It’s been dubbed the spa of the future, but the medical spa is as old as “taking the waters.” According to Hannelore Leavy, founder and executive director of The Day Spa Association, European spas have always been medical, centered around mineral springs and waters. “Treatment was and still is prescribed and monitored by a physician,” said Leavy in an interview from her office in West New York, N.J. Spas established in this country’s early history were also used for medicinal cure, but a transition occurred about mid-20th century, essentially phasing out medicine and emphasizing beauty treatment. American spas are now coming full circle, returning to their roots of integrative wellness.

Water therapy dates back many thousands of years, having been used by highly-developed, ancient civilizations for treating disease and by primitive shamans for purification of body and spirit. Through tradition and legend, continued use of some locations of mineral springs brought about the establishment of healing centers. The spas of Roman times included elaborate bathhouses where an array of treatments associated with healing were offered. Roman expansion and invasion left its mark and spas flourished for centuries on European and Commonwealth soil. Two such locations, Bath in England and Spa in Belgium, are appropriately named and among the more historically famous.

Europeans immigrating to America during this nation’s early settlement brought with them the “old country” concept of the spa. Already widely used by Native Americans, medicinal treatment at natural springs became an established “cure all” available from coast to coast, leading to the building of exclusive spa resorts. In an age where medicine was still based on what we today term alternative therapies, integrative care was the norm. But as health care became more medicalized, and a booming industrial society became more beauty-conscious, the two separated paths. Medicine moved into the hospital and clinic and spas became pampering salons for the wealthy, a trend that remained strong for decades.

What has changed and why are medical spas popping up now? The answer has many facets. Among them, the increasing demand by today’s consumer for alternative therapies and integrative treatment; an emphasis on preventive wellness care; and a medical system that’s been overwhelmed with insurance dictates, paperwork and restrictions on service.

Dr. Michelle Palmer, an esthetics educator and naturopath with a doctorate in alternative therapies, set up her first medical spa 15 years ago. From her headquarters in Phoenix, Ariz., Palmer offered her take on the current trend. “I’ve always had a passion for dealing with the person as a whole. Bodywork, naturopathic and esthetics; that to me is the future. There’s a huge market with naturopaths.” There’s even a course now being offered for nurse practitioners and bodyworkers to become naturopath practitioners. “I think Sept. 11 changed a lot of directions. The more aggressive treatments are down. Today the public is over-educated, but the advantage is that patients want total care and lighter treatments.”

A Medical Spa, By Any Definition?

Just two simple words, and yet, across the board and throughout the industry, there is no consensus as to exactly what a medical spa is and should be. That’s not so surprising in light of the fact that the marriage between medicine and spas is relatively new in our modern experience.

For the most part, Americans have come to expect a routine of sorts in medical care: being ushered in and out as quickly as possible through a stark (sometimes emotionally, as well as physically) environment, being poked and prodded and then dismissed with a prescription, order for lab tests or a “come again, same time next year.” We may feel assured our health is intact, but repeating the experience can certainly wait another year, thank you. On the other hand, our relationship with spas has been one of romance — pampering and personal attention, soothing touch and a sense of rejuvenation upon leaving the premises. Combining the two, in a sense, has become a conundrum. Wellness centers, doctors’ offices with spa services, spas with medical exams, anti-aging treatments and spiritual guidance — which ones qualify as a medical spa? And who will determine that definition?

According to Marian Urban, a leader in the medical spa movement and managing editor of Medical Spas magazine, the word “medical” is the key. Speaking from her office in Santa Fe, N.M., she said, “The medical spa is the European concept. It’s nothing new; that’s how they maintain their health. No matter how you put it, a medical spa should have a physician on board, and it has to be a full-time position.” Even in an accredited facility, if there is no medical doctor on staff, there can be a liability issue. “It’s the way of the future,” she said, “but it needs to be looked at very carefully. You could be facing liability in a lawsuit. A medical spa is not just a face.”

