For dermatologists trained in the procedure and equipped with state-of-the-art devices, laser hair removal is considered an easy and safe procedure, and one that can be readily learned by skilled and trained practice personnel. It’s also a procedure that, barring challenging patient circumstances — such as light hair and dark skin — many dermatologists do happily delegate, or would, regulations permitting.
Who’s Delegating and How
Some dermatologists whose state laws allow them to delegate choose to hand off all or most laser hair removal to well-trained non-physician staff members, on the principle that individuals who do the procedure day in and day out may be those best suited for the task.
“I haven’t done a laser hair procedure in a long time,” says Michael H. Gold, M.D., Medical Director of Gold Skin Care Center in Nashville, TN. “If patients ask if I will be doing the procedure, I say no, and explain that these [staff] are people who do it every second of the day — that if my mom or my wife want a procedure done, they go to my nurses. Once patients hear that, they have a pretty high comfort level.”
Dr. Gold, an Associate Professor of Medicine at Vanderbilt University, only allows R.N.s, nurse practitioners (N.P.s) and physician assistants (P.A.s) to perform the procedures — about 25 “on a good day,” he says. And no procedure is done unless the patient has first been assessed by one of the two dermatologists. It helps that the practice is a longstanding research center for new devices, he admits. “Basically, the patients come here because they know that in this part of the world, we do most of the laser procedures.”
Other dermatologists have either elected not to delegate or to be exceedingly selective about which patients are treated by non-physician staff, for safety and liability reasons. Jeffrey Dover, M.D., Director of SkinCare Physicians in Chestnut Hill, MA, allows one of the two head nurses to perform laser hair removal on what he deems “relatively straightforward cases — the standard fair-skinned, dark-haired patient. But every patient is seen in consult first by a dermatologist, and the H&P is done by the doctor,” he explains.
Dr. Dover also insists on a written prescription for each patient, a document that lists the device to be used and the initial settings — and specifies under which patient-tolerance circumstances settings can be increased. Finally, the dermatologists tell patients that that the physician will “always be on site and available immediately” should questions arise.
“We think this is the ideal situation, especially if it’s a large [skin] area and the highly skilled person is doing the procedure under our direct supervision,” Dr. Dover maintains. “But the assessment and prescription ensure that the patient is a good candidate.” He notes that he personally handles “difficult cases” — particularly procedures on dark skin and those involving large, generally exposed surface areas.
Robert Weiss, M.D., Director of the Maryland Laser, Skin and Vein Institute in Hunt Valley, uses a delegation model similar to Dr. Dover’s. Only N.P.s and P.A.s use the devices, and nearly 100% of the time, a dermatologist is on-site. The dermatologists perform a preliminary consulting visit and suitability assessment on patients — a spot test is done if warranted.
“Our patients are o.k. with the delegation because they [the N.P.s and P.A.s] are so closely supervised by us. We also go through the practice of explaining that there are very few places in the country where physicians actually do the hair removal,” says Dr. Weiss, who is an Associate Professor of Dermatology at Johns Hopkins School of Medicine and President-Elect of the American Society for Dermatologic Surgery (ASDS).
In a somewhat different model, David J. Goldberg, M.D., J.D., Director of Skin Laser & Surgery Specialists of New York & New Jersey, and who also operates a Florida practice, goes by the books as far as regulations are concerned. But he makes adjustments based on patient preferences.
“I don’t delegate in New Jersey because I can’t, and I don’t delegate in New York City because a lot of my patients want the doctor to do it,” says Dr. Goldberg, who also directs laser research at the Mount Sinai School of Medicine. “I do delegate in Florida to the P.A., who works directly under me.” There is always, he adds, “a client base that only wants doctors to do the procedures,” and he schedules accordingly.
A Look at Revenues
Whether they delegate or not, many dermatologists who have laser expertise offer hair removal in their practices. But the actual procedure revenues — or even untapped revenue potential — is a mixed picture.
For some dermatologists who restrict their practice to cosmetics or who delegate the work and operate large laser service centers, laser hair removal can constitute a significant portion — 20% or more — of revenues. But either by professional choice or because of the local market dynamics, namely a plethora of lower-priced service providers, many dermatologists appear to limit laser hair removal to 10% or less of their practice revenues.
Most dermatologists interviewed for this article pegged the procedure at between 5% and 10% of revenues, and most admitted that competitive factors would likely keep that proportion from growing.
Demand, Safety Concerns Put Laser in Limelight
A couple of high-profile catastrophic cases — including a patient who died after being prescribed (and taking) an overdose of a topical anesthetic, and another who incurred severe, disfiguring burns — have prompted a push for more restrictive regulations in some states regarding who can perform the procedure and the degree of physician supervision required.
