Rules and Regulation Violation: Lack of Documented Training

It is well established that academic institutions that specialize in healthcare do a phenomenal job training their students in primary care. In the field of aesthetic dermatology however, physicians (MDs and DOs) may only delegate to others medical providers (LTs, MAs, LVNs, RNs, NPs, PAs) that they know to be capable of performing the delegated task… and the simple truth is that many clinicians who perform aesthetic dermatology treatments (and their supervisors!) have not obtained documented training in the field. Unquantified “on the job” training or “shadowing” or training classes from device manufacturers or pharmaceutical companies simply do not suffice. Moreover, if a physician is to supervise a task that a clinician performs, it can be implied that the physician too should be capable of performing said task and have obtained training indicting so. In fact, the state of California notes that, “One cannot provide guidance, direction, evaluation and oversight unless one is knowledgeable and competent in the procedure being delegated.”

As such, the questions may arise:

1) Am I legally qualified, through my training, to perform a specific aesthetic dermatology treatment that has been delegated to me?


2) Has my supervisor met the necessary criterion to delegate and to oversee the subsequent implementation of that aesthetic dermatology task to me?

Let’s get more granular:

1) Some (not all!) states allow Laser Technicians (LTs) and Medical Assistants (MAs) to implement aesthetic dermatology treatments but only when in compliance with very clear supervisory requirements which naturally include documented training.

2) In Physician Assistant (PA) regulations, PAs cannot be delegated tasks outside of the physician's customary practice or tasks that the PA has not been trained in.

3) While many state nursing (RN) regulations are less specific than PA regulations, again, the state rules still of course require supervision and proper training in any treatment being performed including aesthetic dermatology.

4) Nurse Practitioners (NPs) are often afforded more autonomy but they still must have documented training in all treatments they perform and to offer patients aesthetic dermatology treatments without quantifiable training in the field would be considered a violation.

5) Current California law allows for nurses (RNs) to be supervised by physicians (DOs and MDs) in any specialty, however, the physicians must fulfill his or her supervision obligations. The regulations imply that this would include, regardless of the primary specialty or certification of the physician, being proficient in the procedure being delegated so that they are capable of providing direction, guidance, and evaluation. Thus, physicians clearly need to have been trained in aesthetic dermatology to supervise aesthetic dermatology treatments.

6) It is important to note that the term "core physician" has been used in many discussions, meaning that a supervising physician (MDs and DOs) has specialized training in an area that is appropriate to supervise aesthetic dermatology treatments (the use of energy-based devices and cosmetic injectables), such as plastic surgery or obviously dermatology. If the physician overseeing the implementation of an aesthetic treatment doesn’t have documented training in one of these core specialties then the individual is likely not in compliance with the rules and regulations of many (all?) state medical boards and thus doesn’t meet the requirements to serves as a supervisor. To wit, even a “core” physician without quantification of training in aesthetic dermatology may not be in compliance and may be practicing and supervising treatments unlawfully.

Thus, while many allied healthcare professionals concern themselves with obtaining a job in the field of aesthetic dermatology, they unknowingly put their livelihood in danger by not ensuring that they have met the training documentation requirements to implement delegated treatments and that their physician supervisor is in compliance with state rules and regulations as well.

Here is a basic questionnaire to consider when contemplating whether or not you are legally qualified to perform an aesthetic dermatology treatment:

1) Does your supervising physician have board-certification in a core specialty (dermatology or plastic surgery)?

2) If your supervising physician does not have board-certification in a core specialty, does he or she have documentation indicating that secondary training in aesthetic dermatology has been obtained?

3) If your supervising physician does have board-certification in a core specialty, what documentation does he or she have indicating that the use of energy-based devices and injectables (aesthetic dermatology treatments) were included in his or her core specialty training?

4) Have you yourself, as a health care professional (LT, MA, RN, NP, PA, DO/MD), obtained quantifiable, documented, training in every aesthetic dermatology treatment you implement regardless of your supervisor’s training documentation or lack thereof?

If the answer to any of the above questions is “no”, then preforming an aesthetic dermatology treatments is a likely violation of state rules and regulations and could result in penalties from your governing state board including, but not limited to, fines, the suspension of your license, or even license revocation.

Some examples of lack of qualification include:

1) An NP without documented training in filler injections preforming lip augmentation at a med spa.

2) An LT or MA without documented training in laser medicine implementing laser hair removal at an OB/GYN’s office.

3) An MD or DO with board certification in anesthesiology but without documented training in injectables who performs neuromodulator injections.

4) An RN who actually has obtained documented training in lasers but who performs laser tattoo removal at an older Plastic Surgeon’s office where training in laser medicine was not part of the physician’s training.

5) A PA with no documented training in skin rejuvenation who performs IPL at a “cosmetic center” and is supervised by a general internist with no documented training in aesthetic dermatology.

Healthcare practitioners have an ethical obligation to perform to the highest of standards and that starts with quantifiable, documented training in their field of practice. See, clinicians spend much time, energy, money, and emotion obtaining and maintaining their professional licenses but, shockingly, they occasionally turn a blind eye to their states practice requirements with specific reference to training. In closing, if you practice aesthetic dermatology, please take all necessary immediate actions to protect your license which, in the vast majority cases, is to simply obtain proper, comprehensive, documented, training in the field via in-person accredited training workshops, earn dermatology related CEUs/CMEs, and/or online accredited courses.