Generally, the public has associated medical spas with plastic surgery and other beauty-related procedures, but Urban points out that the medical spa of today focuses on total wellness of the individual. “There are all types of physicians coming in, a wide scope. It’s not just a place you have a facelift. You can spend a week and have a whole battery of tests run for a complete picture of health. In my opinion, medical spas are going to be the hospital of the future, for those looking for alternatives.”

Leavy views the medical spa arena as two very different modalities. “There is the doctor’s office that adds on spa services, like homeopaths, internists, dentists or plastic surgeons. Doctors are discovering that spa services are beneficial to their patients, for relaxation, to relieve anxiety, and as medically beneficial, such as pre- and post-surgery. In skin diseases, it can help with the healing process of the patient. They are also realizing these things are not covered by health insurance and people are willing to pay a lot for it. They don’t have to worry about HMOs. This is an important factor for doctors, to get away from paperwork and health insurance. They can earn income that’s not regulated by health insurance. Studies show that people are going to alternative practices and spending more money for alternative remedies than on regular doctors.

“On the other hand, there’s the spa aligning itself with the medical. Sometimes they must have a medical director, if it’s what the state requires.” Leavy also emphasizes the need for staff to be educated in what to look for in referring a client for medical consultation. “A spa therapist should be able to tell the difference between an age spot and a melanoma.” The spa therapist, as defined by Leavy, is someone trained as an esthetician (also as a massage therapist) who has basic knowledge of spa treatments along with an extensive knowledge of the body and ailments, and contraindications of certain treatments.

According to Palmer, the medical field will have the final say in defining the medical spa. “Whatever they (facilities and staff) are doing, medicine will be responsible. They’re going to regulate it.” It can be a phenomenal team with doctors and estheticians, she said. The doctor can be an M.D. or D.O. You can add an R.N., esthetician, massage therapist, nutritionist and others to create a complete medical spa team. The important aspect of this, she noted, is having the appropriately-trained staff member for each treatment.

While consensus as to definition, defined purpose and guidelines for the operation of medical spas still hangs in limbo, most industry experts seem to agree that one is forthcoming. Through conferences, symposiums and personal encounters, efforts are being made to formally gather opinions and set industry standards. In June 2002, the National Coalition of Esthetic & Related Profession Associations (NCEA) hosted an open forum to share viewpoints and discuss future directions, devoting an entire session to medical issues. The Medical Spa Conference, sponsored by The Spa Professionals Alliance and scheduled for November of this year, has as its headline “How can we find a balance between the spa profession and the medical profession?” Organizers hope to increase awareness and knowledge in the field, said Urban of the conference. “The focus is to bring out education and have people talking one on one, rather than have it be a large trade show. We are coming up with people who have been working with medical spas for years, but haven’t wanted to use the term medical because they’re afraid. It’s not a light word to use.”

Responsibility and Liability

Is the doctor actually in the house? If not, there may be trouble in paradise. While some facilities have taken on full-fledged medical directors, others have contracted for a name and an occasional personal appearance. What responsibilities fall under the title of medical director in a spa and why is full-time presence so necessary?

Susanne Warfield is president and CEO of Paramedical Consultants, Inc. and publisher of PCI Journal. She also serves as executive director of the NCEA and the Society of Dermatology SkinCare Specialists (SDSS). As a leading expert on the business aspects, she addressed several issues that need to be considered regarding medical facilities, medical directors and federal and state regulations.

Speaking in an interview from her Glen Rock, N.J., office, Warfield said, “I contacted the medical director’s association and they have no such definition for a medical director in a medical spa. It’s a gray area. If the medical director is in fact a physician, are they the one whose name is going on the leasing or purchasing contract of a medical device to be used in a spa?”

Under federal regulation, any piece of equipment being sold goes through a classification procedure by the Food and Drug Administration (FDA). How the federal government classifies a device will determine whether or not it is labeled as “prescriptive,” meaning only a prescriptive user can order its purchase. “Then it’s up to each state to determine who can use that device by prescription,” said Warfield. In most states, the order for purchase is limited to physicians. Federal laws not only include medical devices, noted Warfield, but also cosmetics. “Are they drugs? And in some states, the state boards of cosmetology are going after medical spas because they are not properly licensed with the state board of cosmetology.

