MedEsthetics magazines offers business education and in-depth coverage of the latest noninvasive cosmetic procedures for physicians and practice managers working in the medical aesthetics industry.
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SUCCESSFUL DELEGATION Medical aesthetic practices that are hesitant to use physician extenders point to a possible erosion in the quality of patient care and a potential increase in medical liability claims. In February, a team led by dermatologist H. Ray Jalian, MD, of Massachusetts Dermatology Laser and Cosmetic Center, published a review in JAMA Dermatology of litigation stemming from cutaneous laser surgery procedures performed between 1985 and 2012. They found that litigation was becoming more prevalent as the number of procedures increased. Of the 174 cases they reviewed, more than 40% were performed by non-physician operators, who were named in lawsuits along with their physician supervisors. Laser hair removal—the most common laser treatment during most of the period under investigation—generated the largest number of lawsuits. The increase in litigation has brought a concomitant rise in indemnity payments, which have reached a mean of $380,719, according to Dr. Jalian's review, which stressed: "Physicians will be held responsible for the standard of care provided by their nonphysician agents." Avoiding Legal Pitfalls A patient lawsuit isn't the only way physicians can find themselves in legal hot water when it comes to delegating procedures. There are no federal standards dictating who can operate lasers and other types of equipment used in medical aesthetic practices. Instead, each state has its own set of regulations. These vary wildly and can be difficult to decipher. "In California, lasers and IPL (intense pulsed light) or BBL (broadband light) devices can be operated only by physicians, PAs or RNs. Practical nurses and other assistants can help with some procedures like CoolSculpting, Omnilux LED, microdermabrasion and VelaShape, but only under physician supervision," says Delegation Checklist • Be sure physician extenders are qualified to perform the procedures you delegate. Maintain a personnel file for each staff member including all certificates and other evidence of training. • Have all staff members wear name tags that include titles, such as "RN" or "Laser Technician" so there's never any question of who is or isn't a physician. • Don't work with more extenders than you can manage, and never delegate a procedure that you have not mastered yourself. • Always have a physician available and easily accessible should any problem arise. • Chart all procedures, fully explaining any incidents that may occur. Include everything from whether a patch test was done to what settings were used, as well as any follow-up phone calls or letters. • Record complete treatment protocols, keep them easily accessible and update them regularly. • Have each patient sign an informed consent before beginning any procedure. The form should clearly state any possible problems and the range of outcomes, as well as who will be performing the procedure and that person's credentials. patients are amenable. This will not be the case in every office and the physician should be prepared to work closely with his or her own staff to determine which, if any, of their medical device treatments can be delegated to appropriate personnel." In some states there are no regulations governing who can use lasers and in others the regulations are not clear. "In New York there are still a lot of gray areas when it comes to what kind of procedures can be delegated and to whom," says Bruce Katz, MD, director of New York's JUVA Skin & Laser Center. "We are a high profile practice and don't want to take chances. We have Suzanne L. Kilmer, MD, founder of the Laser & Skin Surgery Center of Northern California. The state of Tennessee does not restrict the procedures that can be performed by assistants working under the direct supervision of a physician. "We delegate most laser and light source treatments to appropriate, well-trained staff," says Dr. Gold. "My extenders are well versed in the use of IPLs and most fractionated lasers, RF and ultrasound technologies. We also delegate injections of toxins and fillers to skilled nurses, PAs and NPs, if 34 MAY/JUNE 2013 | MedEsthetics three PAs and an NP doing noninvasive procedures using devices such as the Exilis, the Clear Lift and the Q-switch YAG for tattoo removal. Extenders do not do even minimally invasive procedures." Ferreting out rules of delegation for your practice or your medical spa requires skill and perseverance. Too often busy physicians are tempted to rely on what the practice down the street is doing. Unfortunately, even if that practice has been in business for years, it may not know any more than you do. What's more, new © ISTOCKPHOTO.COM Ferreting out rules of delegation for your practice or your medical spa requires skill and perseverance.