A slippery slope

By Allison Evans, Assistant Managing Editor, May 1, 2022

The Academy has been monitoring and responding to a variety of proposals and bills in the aesthetic arena that would allow non-physician providers, including estheticians, naturopaths, dentists, and optometrists to perform medical procedures for cosmetic purposes, such as administering neurotoxins and dermal fillers, and performing laser treatments.

“It is the Academy’s position that the optimum degree of dermatologic care is delivered when a board-certified dermatologist provides direct, on-site supervision to all non-dermatologist personnel,” said Victoria Pasko, the assistant director of state policy for the American Academy of Dermatology Association (AADA).

What’s more — the public supports the physician-led team care model. According to four nationwide surveys from the AMA’s Scope of Practice Partnership, 84% of respondents prefer a physician to have primary responsibility for the diagnosis and management of their health care, and 91% said that a physician’s years of medical education and training are vital to optimal patient care.

Education and patient safety

According to the Academy’s position statement, the practice of dermatology includes, but is not limited to performing any medical, surgical, or aesthetic act or procedure that can alter or cause biologic change or damage to the skin and subcutaneous tissue, including the use of all lasers, scalpel, light sources, chemical application, the injection or insertion of foreign or natural substances, or soft tissue augmentation.

As more non-physician practitioners encroach on the practice of dermatology and medicine in general, the Academy is engaged in numerous state-level battles to defend the value of dermatologic specialty training and advocate for patient safety.

“We are at a place where more and more, non-physicians want to be able to administer products like botulinum toxin and fillers,” said Lisa Albany, JD, director of state policy at the AADA. “We need to focus on educating policymakers not only on the vast differences in education and training between physicians, particularly specialists, and non-physicians, but also the necessity that any provider must understand and be able to respond to possible complications.”

“We need to focus on educating policymakers not only on the vast differences in education and training between physicians, particularly specialists, and non-physicians, but also the necessity that any provider must understand and be able to respond to possible complications.”

“Ultimately, all of our arguments against scope expansion boil down to three core concepts: education, training, and most importantly for policymakers, patient safety,” said Alabama dermatologist Gregory Bourgeois, MD, FAAD.

“Most legislators aren’t seeing the complications that our physicians are seeing in the office,” Albany noted. Knowledge of vascular anatomy is crucial for all filler injections. While intravascular injection is possible at any location on the face, certain locations carry a higher risk of complications, including filler embolization, necrosis, visual abnormalities, blindness, and stroke.

“We’re really getting to a level where people are not necessarily appropriately trained,” said Alexander S. Gross, MD, FAAD, chair of the AADA’s State Policy Committee. If you’re injecting filler and you end up with necrosis because you injected or compressed an artery, who’s going to take care of that patient? It’s not likely that the dentist or the esthetician would know how to deal with those complications.”

As non-physicians mount arguments based on skills acquired via weekend courses or manufacturer training, the Academy emphasizes that these short-term courses in no way prepare non-physicians to deal with the range of potential patient complications. In a 2021 FDA meeting about dermal filler safety, an industry representative responded to questions about these training programs by explaining that these courses are meant to serve as a foundation for future training — not as a one-and-done course.

Lasers

“Up until about 10 years ago, there was no law in Georgia about who could use lasers,” said Dr. Gross. “It was like the Wild West. There were people who had absolutely no education and training and could still get their hands on a laser.”

A 2019 study published in Dermatologic Surgery found that a higher number of burns and discoloration occurred in cosmetic procedures performed by non-physicians, with improper technique cited most frequently as the reason for these adverse events.

Dr. Gross worked with the Georgia Dermatology Society and Georgia Medical Board to pass a state law that requires people who are not physicians to obtain a special license from the medical board in order to operate a non-ablative laser. Except for laser hair removal and intense pulsed light (IPL), the law also requires physician supervision, he said.

“There’s this misconception that you just plug information into a laser and the laser outputs — anyone can do it,” said Dr. Bourgeois. “But that’s not the case at all. It takes finesse and an understanding of the physics behind the laser, the experience of treating many patients, and knowing that you may only be a few millimeters or milliseconds away from severe complications.”

Naturopaths

Last year the Board of Naturopathy in the state of Washington submitted a proposal that would authorize naturopaths to perform nonsurgical cosmetic medical procedures, including the use of botulinum toxin and fillers, Albany said. The Academy responded to the Board of Naturopathy explaining that these procedures are outside the scope of naturopathy and can represent a significant risk to patient safety when not administered by medical doctors or under direct supervision of a medical doctor.

Washington law defines naturopathy as the “art and science of the diagnosis, prevention, and treatment of disorders of the body by stimulation or support, or both, of the natural processes of the human body.” Allowing naturopaths to perform nonsurgical cosmetic medical procedures is clearly inconsistent with this definition, said Andrea Kalus, MD, FAAD, in her testimony to the Board of Naturopathy on behalf of the Washington State Dermatology Association.

“Properly performing procedures using botulinum toxin or dermal fillers requires specific, long-term training, including part of a medical residency in cutaneous dermatologic procedures,” she continued. The education for naturopaths does not include the appropriate training to use these products. Furthermore, the short-term training offered by manufacturers of these products is insufficient and does not adequately promote patient safety, Dr. Kalus explained. The proposed regulation was defeated.

