Incorporating a MedicalSpa into a Physician -RunPracticeBruce Katz, MDa,b,*, JasonMcBean, MDa

HISTORYOF THE SPADeVierville1 proposed that the modern word ‘‘spa’’came into the English language via the old Walloonword, ‘‘espa,’’ which means fountain, and which inEnglish became ‘‘spaw.’’ It is difficult to pinpointthe actual origin of the first spa and spa treat-ments. The concept of the spa occurred in Europeand Asia where mineral springs and thermal mudwere used to sooth and heal varying ailments.2

During the Roman Empire 1352 public fountainsand 962 public baths were available to the citizensof Rome.3 After exercising, bathers entered the‘‘warm room’’ to acclimate to the subsequent‘‘hot room.’’ After the hot room, patrons wouldundergo an oiling massage and then plunge intoa cold pool.3 Roman soldiers sought hot baths torecuperate after long battles. The baths werereferred to as ‘‘aquae.’’ and the bathing treatmentswere known as ‘‘sanus per aquam’’ (SPA), that is,‘‘health through water.’’

After the fall of the Roman Empire, establish-ments with ‘‘hot rooms’’ disintegrated, but theconcept of the spa flourished with continued useof the major springs. Despite the Church’s disap-proval of bathing, the popularity and use of suchsprings continued. In Renaissance Italy, the ‘‘tak-ing of waters’’ was associated with gentlemanlyideal of a rustic retreat.3

In France and Germany, people frequented spasto improvemedical ailments ranging from renal dis-orders and infertility to paralysis and seizure disor-ders. The Belgian town of Spa became famous for

the healing powers of its mineral hot springs duringthe fourteenth century. It became a place to berestored and pampered and still exists today.

Between the sixteenth and nineteenth centuriesmany prominent figures supported the use of spawaters for treating varying ailments. Leonardo deVinci used the waters at San Pellegrino. Michelde Montaigne was relieved when the spring watersstimulated passage of a kidney stone. CharlesDarwin improved his dyspepsia with a combinationof wet sheet packing, hot air baths, and showers.3

During the eighteenth and nineteenth centuries,the use of mineral springs and the development ofhotels and boarding houses around the vicinity ofnatural springs propelled the popularity of thespa. Transplanted Europeans and North Ameri-cans learned about the healing properties ofwaters from Native Americans, and they devel-oped resorts or health retreats. Some earlyretreats such as Bedford Springs, Pennsylvania,White Sulfur Springs, West Virginia, and HotSprings, Arkansas became household namesrivaling the renowned spas of Europe.4

In the late nineteenth and early twentieth centu-ries, some of the founding fathers of dermatology,among them Ferdinand von Hebra and Louis Duhr-ing, discussed the importance in hydration andbathing for the treatment of psoriasis, ichthyosis,and pemphigus.4 Through the early twentieth cen-tury, the great spas of North American and Europewere popular destinations for the wealthy as wellas the ill, who went there to rejuvenate and recu-perate. As health care became nationalized and

a Juva Skin & Laser Center, 60 East 56th Street Suite 2, New York, NY 10022, USAb Cosmetic Surgery & Laser Clinic, Mount Sinai Medical Center, Mount Sinai School of Medicine, One GustaveL. Levy Place, New York, NY 10029, USA* Corresponding author. Juva Skin & Laser Center, 60 East 56th Street Suite 2, New York, NY 10022.E-mail address: brukatz@gmail.com (B. Katz).