“Another point to consider is the Occupational Safety and Health Administration (OSHA),” said Warfield. Under OSHA are three aspects of medical regulation that can affect medical spas.

• The Bloodborne Pathogen Standard requires facilities to have in place an exposure control plan for blood or other potentially harmful body materials. “Are the estheticians wearing vinyl gloves to perform facial and body treatments that would put them at risk for exposure?” asked Warfield. “In my opinion, these treatments put you at risk.”

• The Hazards Communication Standard has to do with hazardous materials in the workplace. For example, glycolic acid is still classified as a hazardous substance. The American National Standards Institute (ANSI), now adopted by OSHA, regulates the use of lasers. “If the facility has put in a laser, they will be looking at compliance with safety for that,” said Warfield.

• Medical spa owners also need to be aware of the Clinical Laboratory Improvement Amendments (CLIA), which regulate the quality of all laboratory testing (except research) performed on humans in the United States. Some medical spas are doing hair analysis, staining procedures and live blood cell testing. As a medical facility, CLIA regulations will be applicable. “You can’t just put out a shingle and start to do all of these things,” said Warfield.

Whether the business is called a medical facility or medical practice, compliance with these regulations will be required. In each state, the board of medicine will determine if certain equipment can be used by physicians only or under physician supervision. In a survey of state medical boards conducted this year by the American Electrology Association, 13 states have restricted use of laser for hair removal to physicians only, with another seven allowing its use by others under direct physician supervision. “There are also delegation rules as to who a physician can delegate responsibility to and this varies state to state,” said Warfield. “Also the board of cosmetology, how is that going to affect scope of licensure of estheticians? For example, we currently have more than 20 states that do not recognize esthetician licenses in medical practice.

“If a medical spa is in fact medical, there’s a new act to be aware of — the Health Insurance Portability and Accountability Act (HIPAA),” Warfield said. Established in 1996, this act requires all health care organizations that maintain or transmit electronic health information to comply with specific standards in maintaining and transmitting health information on individual patients. Facilities will have to be in final compliance by April 2003.

“So is the medical spa a medical practice or is it a spa?” asked Warfield. The state laws vary and will have an impact on how the medical spa operates, not only as a medical center but also as a cosmetology facility. “Under some state laws, if it is considered cosmetology, then the state laws of cosmetology apply.” Highlighting the term “medical,” Warfield noted if a physician is working out of a medical spa, the consumer is not going to identify herself as a client, but rather as a patient. “No matter how much we want to call them clients, they’re still patients. The consumer perceives this as medical treatment.

“One final point of this is accreditation,” said Warfield. “Some states have enacted rulings that require medical facilities using a certain level of anesthesia to accredit their facility. For example, laser resurfacing requires nerve blocks.” A spa offering this service is required to be accredited. The same is true for other medical procedures now being performed in offices and spas outside of the realm of hospitals and medical centers. Two examples of non-profit, private accrediting organizations are the Joint Commission on Accreditation of Healthcare Organization (JCAHO) and the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF).

Licensing is another factor that requires investigation and varies from state to state. “Check out all the agencies you need to check out,” said Urban, “and have all the licenses in place” whether for business, physician or staff. “This is where it gets tricky. This is brand new and everyone is trying to determine how we insure these people,” she added, with a warning that the malpractice faction is “quickly becoming educated” and is a real threat to these businesses.

Regardless of who is licensed for what, when an independent esthetic practitioner shares the same waiting room with the physician, the physician ultimately carries the responsibility. “When someone is working under a doctor’s office, they become the doctor’s employee,” said Palmer. “The doctor is taking liability. That’s a challenge. Doctors have so much liability that the esthetic industry doesn’t understand. But the bottom line is not am I licensed, but am I properly trained?”

Wellness and Restorative Healing

Much of the impetus of the medical spa movement can be attributed to a new perspective on wellness. Looking at preventive care in the broadest sense, we can include new spa techniques and approaches designed to keep mind, body and spirit at optimum functioning. Some facilities are just recently adopting this attitude, adding anti-aging skin and body treatments performed by trained anti-aging technicians. Others have been doing it for years, under the guise of preventive medicine.

