California Medical Board: Use Of Mid-Level Providers for Lasers, IPLs, Botox, & Other Treatments

The State Medical Board of California has addressed the Use Of Mid-Level Providers for Lasers, IPLs, Botox, & Other Treatments. (Links to PDF) It's a common question that is often brought up over in the discussion areas.

You should read this information carefully. Although it's specific to California, the information is substantially similar to many states.
Read also: Medical Spa Legal: How to...  l  Medspa Legal Discussion Area  l  Building a Medispa inside your practice  l  Medical Spa Franchises

From the Medical Board of California:

Due to an influx of calls to the board regarding who may perform what type of medical / cosmetic procedure and where, the following frequently asked questions and responses are provided for informational purposes and as a reminder. This is a reprint and update to an article published in the October 2002 Action Report.

Who may use Lasers or Intense Pulsed Light devices to remove hair, spider veins, and tatoos?

Physicians may use Lasers or Intense Pulsed Light devices. In addition, Physician Assistants and Registered Nurses (not Licensed Vocational Nurses) may perform these treatments under a physician's supervision. Unlicensed Medical Assistants, Licensed Vocational Nurses, Cosmetologists, Electrologists, or Estheticians may not legally perform these treatments under any circumstance, nor may Registered Nurses or Physician Assistants perform them independently, without supervision.

Who may inject Botox?

Physicians may inject Botox, or they may direct Registered Nurses, Licensed Vocational Nurses, or Physicians Assistants to perform the injection under their supervision. No unlicensed persons, such as Medical Assistants, may inject Botox.

I've been approached by a nurse to be her 'sponsoring physician' for her laser and Botox practice; would that be legal?

No. There is no such thing as a 'sponsoring physician'. Nurses may not, under California law, employ or contract with a physician for supervision. A  nurse may not have a private practice with no actual supervision. While the laws governing nursing recognize "the existence of overlapping functions between physicians and registered nurses" and permit "additional sharing of functions within organized health care systems that provide for collaboration between physicians and registered nurses" (Business and Professions Code section 2725), nurses may only perform medical functions under "standardized procedures." The board does not believe this allows a nurse to have a private medical cosmetic practice without physician supervision.

I've been asked by a layperson to serve as a "Medical Director" for a "medi-spa" that provides laser and other cosmetic medical services; would that be legal?

No. No one who cannot legally practice medicine can offer or provide medical services (Business and Professions Code section 2052). A physician contracting with or acting as an employee of a lay-owned business would be aiding and abetting the unlicensed practice of medicine (Business and Professions Code sections 2264, 2286, and 2400). To offer or provide these services, the business must be a physician-owned medical practice or a professional medical corporation with a physician being the majority shareholder.

I see these ads for "Botox Parties" and think that it has to be illegal. Is it?

The law does not restrict where Botox treatments may be performed, as long as they are performed by a physician or by a registered nurse, licensed vocational nurse, or physicians assistant under a physician's supervision.

Who may perform microdermabrasion?

It depends. If it's a cosmetic treatment, that is to say it only affects the outermost layer of the skin or the stratum corneum, then a licensed cosmetician or esthetician may perform the treatment. If it's a medical treatment, that is to say it penetrates to deeper levels of the epidermis, then it must be performed by a physician, or by a registered nurse or physicians assistant under supervision. Treatments to remove scarring, blemishes, or wrinkles would be considered a medical treatment. Unlicensed personnel, including medical assistants, may not perform any type of microdermabrasion.

I would like to provide non-medical dermabrasion, and hire an esthetician to perform that and also cosmetic facial and skin treatments. What do I need to do?

It is legal for physicians to hire licensed cosmetologists or estheticians to perform cosmetology services, if they have obtained a facility permit from the Bureau of Barbering & Cosmetoloty. All licensed cosmetologists, including estheticians, must perform their services in a facility with a permit.

Why can't I use a medical assistant instead of a nurse?

Medical assistants are not licensed professionals. While doctors have become accustomed to their assistance in medical office practices, medical assistants are not required to have any degree, nor do they have to pass an examination or be licensed. For that reason, the law only allows them to perform technical supportive services as described in sections 2069-2071 of the Business and Professions Code, and Title 16, California Code of Regulations, sections 1366-1366.4.

What is the penalty if I get caught using or helping an unlicensed person to perform medical treatments?

The law provides a number of sanctions, ranging from license discipline to criminal prosecution, for aiding and abetting the unlicensed practice of medicine. Physicians could be charged with aiding and abetting unlicensed practice, and the employee could be charged with the unlicensed practice of medicine. 

