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« American Society for Dermatologic Surgery pushes medical spas bill in California | Main | Medical Spas, California, and the Practice of Medicine »

Mona Spa and Laser Treatments: Do physicians get to deciede what 'medicine' is?

doctorThere has been some back and forth on one of the threads about who gets to decide what medicine is and who can perform it.

Bill Sappenfield, who is part of a medical spa franchise called Mona Spa & Laser (He's Mona's husband I think) has taken the positon that... well, I'll let his comments speak form him.

Bill Sappenfield of Mona Spa & Laser Centers:

"So right you are. We have been running lasers for over 5 years with only estheticians. The medical boards seem to think that only nurse practitioners, physician assistants, and nurses are the only people qualified to run lasers.

Oh Contraire! Estheticians have more knowledge about skin care than 95% of the nursing community. Now don't get me wrong. Any qualified individual can learn and be trained in this business.

I am a firm supporter of the medical community in this business. However; this is the BEAUTY business no matter what the state medical boards say.

Most medical people don't even know what CIDESCO is! (We are 1 of 8 certified CIDESCO day spas in the U.S.) They don't realize that even some dermatologists have failed the CIDESCO exam.

As to your last comment, this is why so many physicians fail in this business. They just can't comprehend why their standard medical protocols and practices aren't working in this industry..."

And then there's this from Bill:

"Medical Board Regulations are regulations for the Medical Board. That does not make it law and even if a state board comes after someone for the "practice of medicine", that individual has the right to defend himself in a court of law. My point is that in most states, no one has questioned these regulations with a few exceptions. You don't have to believe me, but take a look at what is going on Texas and what has happened in Michigan.

It is the courts and the legislature that are the ultimate judges of what is and is not the practice of medicine..."

Of course LH (who is well know to medspaMD members) has a differing point of view:

"...From your previous posts you are a business person. Also,I am not sold that individuals with 600 hours of "training" know skin that well.

I would disagree with you on the idea that there is a significant dividing line between ablative and non-ablative lasers. The non-ablative lasers can cause severe scarring. IPL can cause significant problems as well.

I do think we agree on one thing though. You feel that the physicians can have all of the fillers, botox and ablative lasers and I feel you can have all of the body wraps and facials. I only offer facials, microderms and light chemical peels to my patients. I offer these because I do not want some cosmetologist telling them that they have some topical which is better than botox..."

Of course the problem is that the IPL's and lasers are where the money is. Hair salons and day spas are the second most common business in the U.S. (after restaurants). It's only the medical license that provides any barrier to entry in the practice of medicine and, of course, that's where the money is.. the practice of medicine.

So who gets to decide what constitutes the practice of medicine? Is it the courts or the medical boards? 

Reader Comments (64)

If Bill Sappenfield really feels that someone other than physicians should decide what is medicine we should let him write all the protocols for surgery and medicine. And while we are at it lets give him the honorary title of neurosurgeon.

Should physicians decide what is medicine??????

He needs to stop smoking that stuff he SAYS is only for medicinal purpose. The seventies are over dude.

05.1 | Unregistered CommenterEMD


Give me data that substantiates your position. No one seems to be able to do that. This is a political act not a medical one. Just like what is going on in California. The dividing line is whether or not a laser procedure is ablative or non-ablative. Ablative="the practice of medicine". Non-ablative="not practice of medicine".

Injectables and the rest are the practice of medicine. Non-ablative laser procedures are not.

05.1 | Unregistered CommenterWPS

You want data to show you that doctors get to choose what is medical and what is not?

Ok, It's called MEDICAL SCHOOL.

Lets see how many patients have had horrible results from non ablative treatments in the last several years due to trained physicians. LOTS.


The industry needs to be regulated and it need to be regulated by physicians.

To say that an estetician with six months of training has more knowledge of the skin that an trained MD or even a trained nurse is comedy.

By the way the courts use doctors to guide them as to what is medicine.