In a recent article for Medical Spa magazine (Feb. 2002), author Monica Tuma Brown highlighted the growth of this trend. At The Marsh in Minnetonka, Minn., a blend of traditional and alternative care includes physical therapy and exercise, pool therapy, acupuncture, diet and nutrition programs, and educational classes. The famous Canyon Ranches, with resident physicians and a well-rounded staff of other specialists, including psychologists, counselors and physiologists, offer a holistic lifestyle program. Kentucky’s Foxhollow Wellness Spas now offer a European biological medical clinic and base their treatment on an integration of body, mind, spirit and medicine.

So how do wellness spas fit into the medical spa equation? Dr. Daniel Cosgrove said of the Wellmax Center at La Quinta Golf and Spa Resort, La Quinta, Calif., “We are a high-end preventive medicine center integrated with a spa. Some spas are simple, but we offer a lot of comprehensive, full-medical services. It does benefit and takes the experience of seeing a doctor beyond the tile floor and white coat. We make it pleasant. We’re not a pseudo-medical after-thought attachment to a spa. We’re really more of a spa-linked clinic than a medical spa, but associated with spa people — an integration of the two,” he said.

“Wellmax Center is a genuine medical spa,” said Urban. “A lot of wellness centers do have a physician on board. They were ahead of their time.” Some might not have a doctor on board, or they might not be a medical center. “We have to make sure we use the term correctly.”

For Leavy, of the Day Spa Association, the jury is still out. “Wellness centers have been around for quite a while. A number of providers come together and refer within. It’s one-stop shopping for a person. A wellness center is really not a spa, although they will offer spa services. It’s so difficult to draw a line,” she said. While wellness centers are using alternative medicine and modalities, Leavy views the medical spa as a facility with a medical doctor. “We have not yet set guidelines, it’s not that far yet,” she said. “It’s so new and it needs more investigation.”

Where to Start?

When Palmer consults with a potential spa owner or medical director, she asks them about themselves and their dream place. “Forget about what I want to do,” she said. The process is focused on their clients and services, and tailoring the business to their own preferences and practice. There is no protocol for one specific type of operation. The same goes for esthetic services to be offered. She encourages clients to refer out for what doesn’t fit their practice. “If they want to refer in, have someone doing those services and find a way of working together. If they just do what they do best, everyone wins.” And, she added, if an esthetician feels the spa owner or physician doesn’t respect her specialty and qualifications, find another who does.

“Decide what you want,” said Urban, whether that includes laser, plastic surgery, medical esthetics or massage therapy. “It depends on the direction you want it to take.” Urban has operated her own spa, The Sterling Institute, for 20 years. Since 1993, she has been very active in the integrative movement, bringing educators from Europe to speak to the American spa industry. In 1997, she formed the first Summit of the Masters, which she noted was “ahead of its time” and following the Sept. 11 tragedy, decided to focus on the medical spa movement. “The first medical spa society has been formed,” she said, “and we are forming a board. We’re working with people in the spa industry, pulling from all aspects – medical, spa, legal.

“Physicians have to learn from us as much as we have to learn from them. There’s no way they can do treatments we’ve been doing for years, and we can’t do theirs. If we do it right, we can benefit a lot of people out there, healthwise.” No matter what the specialty, Urban suggests doing a thorough check of licensing, accreditation and other legal issues. “And everyone has to continue training,” she said. “Unless you’re medically-esthetically trained, you can’t work in a medical spa. You have to be appropriately trained to follow the protocol of the medical spa.”

“These are all new areas,” said Warfield. “You have to consider what some of the issues have been in a medical practice. Laws are not written to address medical spas. Technology is way ahead of the law. But you don’t spend the money to open a facility and not know the rules and regulations.”

Lastly, Warfield states the ethical oath by which she encourages others to practice: “Always place the competent, compassionate care of all patients above any financial reward and work diligently with all professional colleagues to create a milieu that fosters the highest attainable degree of care.”