I understand that all of these practices may be illegal, but I see advertisements all the time for these kinds of illegal practices. What should I do?

You may file a complaint with the Medical Board. To do so, please send the advertisement, the publication name and date, and your address and telephone number where you may be reached,  to our Central Complaint Unit at 1426 Howe Avenue, Suite 54, Sacramento, CA 95825. The board will contact the business, inform them of the law, and direct them to cease any illegal practice. If it is simply the advertisement that is misleading, they will be directed to change or clarify the ad.

It is impossible to cover all of the relevant legal issues in a short article, and these questions and answers are not a substitute for professional legal advice. Physicians may want to consult with their attorneys of malpractice carriers about the use of their office personnel. In addition, the board has a number of written materials with more thorough information on this subject. There are legal opinions on the use of lasers and dermabrasion, materials outlining the legal limitations on use of medical assistants, as well as the actual statutes and regulations. To request any of these documents, please contact the Medical Board of California, 1426 Howe Ave., Suite 92, Sacramento, CA 95825, or call (916) 263-2389.

Gruntdoc visits the Dermatologist.

 GruntDoc on bedside manner.

However, Derm's lack of any appreciable bedside manner has me reevaluating one of my longest-held beliefs, that people don't really care if their doctor has a great bedside manner, but only really want a doctor who is very competent and does the job right.

And, painfully, I have to look hard at myself. I am, occasionally, a touch cranky. I try very very hard to not be cranky toward my patients, but I'm not in such denial to say I never act cranky with a patient.

Physician, heal thine own bedside manner. Me first.

Are you a medical spa, medspa, medispa, laser clinic, skin center... or other?

An advanced aesthetic medspa laser clinic and skin center by any other name?

Which fork in the road to choose? Medical spa or medspa was the earliest incarnation of the market. Medispa was another but I've heard Dr. Katz  of Juva Laser Center & Medispa twice say that he's registered that word. Laser clinics and centers, aesthetic medical clinics, there are lots to choose from.

What to call your clinic? Anyone have some thoughts?

What's wrong with 90% of medspa convention presentations?

Everyone's attended useless presentations. My guess is that 90% of all the speakers I've heard have fallen into one or more of the gaffs below.

Which is sad. Hundreds of attendees have paid and given up time to learn something only to be confronted with information that's just not useful. What's up with the speakers? It's really the show organizers fault. The Medical Spa Expo for example is put on by Reed Exhibitions, a business that organizes conventions and expos as a venture. They find a group in the market they're interested in and, voila, instant show. The politics that go into picking speakers are profound. The first presentors are a resouce to the company putting on the expo. They tend to bring in their friends and keep out the competiton.

Now events are often worth going to for the 10% of speakers that are worth listening to. There's often a useful tidbit here and there among the rest as well. But speakers would be better off resisting the most common traps. Here are some tips drawn from my own experience as a speaker and, more importantly, sitting in the audience.

#1. Speakers: No, you can't pitch your lovely company

If you're presentation is really a sales pitch (i.e., your company markets goods or services to the types of people who attend this show), your chances of making it worth sitting on a folding chair for an hour are extremely slim unless you:

• Have your clients speak with you and eliminate all the tricky little references to your company.
• Present new research thats usefull ot the audience and give it away.
  
• Present tactics, jobs, mistakes, etc., anything with numbers. The more, the better.
• Run a workshop at the conference.
• Pitch your physicians or other professionals who are completely and thoroughly unrelated to marketing and sales.

I've seen some absolute horror shows with this one. Please don't regale me with your franchise pitches and tell me how easy it is to make money if only I'd place myself in your caring hands.

#2. Consultants: No tired speeches about your glory days.

Show attendees sit in multiple presentations on the same topic. At medical spa expos it's the marketing baby. Show organizers know this (which is way they often swap postal lists with each other for promotions). They'll pad the schedule with medspa consultants who did lots of stuff in the past but don't own or run a clinic now. If the resume doesn't currently include something other than consulting, it should. This is a lucritive field. Consultants don't make the money or have the info, owners do.

#3. Experts: Avoid overviews

Great -- you've noticed there's a presentation about a topic that promises to pull back the curtin and let you into the good stuff. What you get is not an expert with hands-on experience but a novice with strong opinions about the topic. In either case, the expert and the psuedo-expert, the overview speaches are useless in the daily operations and growth of a business. That's what blogs are for.