05.1 | Unregistered CommenterEMD


Emotional HOOPLA. Lumping non-ablative lasers in with everything else has never been justified. Even Massachusetts states that the definitions and classifications of lasers are obsolete. Just because physicians say that it is the practice of medicine doesn't make it true.

No one is stating that it shouldn't be regulated and that the medical community should not be involved. What we are saying is that the aesthetic community should not be cut out of the picture as has occurred in Florida and California and several other states. Every position concerning changing legislative and regulative laws and rules that we have either personally been a part of, read about, or talked to other people about, all say the same thing. "This is a money grab". Who, for the most part, are the sponsors of this change, the dermatologists. Why? "MONEY & CONTROL". You saw it in Florida. You are now seeing it in California.

I have heard the presentation by a dermatologist to the Tennessee Medical Board who tried to lump in 1064 Yags with CO2 lasers. A total distortion of the true picture!! I have yet to see or hear of any presentation that is backed by stats. If Lloyds of London will insure aestheticians along with MDs, PAs, NPs, and RN's for these non-ablative procedures, then that is good enough for me. Training,education, and the Medical community's participation is what will make this work, not the monopolization of the "Beauty Industry" by a select few.

By the way, Mona is an aesthetician and I will put her knowledge and understanding of skin and skin care up against 98% of the medical community any day of the week.

05.1 | Unregistered CommenterWPS

All I have to say is. Doctors Only.

05.1 | Unregistered CommenterEMD


Why am I not surprised!!

05.1 | Unregistered CommenterWPS

Because you know I'm right.

05.1 | Unregistered CommenterEMD


When you say doctors only do you mean doctors doing all the procedures. How many doctors want to do Laser Hair Removal, IPL treatments, Chemical Peels and the rest of the procedures. I know mine don't.

05.1 | Unregistered CommenterSBJ


Wrong!!! I wish we or someone else had the money to take the medical boards to court. You would be singing a different song!

05.1 | Unregistered CommenterWPS


I am curious as to what you are doing to plead your case with the various medical boards? You are so convinced of what you say, are you organizing the aestheticians' group (unsure of what their organziation is called) to present some data? It seems to me that the onus is on you to or the aestheticians to present some stats. Otherwise, your conjectures are purely anecdotal. Remember, the medical boards are the deciders, not the aesthetican "boards!" And yes, a 1064 Nd-Yag can cause scarring!

05.2 | Unregistered CommenterFiona


We have tried to in vain to get the aesthetic associations and cosmotology boards to actively and monetarily involved in several states.

And no the legislature are the final deciders. That is the dermatology association is pushing for these amended laws. They know if they can get it in as a law, then that's it.

The electrologist associations in many states have done just this. They have had laws enacted that protect their future in the hair removal industry and the medical boards have had to exempt them from their regs.

By the way, a light bulb will scar you if you hold onto it long enough and so will the LED light products that are being sold to spas.

05.2 | Unregistered CommenterWPS

Tell me something WPS.

Do you really thing the medical board is going to take aestheticians and Cosmotologist seriously?

I mean their total time in training is about 6 months. And about 2 of that is spent in book work spread out over the six months. Of that 2 months of book work they spend a week on some basic derm.

Come on. Get serious.

You are going to stand in from of a group of highly trained doctors and tell them that you are able to perform medical treatments without direct physician supervision.

Put yourself in the doctors shoe. what would you do?

Imagine if someone with High school math skills wanted to take care of some (not all just a small part) of your corporate accounting.

05.2 | Unregistered CommenterEMD


We don't let anyone, including RN's, PA's, NP's, Aestheticians, and: yes,
MD's run our lasers without the proper training and certification. It doesn't matter if they are fresh out of school or have been practicing for twenty years. They are not allowed to run lasers until they have met specific criteria for each protocol. Learning, observing,and performing under direct supervision are some of the steps that we require before they are allowed to provide services to clients. Some people pick it up quickly, some don't.

Yes, Aestheticians can run lasers and properly identify skin issues if trained correctly.

You still don't seem to understand that we both agree that a physician is a necessary ingredient in a med spa. We, disagree, that only physicians should be allowed to own and run med spas.