Less-serious complications likely frequently occur, whether they are reported or not, media reports suggest. Several dermatologists interviewed for this article, for instance, mentioned that they increasingly treat patients who have experienced complications or bad outcomes.
“I personally see about a half-dozen [bad outcome] cases a year now, including some really badly botched ones,” says New York City dermatologist Dina Anderson, M.D., who is in solo practice. Those recent cases include one repair of a procedure done on a young woman by a non-dermatologist physician with scant experience — a doctor who was ostensibly eyeing laser hair removal to boost revenue.
“In New Jersey, you have to be an M.D. to touch a laser, but in New York, it’s very ambiguous — a real gray zone.” In her practice, which is essentially a boutique practice and, she says, “about 20% general dermatology,” even if the assistant will do the procedure, Dr. Anderson assesses each patient. She also chooses the laser settings, leaving “only the mechanics” to the assistant.
Dr. Anderson delegates about half of her laser hair procedures to her assistant based on her own schedule and some combination of case complexity and patient request. But she always personally assesses each patient before a procedure. “I think there’s great variation, and if you ask 10 dermatologists [about delegation], you’ll get 10 different answers,” she says, allowing that despite that preference-based variation, she wishes, for patients’ safety, that New York regulations were more stringent.
Dr. Goldberg, who is also a healthcare attorney, concurs with Dr. Anderson’s free-for-all market assessment of New York and other places where regulations are less restrictive. “We’re seeing a cropping up of these medi-spas that do hair removal … and they have an M.D. attached to them,” he says. “But that person may not be a dermatologist — it might be an M.D. who has never had any training in laser procedures.” Those situations, Drs. Anderson and Goldberg concur, are breeding grounds for complications in loosely regulated environments.
In the absence of tighter restrictions, complication rates may increase as a sheer factor of volume. The American Society for Aesthetic Plastic Surgery (ASAPS), which maintains a robust data repository on cosmetic procedures, reported more than 1.4 million laser hair removal procedures for 2006. ASAPS cited increases of more than 10% annually in recent years and identified the procedure as the leading one sought by individuals age 18 and under. According to ASAPS reports, the frequency of non-surgical cosmetic procedures overall has increased more than 700% since the society began collecting data more than a decade ago.
Societies Weigh in on Delegation
The key consideration for dermatologists eyeing delegation is state regulation of laser hair removal, which is, literally speaking, all over the map. (See Physician Supervision Requirements) Most states consider the procedure “medical,” and therefore require physician involvement of some sort. But dermatologists in leadership positions, including Dr. Weiss and Dr. Goldberg, who is on the board of both the American Academy of Dermatology (AAD) and the ASDS, urge colleagues to err on the side of conservative delegation and to abide by professional organizations’ guidelines.
Both the AAD’s and ASDS’s position statements on laser procedure delegation state that delegating physicians should themselves be properly trained and qualified to perform the procedures being delegated, and that personnel should have appropriate, adequate training and experience. Both guidelines also call for dermatologists’ on-site supervision of personnel and immediate availability in the event of problems, or staff or patient questions.
Dr. Weiss admits that politics — and polemic differences of opinions on delegation and associated guidelines — exist. “From the ASDS point of view, we’re trying to balance the needs of members with policies that allow enough physician supervision, to distinguish what we do from other specialties or medi-spas. It’s interesting because we’re going through that discussion right now with the board,” he told Skin & Aging. “We need to maintain the quality and we need to maintain the physician supervision aspect, but we do have to accurately reflect what our members are doing.”
In the meantime, dermatologists might do their part by helping patients become better informed, all sources said. Efforts by the professional societies to educate consumers on possible dangers of undergoing procedures performed by inadequately trained individuals are under way. At the very least, dermatologists should offer patients a list of questions to ask when considering a service provider, Dr. Goldberg urges, and should make the point that in a laser center having an “M.D. on-site” may mean little.
“I tell patients that it’s really ‘buyer beware’ now — that they should ask what kind of physician is on-site, whether the doctor is active or retired, and whether that physician has ever performed laser hair removal,” he says. “It could be a psychiatrist, and it’s commonly not a dermatologist.” More commonly, Dr. Goldberg adds, the medical directors may be retired, and many medi-spas he has heard about in recent years are “overseen” by physicians who have no training in laser hair removal.
In states where regulations are lax or where on-site physician supervision is not required, high-volume spas offering bargain-basement prices for laser hair removal have proliferated. In New York, for instance, the loose regulatory environment has spawned virtual laser hair-removal factories.
Neighboring New Jersey, however, is nearly at the other end of the spectrum; only physicians can perform laser hair removal. In Maryland, recently tightened regulations allow N.P.s and P.A.s to operate lasers, but only under a physician’s direct supervision —unless the operator has formally logged a sufficient number of procedures. In Tennessee, by way of contrast, physician supervision is required but that physician needn’t be on-site, merely “in the state,” Dr. Gold explains. And in Texas, regulations are in limbo because of a persisting court injunction.