Estheticians

There has been an effort from estheticians to create a category of advanced practice estheticians in Oregon and Montana, Albany said. Last June, the Oregon state legislature passed a law that would allow those with an advanced esthetics certification to use IPL devices despite pleas from the Academy to only allow estheticians to use IPL devices with on-site physician supervision. A study in Skin & Aging found that 82% of complications resulting from laser treatments received by non-physicians occurred in facilities that had no on-site physician supervision.

In Montana, a House bill was introduced that would create an advanced practice esthetician license. The way the bill was written would have allowed them to be directly supervised by advanced practice registered nurses (APRNs), physician assistants, podiatrists, optometrists, or dentists. “While the Montana bill died, similar legislation was passed in Nevada,” Albany said.

Dentists

“We are also seeing dentists seeking to administer neurotoxins and dermal fillers,” Albany said. The Arizona Senate and House passed legislation that would allow dentists to administer neurotoxins and dermal fillers for cosmetic purpose. Currently, Arizona law authorizes the use of neurotoxins by dentists for therapeutic purposes that are part of a specific dental care plan. The AADA has urged Arizona Gov. Doug Ducey to oppose the legislation.

“The AADA, and multiple other physician organizations, sent a letter of opposition, although it will be a tough battle since nurse practitioners and physician assistants can already do this,” Albany said. Once a non-physician practitioner is granted permission to perform medical procedures, even if only for cosmetic purposes, it becomes a slippery slope.

Optometrists

In February, a meeting of the Alabama Senate Health Committee took place on whether to give a favorable report to a bill that would allow Alabama optometrists to expand their scope of practice to include procedures currently performed primarily by ophthalmologists.

“They were seeking to allow optometrists to perform surgical and laser procedures around the eye. It would let them cut around the eye in a way they’ve never been allowed to do — and never been trained to do, including performing biopsies of skin lesions around the eye, and using lasers,” Dr. Bourgeois said.

A senator, who serves as chairman of the Health Committee and is also an optometrist, recently announced his upcoming retirement. “For the third straight year, this senator had brought up this bill. Our fear was that since he announced his retirement, his colleagues might pat him on the back on the way out and maybe vote for the bill this time,” he said. The Senate passed the bill, and it is being considered in the House.

Physicians are perfectly accepting of optometrists doing what they have been trained and are qualified to do, Dr. Bourgeois noted. “But they’re trying to jump into an arena where there’s just no substitute for years of medical education and training.”

According to the AMA’s Scope of Practice surveys, 79% of U.S. voters surveyed oppose allowing optometrists without medical degrees to perform eye surgery. There is a qualification that comes from the depth of education, he explained. “You can show optometrists how to recognize a basal cell carcinoma around the eye, but it’s a fine line between being able to know when it’s a basal cell carcinoma, a common skin cancer, versus other lesions that look similar. This is more concerning when in the hands of a health care provider that hardly works with the skin.”

Joining forces

In previous years, Alabama dermatologists joined forces with ophthalmologists to defeat scope expansions by optometrists, Dr. Bourgeois explained. This relationship has proven to be mutually beneficial as ophthalmology has also jumped in and helped dermatology defeat NP and PA scope expansion at the eleventh hour. “It looked great having both ophthalmologists and dermatologists there together because the message was really resounding and fortified.”

“I cannot stress enough the value, if not absolute necessity, of collaborating with state medical societies, the American Medical Association, other national specialties, and of course, state dermatology societies. Legislators can’t ignore it or pass it quietly if a multitude of groups are speaking up,” Pasko said.

Board-certified physicians need to band together on scope issues, Dr. Bourgeois said. As non-physician practitioners try to gain access to performing procedures that constitute the practice of medicine, the result is a slow and steady devaluation of the education and training of board-certified physicians. “Maintain networks not just in dermatology, but outside of it as well, because it all boils down to the same issue.”

“The Academy does a great job of trying to be SkinSerious — trying to convey to the house of medicine and the public what dermatologists do, what we’re trained to do, and the qualifications it took to get there,” Dr. Bourgeois said. (Learn more about SkinSerious®)

“As Academy members, we need to keep working on branding ourselves as the experts in skin, hair, and nails. The Academy has a lot of resources that physicians can use to educate the public that we’re board-certified dermatologists and we’re the experts,” Dr. Gross said. (Access resources on promoting the specialty)

Presence

“If you’re not at the table, you’re on the menu,” Dr. Bourgeois said. “It’s taken a couple of years of being a continuing presence to avoid dangerous scope expansions. The scope creep doesn’t stop; we have to keep showing up.”

“Lawmakers have an ever-increasing amount of influence over how you treat your patients, run your practice, and who can do what. But at the end of the day, they are still accountable to their constituents,” Pasko said. “The AADA’s collective voice is powerful, but to maintain our position of influence, we must be supported by the individual voices of our members. Each AADA member needs to commit to taking it upon themselves to express their views on the scope of practice legislation in question directly with their legislators and cultivating a relationship with their own state representative and senator. Over time, this relationship will bear fruit, and your views will take on even greater importance in your legislators’ eyes.”

Additional DermWorld Resources