05.2 | Unregistered CommenterWPS


You seem to put all aestheticians in the same catagory. Like any field, including yours there are good ones and there are bad ones. For the good ones, the educational process doesn't stop after school, It's just getting started.

Check out This is an international accredidation for the aesthetic industry and this includes physicians. Students must undergo a course of at least 1200 hours of training in practical and theoretical work in a registered CIDESCO School. I have seen dermatologists flunk the final certification process.

There are only 8 accredited CIDESCO spas in the U.S. We are one of them. Mona is a CIDESCO certified diplomat.

05.2 | Unregistered CommenterWPS


I don't put all of them in the same catagory. I just know that they are not doctors.

But you are right. We disagree on who should own the medspa.

I believe it should be a physician. Ultimately it is the physician who is fully trained in the professional management of a human beings health. They are held to the highest of standards. AND even they can make mistakes OR problems and complications can occur in their hands.

So, since we know this is the case why would we want to put this task, at least in its supervisory role onto a minimally trained individual.

By getting an MD an individual has demonstrated a level of professional maturity. A maturity that comes with training, knowledge and ownership of their profession.

It is going to very difficult to get that from an individual who has not made the same ongoing commitment.

It it has to do with a medical treatment, then the physician Must be the owner.

05.2 | Unregistered CommenterEMD

I'm not a physician. My husband is. I've been working with lasers much longer than he has and there are things I know about lasers he doesn't know. What I don't know is how to consistently identify potential complications and then manage complications effectively. For that reason, I don't operate lasers. I could, with much training and his supervision but we have great medical professionals (non-physicians) who have been through thorough training and testing to operate our lasers. But these people would never be so brazen as to think they can do it on their own w/ out a physician available.

I'm sorry. I know I am going to insult someone but the idea of comparing Cidesco to anything medical is assinine. So what derms don't pass it?it's not a dermatology test, it's a cosmetology test.

Oh, and the argument about derms not getting training in aesthetics....they get training in BURNS that is the concern. Plastic get training in serious burns. They are also qualifyied to prescribe medication, to evaluate a medical history. I can't do those things. I'm not a doctor. But, it's okay because I don't want to be a doctor. it seems like a lot of people do. They just don't want to deal with the nuisance of medical school.


How can you compare holding a light bulb for too long vs. someone holding a laser to your face and treating with too high joules, double pulsing, treating with sun exposure, etc.? How about taking a medical history to r/o certain drugs/conditions that may predispose one to photosensitivity?How about being taught critical thinking skills? Any one can be taught to point and shoot a laser, but not everyone is capable of independent assessment and judgment (especially when laser physics is involved). EMD and happy med spa owner are correct -- how can you compare medical training with aesthetic training? Opposite ends of the spectrum!

05.3 | Unregistered CommenterFiona

WPS states: "Yes, Aestheticians can run lasers and properly identify skin issues if trained correctly"

And he is right.

That training is called Medical School and the "If" is if they choose to take the challenge and go to medical school.

05.3 | Unregistered CommenterEMD


Why should a Medical Spa be any different from any other medical practice. Not every medical practice is owned by a doctor. Some doctors do not want the headache of owning the practice they just want to be an employee.

05.5 | Unregistered CommenterSBJ

Most medical practices are either owned by a hospital or by a group of MD's or solo MD.

It is illegal for a non-md to own a medical practice. for example a derm office and hire a derm to work in it.

The only reason hospitals can do this is because they are a medical corporation with Medical directors and there is a clear line between the business and medical side. But I think they are just exempt because there is no better way to do it.

So if a doctor does not want the headache (and Believe me I know all about the headache) of running their own practice they can join a group (like a multispecialty group) or work for a hospital.

So maybe a group of doctors or a solo doctor has Medspa and wants to hire a new physician.

So to answer your question, every Medical practice (medical meaning IM, FP, etc) is owned by a doctor. Since MedSpas are medical practices they should also be owned by doctors.

lasers, IPL's, botox, featherlifts, liposuction etc are all considered medical treatments.