Will the Regulatory Situation Improve?
Some dermatologists expect that the regulatory laxness, where it exists, will go away, but that’s unlikely to occur soon, given powerful lobbying forces. In Massachusetts, for instance, electrologists — who several dermatologists interviewed for this article admit are good candidates for performing laser procedures when properly trained — are pushing for looser regulations. The bill under consideration would enable them to perform laser hair removal without physician supervision.
The Massachusetts development bucks the overall trend. “The regulatory climate is getting more restrictive, but at a very slow rate,” Dr. Goldberg explains. “For the most part, what we’re seeing are slight modifications. You don’t have states going from no restrictions at all to the New Jersey model.”
Amy J. McMichael, M.D., Associate Professor of Dermatology at Wake Forest University School of Medicine in Winston-Salem, N.C., thinks the regulatory ambiguity and lack of standardization create problems for dermatologists and patients.
“The fact that every single state is different, and that training requirements vary so much — that’s all part of the problem,” Dr. McMichael, a recognized hair expert, says. Just as other dermatologists have noted, she concurs that the mere fact of requiring physician oversight or having a designated medical director isn’t always meaningful, in terms of patient safety.
“In North Carolina, the regulations say that there must be a physician who is responsible, but that doesn’t mean the physician has to be on the premises,” Dr. McMichael says, or that she or he must have targeted laser training. In the state, regulations have become more stringent. Now, non-physicians, including P.A.s and N.P.s, who have the requisite training hours can perform laser hair removal, but only if they have been trained by physicians.
Laser Safety: A Relative Matter
The increasing use of and experience with lasers in hair removal can and should confer safety gains, but that’s not necessarily the case — especially when inexperienced operators are involved.
“Lasers are getting stronger, which potentially makes them less safe,” observes Dr. Goldberg, who is also Chief Editor for the Journal of Cosmetic and Laser Surgery. “The flip side is that the cooling apparatus is getting better and better. So lasers are getting safer even though they’re getting more powerful.” Essentially, getting the settings “right” is a matter of training and experience, as most equipment isn’t designed to prevent operator error through sensors or other mechanisms.
“You have to have the knowledge to do this correctly,” Dr. Goldberg says.
One way to bridge the tremendous gulf that exists in the non-physician competence and training realm, Dr. Weiss suggests, would be to promote development of laser technician certification programs. “There’s really no formalized education and certification, but in an ideal world,” he says, “I would like to see the radiologic technician model used.” (In that field, technicians can pursue basic and advanced certification in a number of imaging modalities.)
On the physician side, too often, loose regulations allow for supervising physicians to assume that role “in name only,” Dr. McMichael adds, and when license problems might preclude their practicing elsewhere. “There are a lot of questions I would ask as a patient, but often, people are just going for the lowest price.”
Dr. Dover concurs. “A lot of my patients who come here for other things go elsewhere for laser hair removal, because it’s less expensive and more convenient. We frankly can’t compete with the $69 advertisements,” he says. “Nor do we have time to.”
For dermatologists trained in the procedure and equipped with state-of-the-art devices, laser hair removal is considered an easy and safe procedure, and one that can be readily learned by skilled and trained practice personnel. It’s also a procedure that, barring challenging patient circumstances — such as light hair and dark skin — many dermatologists do happily delegate, or would, regulations permitting.
Who’s Delegating and How
Some dermatologists whose state laws allow them to delegate choose to hand off all or most laser hair removal to well-trained non-physician staff members, on the principle that individuals who do the procedure day in and day out may be those best suited for the task.
“I haven’t done a laser hair procedure in a long time,” says Michael H. Gold, M.D., Medical Director of Gold Skin Care Center in Nashville, TN. “If patients ask if I will be doing the procedure, I say no, and explain that these [staff] are people who do it every second of the day — that if my mom or my wife want a procedure done, they go to my nurses. Once patients hear that, they have a pretty high comfort level.”
Dr. Gold, an Associate Professor of Medicine at Vanderbilt University, only allows R.N.s, nurse practitioners (N.P.s) and physician assistants (P.A.s) to perform the procedures — about 25 “on a good day,” he says. And no procedure is done unless the patient has first been assessed by one of the two dermatologists. It helps that the practice is a longstanding research center for new devices, he admits. “Basically, the patients come here because they know that in this part of the world, we do most of the laser procedures.”
Other dermatologists have either elected not to delegate or to be exceedingly selective about which patients are treated by non-physician staff, for safety and liability reasons. Jeffrey Dover, M.D., Director of SkinCare Physicians in Chestnut Hill, MA, allows one of the two head nurses to perform laser hair removal on what he deems “relatively straightforward cases — the standard fair-skinned, dark-haired patient. But every patient is seen in consult first by a dermatologist, and the H&P is done by the doctor,” he explains.
