatment plan for each patient, and obtain patient consent if the procedure is being done by a nonphysician.
- Obligate any nonphysicians to wear badges that clearly identify their licensure and communicates that they are not physicians.
The AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that threaten patient safety and undermine physician-led, team-based care.
What can go wrong
Physicians are trained and familiar with appropriate sterilization protocols for procedures like microneedling and platelet-rich plasma injections, which involve drawing blood. All medical procedures, even those that are minimally invasive can have complications.
“You have to use precautions to avoid transmitting bloodborne pathogens” and lidocaine toxicity, said Dr. Council.
Things can also go wrong with soft-tissue augmentation with dermal fillers. If these fillers are inadvertently injected into blood vessels, they can block the blood vessel, which can lead to blindness or tissue death. Lasers used in inappropriate settings or with inappropriate supervision can cause disfigurement and burns.
“Complications can happen anywhere. But the reality is that board-certified dermatologists and other specialized physicians are going to have medical training to better avoid and treat complications of medical procedures. They also know how to appropriately manage them,” said Dr. Council.
Right treatment for the right patient
Physicians, Dr. Council noted, are trained in preventing, identifying and managing complications. Prevention includes selecting appropriate patients for the appropriate medical procedure
It is not appropriate to do laser procedures on all skin types, said Dr. Council. “For example, some skin types have increased risk. If a patient is not a good candidate, you would turn that patient away for that procedure and not proceed,” she said.
Appropriate protocols ensure that the physician is choosing a proper laser setting.
“You are protecting patient's eyes during the laser procedures. You are doing appropriate sterilization protocols to avoid infection transmission. All of that has to be in place,” Dr. Council said.
If something does go wrong, the physician must identify that it is a complication—and be available to the patient. It is also important to know how to manage complications. If a patient gets a burn from a laser and the physician does not identify that the patient’s skin is changing color and continues to do the treatment, they are going to burn a much larger area. It is the physician’s job to realize that something is not right—to stop the procedure and treat and minimize that complication.
Medical literature reveals that laser injuries most often occur during delegated procedures, she noted.
Questions patients should ask
The ASDSA’s model bill on medical spa safety says that medical spas should have an on-site physician to supervise and help deliver safe medical care.
On the regulatory side, guidance the Food and Drug Administration issued in 2023 states that anyone considering a neurotoxin or dermal filler should work with licensed healthcare providers who are trained to inject dermal fillers and manage complications, and understand the risks and benefits of treatment.
In one alarming development, some medical spas are drawing from a counterfeit supply of neurotoxins that’s more potent than the normal cosmetic Botox that dermatologists use. The result? Iatrogenic botulism.
“I am part of a large health care system,” Dr. Council noted. “We only order direct from the manufacturers, not places that could have potentially counterfeit supplies.”
“Patients should be going to a reputable place to receive medical care. Medical risks should be thoroughly evaluated for all procedures regardless of whether it is a medical spa or a physician’s office,” she said.
The ASDSA urges patients considering a procedure at a medical spa to ask:
- Who owns and operates the med spa?
- Who is performing the medical procedure?
- Do they have the proper education, training and oversight at the facility?
There's still a lot of misinformation, especially on social media, about medical spas but the message about potential dangers is starting to break through, including a recent episode of HBO’s “Last Week Tonight With John Oliver.”
“We are making some progress, at least with the public perspective,” Dr. Council said.
