The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 6

special article
So You Want to Open a Med-Spa?
by sandra johnson, md, FAAD
“First do no harm” is the oath we take as physicians.
We are all so blessed to be physicians.
Personally, I am honored to be a dermatologist.
I love skin and everything about skin. I especially
enjoy both the art and science of dermatology.
I am writing this article in response
to being repeatedly asked by entrepreneurs,
estheticians, physicians, and nurses, what the
best way is to open a medi-spa or laser center.
I have decided to assemble my thoughts and
share them with all of you. My first reaction is
flattery. I wonder if you want to do this because
it looks so easy and so fun. Is it because at
Johnson Dermatology, the only people who do
the injections are two board-certified dermatologists
and a nurse practioner who works very
closely with me? Is it because we have more
than 15 laser, light, and energy devices? Is it
because we are one of the top 150 practices
in the country for Allergan, and we do not use
breast implants or cool sculpting or cool tone?
Is it because we are in the top 1% of practices
in the country for Evolus? Is it because we are
the #1 practice in Arkansas for Colorescience
and the #7 practice in the U.S. for Skin Medica?
After I stop being flattered and prideful, the first
question I want to know is why? What is your
motivation? Do you love skin? Do you enjoy
doing these procedures? Is it for the money?
Are you unhappy with what you are doing and
think this will make you happy? Whatever your
reason, I encourage you to understand the
state laws. Since I am fortunate to practice
in the great state of Arkansas, I will limit the
following to what I understand about our state
laws. I will also state that I do not understand
the laws from the dental board (their website
is https://www.asbde.org/) or the nursing
board (their website is https://www.ark.org/
bon/licensure/status.php). Station THV11 in
Little Rock addressed this issue on November
25, 2019, and stated that the Arkansas Dental
Board does not have guidance on this matter.
Both the Arkansas State Medical Board and
Arkansas State Board of Nursing are currently
trying to address these important issues with
new regulations. I will gladly share these proposed
and currently active regulations with
anyone who wants to contact me.
The Arkansas State Medical Board is the organization
that has given me my medical license
and that has given the facility where I practice
a medical license. The American Board of Dermatology
has given me board certification in
2000, 2010 and 2020. The Arkansas Medical
Act and Regulation was last revised by our Arkansas
State Medical Board in August 2018. It
clearly states that in our great state, all medical
practices must be owned by a medical doctor,
according to Regulation 4-29-305. For example,
I need and have two medical licenses for
the state of Arkansas. One is for me personally
to practice medicine, and one is for Johnson
Dermatology for the practice of medicine to
occur at our location. This means that a nurse,
entrepreneur, or esthetician cannot own a
medical practice in the state of Arkansas since
they cannot apply for the practice of medicine
at their location as I understand the law.
If you are a physician who wants to open
and run a medi-spa in the state of Arkansas,
there are a few other rules and laws that I
have learned. One is that every patient must
be seen and evaluated by a licensed medical
provider such as a physician, nurse practioner,
or physician assistant before a laser treatment
or injection. I do not know what the law is for
dentists. This means that realistically I could
not own a practice in Mena where an esthetician
is injecting Botox Cosmetic (a medical
procedure) or performing laser hair reduction
(a medical procedure) on a patient while I was
seeing patients at Johnson Dermatology in Fort
Smith. I also legally should not purchase fillers
for a registered nurse to inject them at another
location where I do not see the patient first.
Also, a registered nurse cannot inject or laser
a patient unless that patient is first evaluated
by a physician or physician assistant or nurse
practitioner. Evaluating a patient for injectables
or laser is considered the practice of medicine,
and registered nurses do not have this in their
scope of practice.
Another interesting fact I learned many years
ago is that most lawsuits for laser procedures
are performed by non-core physicians or their
delegated person. The article on the subject is
titled “Common Causes of Injury and Legal Action
in Laser Surgery,” by H. Ray Jalian, MD;
Chris A. Jalian, JD; Mathew M. Avram, MD,
JD in JAMA Dermatol. 2013;149(2):188-193.
Before you decide to add these procedures to
your practice, you may want to confirm that
you will have malpractice insurance coverage,
if that is important to you. I am not sure what
the law is for this, but I do know that I am covered
for these procedures from our malpractice
insurance carrier since the 1990s, State Volunteer
Mutual Insurance Company.
The American Med Spa organization also has
clear guidelines about the practice of medicine
within a medical spa. Here is a link to an article
from their website: https://www.americanmed-
spa.org/news/169407/Want-to-be-a-Medical-
Director-at-a-Medical-Spa-Beware.htm
The American Academy of Dermatology has a
position statement about medi-spas that reads,
“Medical spas are facilities that offer a range
of services, including medical and surgical
procedures, for the purpose of improving an
individual’s well-being and/or appearance. The
distinguishing feature of medical spas is that
medicine and surgery are practiced in a nontraditional
setting. Procedures by any means,
methods, devices, or instruments that can alter
or cause biologic change or damage the skin
and subcutaneous tissue constitute the practice
of medicine and surgery. These include
but are not limited to the use of: scalpels; all
lasers and light sources, microwave energy,
electrical impulses, and all other energy emitting
devices; thermal destruction; chemical
application; particle sanding; and other foreign
or natural substances by injection or insertion.
Any procedure that constitutes the practice of
medicine, including but not limited to any procedure
using a Food and Drug Administration
(FDA)-cleared or regulated device that can alter
or cause biologic change or damage, should
be performed only by an appropriately-trained
physician or appropriately-trained non-physician
personnel under the direct, on-site supervision
of an appropriately-trained physician in
accordance with applicable local, state, or federal
laws and regulations."
270 • The Journal of the Arkansas Medical Society www.ArkMed.org