Dr. Dover also insists on a written prescription for each patient, a document that lists the device to be used and the initial settings — and specifies under which patient-tolerance circumstances settings can be increased. Finally, the dermatologists tell patients that that the physician will “always be on site and available immediately” should questions arise.
“We think this is the ideal situation, especially if it’s a large [skin] area and the highly skilled person is doing the procedure under our direct supervision,” Dr. Dover maintains. “But the assessment and prescription ensure that the patient is a good candidate.” He notes that he personally handles “difficult cases” — particularly procedures on dark skin and those involving large, generally exposed surface areas.
Robert Weiss, M.D., Director of the Maryland Laser, Skin and Vein Institute in Hunt Valley, uses a delegation model similar to Dr. Dover’s. Only N.P.s and P.A.s use the devices, and nearly 100% of the time, a dermatologist is on-site. The dermatologists perform a preliminary consulting visit and suitability assessment on patients — a spot test is done if warranted.
“Our patients are o.k. with the delegation because they [the N.P.s and P.A.s] are so closely supervised by us. We also go through the practice of explaining that there are very few places in the country where physicians actually do the hair removal,” says Dr. Weiss, who is an Associate Professor of Dermatology at Johns Hopkins School of Medicine and President-Elect of the American Society for Dermatologic Surgery (ASDS).
In a somewhat different model, David J. Goldberg, M.D., J.D., Director of Skin Laser & Surgery Specialists of New York & New Jersey, and who also operates a Florida practice, goes by the books as far as regulations are concerned. But he makes adjustments based on patient preferences.
“I don’t delegate in New Jersey because I can’t, and I don’t delegate in New York City because a lot of my patients want the doctor to do it,” says Dr. Goldberg, who also directs laser research at the Mount Sinai School of Medicine. “I do delegate in Florida to the P.A., who works directly under me.” There is always, he adds, “a client base that only wants doctors to do the procedures,” and he schedules accordingly.
A Look at Revenues
Whether they delegate or not, many dermatologists who have laser expertise offer hair removal in their practices. But the actual procedure revenues — or even untapped revenue potential — is a mixed picture.
For some dermatologists who restrict their practice to cosmetics or who delegate the work and operate large laser service centers, laser hair removal can constitute a significant portion — 20% or more — of revenues. But either by professional choice or because of the local market dynamics, namely a plethora of lower-priced service providers, many dermatologists appear to limit laser hair removal to 10% or less of their practice revenues.
Most dermatologists interviewed for this article pegged the procedure at between 5% and 10% of revenues, and most admitted that competitive factors would likely keep that proportion from growing.
Demand, Safety Concerns Put Laser in Limelight
A couple of high-profile catastrophic cases — including a patient who died after being prescribed (and taking) an overdose of a topical anesthetic, and another who incurred severe, disfiguring burns — have prompted a push for more restrictive regulations in some states regarding who can perform the procedure and the degree of physician supervision required.
Less-serious complications likely frequently occur, whether they are reported or not, media reports suggest. Several dermatologists interviewed for this article, for instance, mentioned that they increasingly treat patients who have experienced complications or bad outcomes.
“I personally see about a half-dozen [bad outcome] cases a year now, including some really badly botched ones,” says New York City dermatologist Dina Anderson, M.D., who is in solo practice. Those recent cases include one repair of a procedure done on a young woman by a non-dermatologist physician with scant experience — a doctor who was ostensibly eyeing laser hair removal to boost revenue.
“In New Jersey, you have to be an M.D. to touch a laser, but in New York, it’s very ambiguous — a real gray zone.” In her practice, which is essentially a boutique practice and, she says, “about 20% general dermatology,” even if the assistant will do the procedure, Dr. Anderson assesses each patient. She also chooses the laser settings, leaving “only the mechanics” to the assistant.
Dr. Anderson delegates about half of her laser hair procedures to her assistant based on her own schedule and some combination of case complexity and patient request. But she always personally assesses each patient before a procedure. “I think there’s great variation, and if you ask 10 dermatologists [about delegation], you’ll get 10 different answers,” she says, allowing that despite that preference-based variation, she wishes, for patients’ safety, that New York regulations were more stringent.
Dr. Goldberg, who is also a healthcare attorney, concurs with Dr. Anderson’s free-for-all market assessment of New York and other places where regulations are less restrictive. “We’re seeing a cropping up of these medi-spas that do hair removal … and they have an M.D. attached to them,” he says. “But that person may not be a dermatologist — it might be an M.D. who has never had any training in laser procedures.” Those situations, Drs. Anderson and Goldberg concur, are breeding grounds for complications in loosely regulated environments.
