In the past 7 years, technological advances have made nonsurgical medical procedures less expensive and more widely available. Trendy spas that offer facials, massages, manicures, and pedicures have transformed into medical spas that offer procedures—such as laser hair removal and microdermabrasion—that have been traditionally performed in physicians’ offices.

Although these services offered at medical spas are considered medical, they are often performed without the direct supervision of a physician. As the medical-spa industry continues to grow, state lawmakers are taking a closer look at it. California State Sen Liz Figueroa (D–Fremont) has introduced Senate Bill 1423, which, if passed, will require physicians to be present during all laser and aesthetic medical procedures. A related bill, also introduced by Figueroa, would make it a misdemeanor for anyone but a physician, nurse, or physician assistant (PA) to use laser devices.

Figueroa says a lack of regulation in California’s medical-spa industry has helped spur the rapid expansion of the industry, but has also raised serious safety concerns.

“Right now, there are no standards for any individual performing laser treatments,” says Figueroa, who has had constituents come to her with burns and scars they say are from improper use of laser equipment at medical spas. “I just want to make sure the consumers are safe. I don’t want to hinder anyone’s business.”

Currently, medical law in California:

• provides for the licensing and regulation of physicians and surgeons by the Medical Board of Cali­fornia (MBC);
• provides for the licensing and regulation of PAs by the Physician Assistant Committee under the MBC;
• allows a PA to perform medical services as set forth by regulations when the services are rendered under the supervision of a licensed physician and surgeon;
• provides for the licensing and regulation of registered nurses (RNs) by the Board of Registered Nursing; and
• allows the RN to work independently, dependently, or interdependently in relation to physicians depending on the circumstances.

Michelle Ehrlich, MD, a plastic surgeon and dermatologist who practices in Rolling Hills Estates, Calif, says the dangers of unsupervised medical procedures outweigh the benefits.

“Lasers are surgical devices that, when used correctly, have the potential to provide safe and effective medical and cosmetic improvement,” Ehrlich says. “If used incorrectly by an inexperienced operator, or by an operator who does not have the appropriate medical background to manage complications immediately, these same surgical devices can cause serious injury, including burns, scarring, and blindness.”

If passed, the Senate Bill will require a physician who delegates the performance or administration of any elective aesthetic medical procedure, or treatment using lasers or intense pulsed-light devices, to a licensed health care provider (LHCP) to:

• personally observe all elective aesthetic procedures delegated to an LHCP until assured of the LHCP’s competency;
• establish written standardized procedures or protocols for the care of a patient when he or she has delegated the performance of an elective aesthetic medical procedure or treatment to an LHCP;
• review, countersign, and date a minimum of 10% of medical records of patients within 30 days;
• have continuing responsibility for follow-up of the progress of the patient and to make sure that the LHCP does not function autonomously;
• be responsible for all medical services provided by the LHCP.

On the basis of a survey of its members, the Association of Medical Esthetic Nurses (AMEN) has taken the position that the bill is antinurse and establishes a precedent for further restrictions on settings where nurses practice with a significant degree of independence.

AMEN recognizes that untrained and unqualified providers of aesthetic services can pose a risk to the public. However, it does not believe that “on-site” supervision of all nurses by a physician is necessary, cost-efficient for consumers, or even the best way to ensure patient safety.

According to Sasha Parker, RN, president of AMEN, the notion of nurses practicing pursuant to protocols and standardized procedures is nothing new.

“In hospitals, home care situations, clinics, and other practice settings, nurses are involved with patients who are less healthy, who have more complex problems, pose higher risk factors, and require more invasive responses should certain incidents arise,” Parker says. “Yet there is no call to alter those practice settings with an ‘on-site’ supervision requirement.”

The two houses of the Florida Legislature have passed similar bills that restrict the ability of nurse practitioners and physician assistants to perform aesthetic treatments using laser and intense pulsed-light systems, but Gov Jeb Bush has not signed either because opposition to these measures has developed.

Other states considering the passage of similar bills are Georgia, North Carolina, and Texas.