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Medical spas can be a good business, but with ethical challenges

Could opening a medispa recharge your career?

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Sept. 14, 2009.

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Kathleen is a middle-age physician experiencing professional burnout. Dwindling insurance reimbursements, increasing time demands from patients and professional committees, and the business of running her practice, plus an exhausting daily routine, all have made her question her once-idealistic commitment to medicine. Lately, she has noticed the proliferation of medical spas in her city, some operated quite profitably by her colleagues, and wonders if this might be a solution.

Reply: Medical spas, also known as medispas, are a growing phenomenon. They offer the appeal of day spas along with noninvasive, cosmetic dermatological and surgical treatments. In addition to standard spa fare such as facial treatments or waxing, the medispa might provide laser hair removal, various other nonablative light-based therapies, and cosmetic botulinum toxin and filler treatments. Some offer massage services and aromatherapy. The environment in the spa tends to be far more luxurious than in the standard medical office, and the wait time for an appointment is usually shorter.

Medispas may be freestanding or attached to a medical practice (for "one-stop shopping"). They may operate with physician assistants, estheticians or nurses, offering many services with varying degrees of medical supervision, on- or off-site. Professional supervision might come from dermatologists or plastic surgeons, but it also could come from other medical practitioners such as obstetricians, emergency medicine physicians and family physicians, or even from nonphysicians such as naturopaths, electrologists and midlevel practitioners.

No national standards govern who can own or operate a medispa, what type of training and credentialing spa staff must have, who can perform laser therapy or inject neurotoxins or fillers, or what type or level of supervision is required.

Medispas are big business. The number of medical spas has grown by an estimated 85% during the last two years, according to industry sources, and annual revenues are in excess of $2 billion. A significant portion of a medical spa's revenue comes from the sale of products, such as cosmetics and cosmeceuticals.

The ethical dilemmas associated with medispas arise from the question central to all areas of medical entrepreneurship. Are medical spas profit-driven business enterprises or are they an integral part of the health care system? Do medispas fulfill consumer desires or do they relieve suffering and promote wellness? Do they follow the business model in which an enterprise has a fiduciary duty solely to shareholders, or do they follow the medical professional model in which physicians have a duty to place the interests of their patients above their own, economic or otherwise?

These duties coexist and conflict in many medical business ventures, but because the medical procedures offered in the medispa have the potential to cause harm, health care professionals all have a duty that transcends the obligations of the business contract. Patients expect no less, and the balance between the dual roles of healer and entrepreneur is central to the ethical operation of a medispa.

Some of the ethical dilemmas concern supervision, the nature of the procedures offered and the sale of goods. Who operates the spa (or how many spas are operated by that individual) and who supervises the individuals performing procedures (and in what manner) are legislated by each state. All physicians, by virtue of their licenses, can perform any medical procedures offered in a medispa.

Dermatologists and plastic surgeons have the most sophisticated knowledge of medical, surgical and laser procedures involving the skin and management of pigmentary disorders. Yet practitioners from such diverse backgrounds as occupational health, internal medicine and obstetrics have entered the field. Midlevel practitioners and electrologists have lobbied to provide services independently. From the technical standpoint, many of the procedures, including injecting fillers or operating a laser according to the manufacturer's guidelines, are not inherently complex. Assessing the patient's needs, however, or performing a procedure optimally, are things that cannot be learned in a short, hands-on course or from an operator's manual.

The supervising clinician should evaluate each patient, participate in obtaining informed consent, and be thoroughly familiar with the skills and limitations of those to whom procedures are delegated. Supervisors should remain actively involved with the course of treatment, being ready to deal in timely fashion with adverse events or complications. Anecdotes attest to complications, poor outcomes and burns arising from inexperience or poor judgment of inadequately trained or supervised operators.

Each state Legislature must balance the viewpoints and demands of stakeholders when regulating medical spas to satisfy the best interest of the consumer. In Florida, the Safe Supervision Bill, enacted in 2006, stipulates that medispas must be supervised by a plastic surgeon or dermatologist. Draft legislation in Massachusetts would allow "sufficiently trained or experienced" (in what way is not stated) physicians, nurses or electrologists to perform procedures and require them to be on site at all times when the facility is open.

Much has been written about the sale of cosmeceuticals. Although the AMA's ethical guidelines proscribe display or sale at a profit of products such as cosmetics and similar "nondurable goods" in medical offices, this is widely ignored. It is estimated that more than half of all dermatologists in the U.S. engage in this practice. The American Academy of Dermatology's ethical guidelines state that such sales must be in the patient's best interests, but don't specify how this is determined.

Although it is agreed that dermatologists and plastic surgeons are the professionals most knowledgeable about skin care, it should be noted that virtually all nonprescription cosmeceutical and cosmetic products sold through medical spas and physicians' offices lack conclusive evidence of clinical efficacy. Lending one's status as a physician to the sale of clinically unproven products in a medical setting, even a medical spa, is ethically questionable, since patients and consumers place their trust in health care professionals to provide medically sound advice and to protect their interests.

Not to be overlooked is the impact of the medispa movement on access to essential medical services. Although the explosive boom in cosmetic dermatology has fueled demand for services, this has occurred while the need for medical and surgical dermatology services has grown in our aging population. Well-publicized studies and investigative newspaper reports have shown that in most metropolitan areas the wait for an appointment to examine a changing mole is significantly longer than the wait for receiving an injection of cosmetic botulinum toxin.

Given the scarcity of the medical work force, particularly in dermatology, which has among the highest wait times of any specialty, we must ask whether limited medical resources should be directed toward cosmetic procedures, supervision of estheticians, selling of cosmeceuticals and running of spa enterprises. Undoubtedly, personal choices are being made about income and professional lifestyle.

What is Kathleen to do? Would she be opening a medispa for the "right" reasons? Is she truly interested in esthetic medicine or does she look upon this venture as a "cash cow" for her practice that does not entail dealing with third-party payers, hospitals or working longer hours? Is she adequately trained and qualified to perform and supervise these procedures, even with a brief hands-on course?

If she is not already practicing a specialty that deals with skin esthetics, then her knowledge base and clinical sophistication in this area are bound to be superficial. How does she feel about offering and marketing procedures for which there might be little credible evidence of efficacy? Is she comfortable selling nonprescription cosmeceuticals and cosmetics to her patients, or does she harbor reservations about the ethics of this practice? Is she looking for something to stimulate her intellectually or to bring her back to what excited her about medicine when she entered it, or rather for a sideline to her practice or a complete "professional makeover" that exposes her to a different clientele, business model and professional lifestyle?

Professional oaths are not vows of poverty. There is nothing inherently unethical about medical entrepreneurship, nor is there anything inherently evil about money in medicine, unless its pursuit and acquisition cause physicians to mismanage conflicts of interest and to overlook their professional obligations to their patients.

If the bottom line is the primary motivation for opening and operating a medispa, or if the supervision of those performing the procedures in the spa is spread so thin as to be essentially ineffective, or if patients become clients or consumers whose satisfaction takes precedence over protecting their best interests, the setting is ripe for ethical challenges.

Lionel Bercovitch, MD, clinical professor of dermatology, Warren Alpert Medical School of Brown University, Rhode Island; pediatric dermatologist, Hasbro Children's Hospital and Rhode Island Hospital; founder of a seminar course, "Dermatoethics," in which residents and faculty study and discuss contemporary issues in ethics and professionalism in dermatology.

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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