In the absence of tighter restrictions, complication rates may increase as a sheer factor of volume. The American Society for Aesthetic Plastic Surgery (ASAPS), which maintains a robust data repository on cosmetic procedures, reported more than 1.4 million laser hair removal procedures for 2006. ASAPS cited increases of more than 10% annually in recent years and identified the procedure as the leading one sought by individuals age 18 and under. According to ASAPS reports, the frequency of non-surgical cosmetic procedures overall has increased more than 700% since the society began collecting data more than a decade ago.
Societies Weigh in on Delegation
The key consideration for dermatologists eyeing delegation is state regulation of laser hair removal, which is, literally speaking, all over the map. (See Physician Supervision Requirements) Most states consider the procedure “medical,” and therefore require physician involvement of some sort. But dermatologists in leadership positions, including Dr. Weiss and Dr. Goldberg, who is on the board of both the American Academy of Dermatology (AAD) and the ASDS, urge colleagues to err on the side of conservative delegation and to abide by professional organizations’ guidelines.
Both the AAD’s and ASDS’s position statements on laser procedure delegation state that delegating physicians should themselves be properly trained and qualified to perform the procedures being delegated, and that personnel should have appropriate, adequate training and experience. Both guidelines also call for dermatologists’ on-site supervision of personnel and immediate availability in the event of problems, or staff or patient questions.
Dr. Weiss admits that politics — and polemic differences of opinions on delegation and associated guidelines — exist. “From the ASDS point of view, we’re trying to balance the needs of members with policies that allow enough physician supervision, to distinguish what we do from other specialties or medi-spas. It’s interesting because we’re going through that discussion right now with the board,” he told Skin & Aging. “We need to maintain the quality and we need to maintain the physician supervision aspect, but we do have to accurately reflect what our members are doing.”
In the meantime, dermatologists might do their part by helping patients become better informed, all sources said. Efforts by the professional societies to educate consumers on possible dangers of undergoing procedures performed by inadequately trained individuals are under way. At the very least, dermatologists should offer patients a list of questions to ask when considering a service provider, Dr. Goldberg urges, and should make the point that in a laser center having an “M.D. on-site” may mean little.
“I tell patients that it’s really ‘buyer beware’ now — that they should ask what kind of physician is on-site, whether the doctor is active or retired, and whether that physician has ever performed laser hair removal,” he says. “It could be a psychiatrist, and it’s commonly not a dermatologist.” More commonly, Dr. Goldberg adds, the medical directors may be retired, and many medi-spas he has heard about in recent years are “overseen” by physicians who have no training in laser hair removal.
In states where regulations are lax or where on-site physician supervision is not required, high-volume spas offering bargain-basement prices for laser hair removal have proliferated. In New York, for instance, the loose regulatory environment has spawned virtual laser hair-removal factories.
Neighboring New Jersey, however, is nearly at the other end of the spectrum; only physicians can perform laser hair removal. In Maryland, recently tightened regulations allow N.P.s and P.A.s to operate lasers, but only under a physician’s direct supervision —unless the operator has formally logged a sufficient number of procedures. In Tennessee, by way of contrast, physician supervision is required but that physician needn’t be on-site, merely “in the state,” Dr. Gold explains. And in Texas, regulations are in limbo because of a persisting court injunction.
Will the Regulatory Situation Improve?
Some dermatologists expect that the regulatory laxness, where it exists, will go away, but that’s unlikely to occur soon, given powerful lobbying forces. In Massachusetts, for instance, electrologists — who several dermatologists interviewed for this article admit are good candidates for performing laser procedures when properly trained — are pushing for looser regulations. The bill under consideration would enable them to perform laser hair removal without physician supervision.
The Massachusetts development bucks the overall trend. “The regulatory climate is getting more restrictive, but at a very slow rate,” Dr. Goldberg explains. “For the most part, what we’re seeing are slight modifications. You don’t have states going from no restrictions at all to the New Jersey model.”
Amy J. McMichael, M.D., Associate Professor of Dermatology at Wake Forest University School of Medicine in Winston-Salem, N.C., thinks the regulatory ambiguity and lack of standardization create problems for dermatologists and patients.
“The fact that every single state is different, and that training requirements vary so much — that’s all part of the problem,” Dr. McMichael, a recognized hair expert, says. Just as other dermatologists have noted, she concurs that the mere fact of requiring physician oversight or having a designated medical director isn’t always meaningful, in terms of patient safety.
“In North Carolina, the regulations say that there must be a physician who is responsible, but that doesn’t mean the physician has to be on the premises,” Dr. McMichael says, or that she or he must have targeted laser training. In the state, regulations have become more stringent. Now, non-physicians, including P.A.s and N.P.s, who have the requisite training hours can perform laser hair removal, but only if they have been trained by physicians.