The aethetician can't inject botox because she/he is not a doctor. Therefore they should not be able to own a doctors office.

05.5 | Unregistered CommenterEMD


Are you practicing law? Since when did you become the expert in all 50 states on what is and what isn't legal. What you state is only true in some states, not all.

As far as your previous comment, let's take a look at chemical peels. There is a dividing line between a physician prescribed peel and a peel that can be administered by aestheticians. If what you have been stating is true, then all peels should be administered by MD's. People can and have gotten burnt with non prescribed chemical peels.

Why haven't we had a big hullaboo about peals? I will tell you why, "MONEY". There is not enough money in peals for the medical community to try to take it over. Same analysis with lasers: nonablative vs ablative. Difference "MONEY"

This is my last response on this subject. You and people of like mind have no business trying to steal an industry from people who have the right to take advantage of technological improvements in treatments. as long as it safe to do so. The aesthetic industry, with the proper training and education is fully capable of providing safe nonablative laser work. Ask Lloyds of London!!

05.5 | Unregistered CommenterWPS

ANd now my 2-cents' worth...Here in Canada, we have laws that only cover true ablative devices, such as CO2 and Erbium. We can use, in a spa setting, up to Strong non-ablative devices, in including lasers of up tp 1540nm, and pulsed light of any strength, with NO medical directors. I wonder why that is...hmm...

05.5 | Unregistered CommenterLuker

Because you are in Canada and you don't get sued like in the US. hmmm.

Besides, why should physicians give up their rights so someone can make money.

05.5 | Unregistered CommenterEMD

You know what the reality of it is?

If you have an MD and an Aesthetician running two spas next to each other both doing laser treatments, people will go to the doctor before they go to the Aesthetician unless they want their nails done.

As far as the money things goes. I could say the same thing to you.

You want to be able to do it so you can make more money.

05.5 | Unregistered CommenterEMD

Just went to an esthetics show yesterday, and what an eye-opener! Every laser rep I talked to lamented how doctors are not really business people, and that they should be represented by those who know how to sell. BTW, the companies represented there were not selling medical devices, as far as they were saying, so no CO2 lasers, no erbium lasers, but Fraxel was represented ( with their re:fine laser) and everyone assuring me that it's all perfectly legal to buy and use these devices. here was even talk that low-fluence erbium treatments are on the legal horizon here.

Don't you think that American laws may be a little too strict, as far as the milder treatments go?? Remember, we have laws here, too, and lawyers that make lots of money prosecuting with these laws, as well as dealing with malpractice. You can only enforce what's represented by law, and as far as ablative devices go, they are.

Now, EMD, do you have a perfectly clinical environment at your practice?? Or does it suspiciously look like a boutique, like so many other medispas out there? Clinical settings should look like labs, no?? That way, we know we are dealing with people of science, for sure!! In cosmetics, it all about the 'look'. I feel that, as long as the people involved are properly trained, it should not be a problem. I believe there should be national standards in place to protect the public at large. Do doctors necessarily botch procedures less than estheticians??

05.6 | Unregistered CommenterLuker

Q: Do you know how you know when the laser sales reps are telling the truth?

A: When they are not talking. At least then they are only thinking up the next BS line to tell you.

As far as cosmetic procedures and lasers. As long as the person doing it is being supervised by an MD/DO then it is fine with me. I've said that before.
But the bottom line is that these are medical treatments. Thus the name "MedSpa". Therefore the physician gets to own the clinic.

I know people want to make more money in their day spa. Physicians want to make more money in their MedSpa.

The problem is you have to earn that right. Go medical school.

05.6 | Unregistered CommenterEMD


A Physician Management Group can own a medical practice and the doctors actually work for the PMG. It doesn't matter if it is one specialty or multispecialties.

You are right when you say non MD's can't own a medical practice, but you can sent up a PMG that actually owns the practice. The PMG can be owned by business folks or MD's or the PMG can't just be owned by a single person. All the employees a employed through the PMG that owns the practice. The same as the way a hospital would organize, but on a much smaller scale.