#4. Don't ignore format

Most shows tend to focus primarily on one particular type of presentation such as group panels, intensive workshops, case studies, roundtables, etc. Stick with what you're supposed to be there for. Here's a link to Guy Kawasaki's 10/20/30 powerpoint rule. Required reading for anyone presenting anything anywhere.

#5. Copywrite or sell your presentation

The last time I saw this I was at a Thermage presentation by Virginia Stevens M.D.. Doctor Stevens was presenting information for performing Thermage treatments on the body for a packed room of docs. Everyone sat speachless while Dr. Stevens literally flew through her presentation without pause, questions or clairity. The reason became apparent at the end when Dr. Stevens last slide showed the ordering information available for the presentation on her website for a mere $295. The Thermage sales people were horrified and apologized to everyone (out of hearing of Dr. Stevens).

If you're going to accept the invitation to present, then present, don't sell. You just piss people off.

#6. Let go of your ego

Yeah, you're the expert. But the audience is smart too. Prancing around as the man with the plan will get you used and discarded. I sat on a panel with one doctor (remaining nameless here) who bluntly told the audience that he had the ego of any three men. (He was completely believable too.) But that was the end. The audience totally tuned him out an he was forced to elbow his way in to answers. Everybody has an ego. We just don't want to hear about yours.

technorati tags: medspa, expo, medicalspa, consultants, training

Medspas Online: Search by Tag

Start here: Understanding why physicians & medical spas are a legal nightmare.

It's the wild west out there. The advent and introduction of technologies that don't depend exclusively on the physician to perform the treatment has caused an explosion in both the ease and popularity of these new treatments, and the problems that have come from businesses pushing the physician out of the treatment room, and the competitive forces that pressure doctors to cut corners. So just what is the current situation in the market?

Medical Spa Franchises

What's wrong with medical spa franchises?
8 things you should know about medspa franchises. 

You'll notice that I'm not a great proponent of the current batch of medspa franchises? Why? The short answer is that they're not physician-centric and offer close to nothing in the way of differentiators for the physician. 

Medical Spa Consultants

Physician Partnerships

Corporate Practice of Medicine

Google search on "corporate practice of medicine"

Number two on the list of problems in doing business with a physician is this, the corporate practice of medicine doctrine prohibits corporations from providing professional medical services. Physicians should be very cautious. When entering into employment agreements with corporations which permit lay persons control over a physician’s practice, physicians should be especially circumspect. Physicians must also be aware than any restrictive covenants, whether reasonable or not, may be considered void against public policy and therefore unenforceable. Non-physicians partnered with a medspa Medical Director may have no legal contract.

Day Spas & Aestheticians

Dermatologists & Plastic Surgeons vs everyone else? 

Lawyers.

This was an actual courtroom exchange:

* Lawyer: "Doctor, before you performed the autopsy, did you check for a pulse?"
* Witness: "No."
* Lawyer: "Did you check for blood pressure?"
* Witness: "No."
* Lawyer: "Did you check for breathing?"
* Witness: "No."
* Lawyer: "So, then it is possible that the patient was alive when you began the autopsy?"
* Witness: "No."
* Lawyer: "How can you be so sure, Doctor?"
* Witness: "Because his brain was sitting on my desk in a jar."
* Lawyer: "But could the patient have still been alive nevertheless?"
* Witness: "Yes, it is possible that he could have been alive and practicing law somewhere."
(via Medrants)

Kevin MD on chiropractic care promo.

Kevin MD is checking on the push from Chiropractors:

From the Chiropractic Association Artilce. "A new survey showing that nearly half of all Americans are concerned about the safety of the medical care they receive should send a strong signal to the health and insurance industries that safer non-drug, non-surgical treatments should be considered whenever possible, according to the American Chiropractic Association (ACA)."

Laser Clinic? Med Spa? Listen and Sell.

Before you laser clinic or med spa staff is selling Thermage, Fraxel or Botox... they'll need to listen.

From the Church of the Customer Blog reports a new study that found customers who feel ‘listened to’ are more likely to buy, and far more likely to recommend you to a friend. Ok sure, hardly a revelation, but the strength of the response was considerable. From their site:

Communispace surveyed 2,196 members of their clients communities -- twenty communities representing fifteen companies. They found that:

• 82% of community members said they were more likely to recommend the company's products than before joining the community
• 54% said they were more inclined to purchase products from the company since joining the community

Glucosamine study may impact the way dermatologists treat UV- related skin damage.

The panel determined that n-acetyl glucosamine, a more stable form of glucosamine, reduced the amount of melanin in skin cells, meaning there was less excess pigment in the skin to cause age spots.