Laser Safety: A Relative Matter
The increasing use of and experience with lasers in hair removal can and should confer safety gains, but that’s not necessarily the case — especially when inexperienced operators are involved.
“Lasers are getting stronger, which potentially makes them less safe,” observes Dr. Goldberg, who is also Chief Editor for the Journal of Cosmetic and Laser Surgery. “The flip side is that the cooling apparatus is getting better and better. So lasers are getting safer even though they’re getting more powerful.” Essentially, getting the settings “right” is a matter of training and experience, as most equipment isn’t designed to prevent operator error through sensors or other mechanisms.
“You have to have the knowledge to do this correctly,” Dr. Goldberg says.
One way to bridge the tremendous gulf that exists in the non-physician competence and training realm, Dr. Weiss suggests, would be to promote development of laser technician certification programs. “There’s really no formalized education and certification, but in an ideal world,” he says, “I would like to see the radiologic technician model used.” (In that field, technicians can pursue basic and advanced certification in a number of imaging modalities.)
On the physician side, too often, loose regulations allow for supervising physicians to assume that role “in name only,” Dr. McMichael adds, and when license problems might preclude their practicing elsewhere. “There are a lot of questions I would ask as a patient, but often, people are just going for the lowest price.”
Dr. Dover concurs. “A lot of my patients who come here for other things go elsewhere for laser hair removal, because it’s less expensive and more convenient. We frankly can’t compete with the $69 advertisements,” he says. “Nor do we have time to.”
For dermatologists trained in the procedure and equipped with state-of-the-art devices, laser hair removal is considered an easy and safe procedure, and one that can be readily learned by skilled and trained practice personnel. It’s also a procedure that, barring challenging patient circumstances — such as light hair and dark skin — many dermatologists do happily delegate, or would, regulations permitting.
Who’s Delegating and How
Some dermatologists whose state laws allow them to delegate choose to hand off all or most laser hair removal to well-trained non-physician staff members, on the principle that individuals who do the procedure day in and day out may be those best suited for the task.
“I haven’t done a laser hair procedure in a long time,” says Michael H. Gold, M.D., Medical Director of Gold Skin Care Center in Nashville, TN. “If patients ask if I will be doing the procedure, I say no, and explain that these [staff] are people who do it every second of the day — that if my mom or my wife want a procedure done, they go to my nurses. Once patients hear that, they have a pretty high comfort level.”
Dr. Gold, an Associate Professor of Medicine at Vanderbilt University, only allows R.N.s, nurse practitioners (N.P.s) and physician assistants (P.A.s) to perform the procedures — about 25 “on a good day,” he says. And no procedure is done unless the patient has first been assessed by one of the two dermatologists. It helps that the practice is a longstanding research center for new devices, he admits. “Basically, the patients come here because they know that in this part of the world, we do most of the laser procedures.”
Other dermatologists have either elected not to delegate or to be exceedingly selective about which patients are treated by non-physician staff, for safety and liability reasons. Jeffrey Dover, M.D., Director of SkinCare Physicians in Chestnut Hill, MA, allows one of the two head nurses to perform laser hair removal on what he deems “relatively straightforward cases — the standard fair-skinned, dark-haired patient. But every patient is seen in consult first by a dermatologist, and the H&P is done by the doctor,” he explains.
Dr. Dover also insists on a written prescription for each patient, a document that lists the device to be used and the initial settings — and specifies under which patient-tolerance circumstances settings can be increased. Finally, the dermatologists tell patients that that the physician will “always be on site and available immediately” should questions arise.
“We think this is the ideal situation, especially if it’s a large [skin] area and the highly skilled person is doing the procedure under our direct supervision,” Dr. Dover maintains. “But the assessment and prescription ensure that the patient is a good candidate.” He notes that he personally handles “difficult cases” — particularly procedures on dark skin and those involving large, generally exposed surface areas.
Robert Weiss, M.D., Director of the Maryland Laser, Skin and Vein Institute in Hunt Valley, uses a delegation model similar to Dr. Dover’s. Only N.P.s and P.A.s use the devices, and nearly 100% of the time, a dermatologist is on-site. The dermatologists perform a preliminary consulting visit and suitability assessment on patients — a spot test is done if warranted.
“Our patients are o.k. with the delegation because they [the N.P.s and P.A.s] are so closely supervised by us. We also go through the practice of explaining that there are very few places in the country where physicians actually do the hair removal,” says Dr. Weiss, who is an Associate Professor of Dermatology at Johns Hopkins School of Medicine and President-Elect of the American Society for Dermatologic Surgery (ASDS).