05.6 | Unregistered CommenterSBJ

Oh, as far as doctors being bad in business. That is most likely true for most doctors. they are doctors not businessmen.

However, I know some pretty good doctors that are good in business as well.
Besides it is much harder to become a doctor than it is to become a businessman (MBA or sales or whatever) or an esthetician.

So, I can hire a salesman. Most doctors don't want to work for an esthetician.

By the way when you say trained esthetician you have to be more specific. because laser training can be anywhere from learning how to treat using the basic skills to learning all the laser physics etc. Physicians learn it all even though they may not do the treatments themselves.

05.6 | Unregistered CommenterEMD


Are you a Canadian?? Do you live in Canada?? As I said, by LAW, we are LEGALLY able to pruchase, and use, any NON-ablative light/laser device. I have since checked with Health Canada, and I have found this to be true. Doctor's privledge or not, the law is the LAW!! Hoping you understand this as, no matter what your opinion, Canada is free of such consstraints as exsist in the USA.

05.6 | Unregistered CommenterLuker

I'm not Canadian.

As for the US I think we should stay away from the Canadian Medical System.

05.6 | Unregistered CommenterEMD

Just on a side note I have question.

Why should the Medical community give up their control over Medspas and medical cosmetic issues?

05.6 | Unregistered CommenterEMD


When you mention supervise by a MD/DO do you mean on-site supervision the entire time a clinic is open.

05.6 | Unregistered CommenterSBJ


Wake up and smell the "Chipped Beef Homeboy" The physicians don't have all the control.

05.6 | Unregistered CommenterLOL


Last time I checked doctors made medical decisions.
I'm not your homeboy. what are you from some prison gang???


I mean physician on site the entire time the clinic is open. That is good medicine.

05.6 | Unregistered CommenterEMD


Is that for all clinics or just Med Spa's. I know a great deal of Doc's and me included (I am not a doc) that have clinics w/ a NP or PA in the clinic and the doc is required to be in the clinic 4-8 hrs per week.

I know some of the docs never go to their outlying clinics even though they are required too. Now even Walgreens and other Drug Stores have a NP in the stores seeing patients usually IM/Family Practice

Docs that own multiple clinics would rather have a NP, PA or RN's in the clinics rather than hire another MD, me included.

05.6 | Unregistered CommenterSBJ

As far as EMD is concerned, universal health care is the worst thing that could have happened to the world, as far as I can see...not just for us here. Who else feels that way?? And as I have said, these non-ablative devices that I have mentioned are perfectly legal in Canada, no mention of doctors. That's all!

05.6 | Unregistered CommenterLuker


No, universal health care would be the 2nd worst thing that could happen to the world. The worst thing would be that we were all forced to drink that pond scum you call beer with the sewer-like aftertaste. But, apparently, if you drink enough of that nasty stuff even UHC looks good.

05.6 | Unregistered CommenterProDocs


I say Medical Doctor at all times at the clinic.

As far as general Medicine goes, I believe that other than the US the only other countries that use NP/PA or equal to that are the so called third world countries.

I think NP and PA can do a good job but they have much more training than the esthetician. Even they have to be supervised in most states.

Luker, stop drinking that beer. LOL.

05.6 | Unregistered CommenterEMD

To my understanding the Medical board can certainly determine the scope of medical practice, it does not possess the authority to determine the scope of practice for other professions though. This has been evidenced many times by cases brought against nurses or even chiropractors.

If a nurse injects a medication s/he is practicing nursing. If a physician performs an identical procedure s/he is practicing medicine.

If a chiropractor performs an identical procedure as a physical therapist and both fall within their respective areas of practice, then they are each practicing their own profession.

I don't think the issue here is solely what constitutes the practice of medicine, but what constitutes aesthetic and nursing practice as well.
Nurses and estheticians have the right to grow with their professions too. I'm not going to have someone tell me that I'm incapable of determining candidacy or safely offering treatments for procedures I've performed with high client satisfaction and very minimal complications for years. I may not have been able to do this the day I left school, but none of you were probably 'good for' a lot of the functions you serve as docs right when you graduated.