In a somewhat different model, David J. Goldberg, M.D., J.D., Director of Skin Laser & Surgery Specialists of New York & New Jersey, and who also operates a Florida practice, goes by the books as far as regulations are concerned. But he makes adjustments based on patient preferences.
“I don’t delegate in New Jersey because I can’t, and I don’t delegate in New York City because a lot of my patients want the doctor to do it,” says Dr. Goldberg, who also directs laser research at the Mount Sinai School of Medicine. “I do delegate in Florida to the P.A., who works directly under me.” There is always, he adds, “a client base that only wants doctors to do the procedures,” and he schedules accordingly.
A Look at Revenues
Whether they delegate or not, many dermatologists who have laser expertise offer hair removal in their practices. But the actual procedure revenues — or even untapped revenue potential — is a mixed picture.
For some dermatologists who restrict their practice to cosmetics or who delegate the work and operate large laser service centers, laser hair removal can constitute a significant portion — 20% or more — of revenues. But either by professional choice or because of the local market dynamics, namely a plethora of lower-priced service providers, many dermatologists appear to limit laser hair removal to 10% or less of their practice revenues.
Most dermatologists interviewed for this article pegged the procedure at between 5% and 10% of revenues, and most admitted that competitive factors would likely keep that proportion from growing.
Demand, Safety Concerns Put Laser in Limelight
A couple of high-profile catastrophic cases — including a patient who died after being prescribed (and taking) an overdose of a topical anesthetic, and another who incurred severe, disfiguring burns — have prompted a push for more restrictive regulations in some states regarding who can perform the procedure and the degree of physician supervision required.
Less-serious complications likely frequently occur, whether they are reported or not, media reports suggest. Several dermatologists interviewed for this article, for instance, mentioned that they increasingly treat patients who have experienced complications or bad outcomes.
“I personally see about a half-dozen [bad outcome] cases a year now, including some really badly botched ones,” says New York City dermatologist Dina Anderson, M.D., who is in solo practice. Those recent cases include one repair of a procedure done on a young woman by a non-dermatologist physician with scant experience — a doctor who was ostensibly eyeing laser hair removal to boost revenue.
“In New Jersey, you have to be an M.D. to touch a laser, but in New York, it’s very ambiguous — a real gray zone.” In her practice, which is essentially a boutique practice and, she says, “about 20% general dermatology,” even if the assistant will do the procedure, Dr. Anderson assesses each patient. She also chooses the laser settings, leaving “only the mechanics” to the assistant.
Dr. Anderson delegates about half of her laser hair procedures to her assistant based on her own schedule and some combination of case complexity and patient request. But she always personally assesses each patient before a procedure. “I think there’s great variation, and if you ask 10 dermatologists [about delegation], you’ll get 10 different answers,” she says, allowing that despite that preference-based variation, she wishes, for patients’ safety, that New York regulations were more stringent.
Dr. Goldberg, who is also a healthcare attorney, concurs with Dr. Anderson’s free-for-all market assessment of New York and other places where regulations are less restrictive. “We’re seeing a cropping up of these medi-spas that do hair removal … and they have an M.D. attached to them,” he says. “But that person may not be a dermatologist — it might be an M.D. who has never had any training in laser procedures.” Those situations, Drs. Anderson and Goldberg concur, are breeding grounds for complications in loosely regulated environments.
In the absence of tighter restrictions, complication rates may increase as a sheer factor of volume. The American Society for Aesthetic Plastic Surgery (ASAPS), which maintains a robust data repository on cosmetic procedures, reported more than 1.4 million laser hair removal procedures for 2006. ASAPS cited increases of more than 10% annually in recent years and identified the procedure as the leading one sought by individuals age 18 and under. According to ASAPS reports, the frequency of non-surgical cosmetic procedures overall has increased more than 700% since the society began collecting data more than a decade ago.
Societies Weigh in on Delegation
The key consideration for dermatologists eyeing delegation is state regulation of laser hair removal, which is, literally speaking, all over the map. (See Physician Supervision Requirements) Most states consider the procedure “medical,” and therefore require physician involvement of some sort. But dermatologists in leadership positions, including Dr. Weiss and Dr. Goldberg, who is on the board of both the American Academy of Dermatology (AAD) and the ASDS, urge colleagues to err on the side of conservative delegation and to abide by professional organizations’ guidelines.
Both the AAD’s and ASDS’s position statements on laser procedure delegation state that delegating physicians should themselves be properly trained and qualified to perform the procedures being delegated, and that personnel should have appropriate, adequate training and experience. Both guidelines also call for dermatologists’ on-site supervision of personnel and immediate availability in the event of problems, or staff or patient questions.
Dr. Weiss admits that politics — and polemic differences of opinions on delegation and associated guidelines — exist. “From the ASDS point of view, we’re trying to balance the needs of members with policies that allow enough physician supervision, to distinguish what we do from other specialties or medi-spas. It’s interesting because we’re going through that discussion right now with the board,” he told Skin & Aging. “We need to maintain the quality and we need to maintain the physician supervision aspect, but we do have to accurately reflect what our members are doing.”
In the meantime, dermatologists might do their part by helping patients become better informed, all sources said. Efforts by the professional societies to educate consumers on possible dangers of undergoing procedures performed by inadequately trained individuals are under way. At the very least, dermatologists should offer patients a list of questions to ask when considering a service provider, Dr. Goldberg urges, and should make the point that in a laser center having an “M.D. on-site” may mean little.
“I tell patients that it’s really ‘buyer beware’ now — that they should ask what kind of physician is on-site, whether the doctor is active or retired, and whether that physician has ever performed laser hair removal,” he says. “It could be a psychiatrist, and it’s commonly not a dermatologist.” More commonly, Dr. Goldberg adds, the medical directors may be retired, and many medi-spas he has heard about in recent years are “overseen” by physicians who have no training in laser hair removal.
In states where regulations are lax or where on-site physician supervision is not required, high-volume spas offering bargain-basement prices for laser hair removal have proliferated. In New York, for instance, the loose regulatory environment has spawned virtual laser hair-removal factories.
Neighboring New Jersey, however, is nearly at the other end of the spectrum; only physicians can perform laser hair removal. In Maryland, recently tightened regulations allow N.P.s and P.A.s to operate lasers, but only under a physician’s direct supervision —unless the operator has formally logged a sufficient number of procedures. In Tennessee, by way of contrast, physician supervision is required but that physician needn’t be on-site, merely “in the state,” Dr. Gold explains. And in Texas, regulations are in limbo because of a persisting court injunction.
Will the Regulatory Situation Improve?
Some dermatologists expect that the regulatory laxness, where it exists, will go away, but that’s unlikely to occur soon, given powerful lobbying forces. In Massachusetts, for instance, electrologists — who several dermatologists interviewed for this article admit are good candidates for performing laser procedures when properly trained — are pushing for looser regulations. The bill under consideration would enable them to perform laser hair removal without physician supervision.
The Massachusetts development bucks the overall trend. “The regulatory climate is getting more restrictive, but at a very slow rate,” Dr. Goldberg explains. “For the most part, what we’re seeing are slight modifications. You don’t have states going from no restrictions at all to the New Jersey model.”
Amy J. McMichael, M.D., Associate Professor of Dermatology at Wake Forest University School of Medicine in Winston-Salem, N.C., thinks the regulatory ambiguity and lack of standardization create problems for dermatologists and patients.
“The fact that every single state is different, and that training requirements vary so much — that’s all part of the problem,” Dr. McMichael, a recognized hair expert, says. Just as other dermatologists have noted, she concurs that the mere fact of requiring physician oversight or having a designated medical director isn’t always meaningful, in terms of patient safety.
“In North Carolina, the regulations say that there must be a physician who is responsible, but that doesn’t mean the physician has to be on the premises,” Dr. McMichael says, or that she or he must have targeted laser training. In the state, regulations have become more stringent. Now, non-physicians, including P.A.s and N.P.s, who have the requisite training hours can perform laser hair removal, but only if they have been trained by physicians.
Laser Safety: A Relative Matter
The increasing use of and experience with lasers in hair removal can and should confer safety gains, but that’s not necessarily the case — especially when inexperienced operators are involved.
“Lasers are getting stronger, which potentially makes them less safe,” observes Dr. Goldberg, who is also Chief Editor for the Journal of Cosmetic and Laser Surgery. “The flip side is that the cooling apparatus is getting better and better. So lasers are getting safer even though they’re getting more powerful.” Essentially, getting the settings “right” is a matter of training and experience, as most equipment isn’t designed to prevent operator error through sensors or other mechanisms.
“You have to have the knowledge to do this correctly,” Dr. Goldberg says.
One way to bridge the tremendous gulf that exists in the non-physician competence and training realm, Dr. Weiss suggests, would be to promote development of laser technician certification programs. “There’s really no formalized education and certification, but in an ideal world,” he says, “I would like to see the radiologic technician model used.” (In that field, technicians can pursue basic and advanced certification in a number of imaging modalities.)
On the physician side, too often, loose regulations allow for supervising physicians to assume that role “in name only,” Dr. McMichael adds, and when license problems might preclude their practicing elsewhere. “There are a lot of questions I would ask as a patient, but often, people are just going for the lowest price.”
Dr. Dover concurs. “A lot of my patients who come here for other things go elsewhere for laser hair removal, because it’s less expensive and more convenient. We frankly can’t compete with the $69 advertisements,” he says. “Nor do we have time to.”