If you follow your own arguments, you should be demanding 24 hour physician supervision at nursing homes. Maybe even using your medical judgment to keep tattoo-seekers safe from harm. This is really just about money and has very little to do with protecting the public.

05.7 | Unregistered Commenteresto


Yes NP's & PA's do have to be supervised by MD and even RN's but it is not direct supervision meaning in-direct supervision. The meaning of in-direct supervision is MD not on site all hours the clinic is open. Now of course this will vary depending on each state.

05.7 | Unregistered CommenterSBJ

Again no one has answered my question.

Why should physicians give up their turf to anyone?

05.7 | Unregistered CommenterEMD


Your turf is curing and preventing diseases, treating injuries and fixing deformities. It is, also, injectables and ablative cosmetic procedures.

You are moving into the aesthetic turf when you provide non ablative laser procedures, facials, massages and microdermabrasion.


05.7 | Unregistered CommenterWPS


It is not physicians giving truf, but you have heard of the ole saying live and let live. Like I said earlier not all physicians want to be a clinic owner.

05.7 | Unregistered CommenterSBJ


All the lasers non-ablative or ablative were introduced to doctors first. Not estheticians. All the research was done in a doctors office or by physicians that makes it our turf.

You can keep your chemical peels, facials and microderm. go to it, have a great time.


I have never seen one study that say the chief researcher was the great esthetician from anywhere.

It is always MD.

05.7 | Unregistered CommenterEMD


I would say that the chief researcher for chemicals peels and microderm equipment wasn't a aesthetician either, but that doesn't mean they aren't qualified or can't be trained to do the procedures.

05.7 | Unregistered CommenterSBJ

I never said they should not be trained do do procedures.

But, WPS seems to think that somehow doctors are moving in on his turf.

In reality physicians are the ones who started the medical spa concept and placed medical grade lasers in those offices. Now thing have changed and some of those lasers are safer than others.

So he is just mad because the people who started this want it back.

05.7 | Unregistered CommenterEMD

The state regulations of virtually every state I have checked up to this point include "operation of lasers" (and frequently any light-based device) in their definition of "the practice of medicine". In most states, licensed physicians are allowed to delegate certain procedures --but usually only to individuals licensed under a medical board (i.e., nursing) based on a wide variety of additional rules and regulations (i.e., written protocols, prescription agreements, etc.). Many non-medical personnel are apparently practicing medicine without a license and are subject to a wide variety of fines and other penalties.

Until someone changes the laws and regulations in your state, there is really not much to argue about in regard to the issue of who can purchase and operate lasers. It just so happens that thousands of "med spas" appear to be quietly flying under the radar. But if someone wants to know what is LEGAL -- at this point, Trix are for kids and lasers are for doctors....

med spa guy,

And I for one would like keep the trix for kids and lasers for doctors.

By the way the laser companies that sold those lasers to the non-mds should be looked into just like the ones practicing medicine without a license.

05.7 | Unregistered CommenterEMD


Is Laser Hair Removel really considered practicing medicine.

05.8 | Unregistered CommenterLOL

Some time back our MB decreed that the use of all lasers and most light based medical devices was the practice of medicine so laser hair removal is the practice of medicine in my state. The MB then ruled that the use and operation of lasers and light based medical devices could not be delegated by a physician to a non physician (except in a very very limited exception in hair removal). So, physicians must perform all procedures. We have not employed a nurse, PA or NP for several years.

This has led to many questions and much uncertainty. If a patient comes to your office for a consultation about a laser treatment does the physician have to participate? Since the procedure is the practice of medicine and can't be delegated, is an office employee who performs the consultation actually diagnosing and recommending a medical treatment, thus practicing medicine without a license? To date the MB has not given an advisory opinion. In addition to performing all procedures we participate, to some degree, in all consultations to protect ourselves and our employees.

Be careful what you wish for. I think our states rules are the coming trend and we are just ahead of the curve.

05.8 | Unregistered CommenterProDocs

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