KEYWORDS! Medispa ! Medical spa ! Cosmeceuticals! Branding ! Benchmarking

Dermatol Clin 26 (2008) 307–319doi:10.1016/j.det.2008.03.0080733-8635/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved. derm

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modern medicine became more efficient, how-ever, the popularity of spas began to decline.In the latter part of the twentieth century and con-

tinuing to the present, spas re-emerged as destina-tion resorts and places for health maintenance asa complement to modern medicine. The resur-gence in the popularity of the spa sprung from thegrowing depersonalization of the modern healthcare system and from a greater emphasis on well-ness and preventive medicine. Over time, spas be-came destination locales for health maintenance.Three major markers delineate the evolution of

the spa industry in the United States. In the1940s Rancho La Puerta in Tecate, Mexico,focused on a return to nature and minimalismand emphasized healthy eating and fitness. Inthe 1950s the Golden Door in southern Californiadeveloped intimate, small centers of pamperingand relaxation. In 1979 the Canyon Ranch in Tuc-son, Arizona integrated health and healing into themodels pioneered by Rancho La Puerta and TheGolden Door.2 Traditional spas now are orientedtoward providing pampering and beauty treat-ments such as massages and facials and servingas relaxation centers for the wealthy. As such,the popular modern spa descends from theancient practice of bathing in hot springs andmineral waters.

EMERGENCE OF THEMEDICAL SPADespite the advances and evolution of the spa,patients and clinicians recognized the lack oftrue medical benefits from typical spa treatmentssuch as facials, body treatments, and skin careproducts. The advent of topical dermatologicagents with proven anti-aging and therapeuticeffects, as well as new technologies to treat med-ical conditions with minimal downtime paved theway for the emergence of medical spas. Theconcept of one-stop shopping for both crediblespa treatments and prescription-grade medica-tions appeals to a large segment of the population.Medications that have demonstrated anti-aging

properties include retinoids, alpha- and beta-hydroxy acids, 5-fluorouracil, and chemical peels.Modalities that have a central role in aesthetic-based medicine include laser hair removal, vascu-lar lasers, laser photo rejuvenation, injectablefillers, chemical sclerosants, and chemical dener-vating agents. These tools are available to thewell-trained physician, require virtually no down-time, and can augment the services availablein a traditional spa dramatically. The services ofan aesthetically trained physician joined withthe pampering, wellness-oriented environmentof a spa can meet baby boomers’ demand for

credible spa treatments, provide the convenienceof one-stop shopping, and eliminate the cold,sterile, and depersonalized environment of thetraditional medical office.What is a medical spa? First, one should define

the traditional spa. The International Spa Associa-tion defines the traditional spa as an entity devotedto enhancing overall well-being through a varietyof professional services that encourage therenewal of mind, body, and spirit.5 The medicalspa is a facility that operates under the supervisionof a licensed health care professional whoseprimary purpose is to provide comprehensivemedical and wellness care in an environment thatintegrates spa services with traditional and com-plementary and/or alternative therapies and treat-ments. The facility operates within the scope ofpractice of its staff, which can include bothaesthetic/cosmetic and prevention/wellness pro-cedures and services.To comprehend better the full scope of amedical

spa, it is instructive to take a look inside the firstmedical spa, the Juva MediSpa. Its founder (BK)actually coined and trademarked the term ‘‘medi-spa.’’ Juva MediSpa was a traditional cosmeticdermatology practice on the Upper East Side inManhattan, New York, that employed one aesthe-tician. In this practice the author (BK) recognizedthree trends. (1) There was increased patientdemand for integrated services. (2) Traditionalspa treatments did not offer lasting skin benefits.(3) He was treating an increasing number ofpatients suffering adverse reactions caused bypoorly trained personnel at various spa locations.As a result, in 1999, the center moved to a larger,5000-square-foot facility in midtown Manhattan,and the first physician-formulated medical spatreatments were born.At the new facility a warm and inviting environ-

ment welcomes the patient as he or she entersfrom the elevator (Fig. 1). At the front desk, the

Fig.1. Reception desk at Juva MediSpa.

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patient is provided with an informational brochurethat details the services offered by the center andintake forms that the patient completes in thespacious reception area. Unlike a traditional spa,the patient completes a detailed demographicand medical history form. Unlike a traditionalspa, physicians are on site to assist the aestheti-cian with patient care, to answer patient questions,or to provide consultations.

Unlike a traditional medical office, the waitingarea of the Juva MediSpa is luxurious and invitingwith comfortable, cushioned chairs and additionalbrochures that provide information ranging fromthe prevention of skin cancer to the latest lasertechnology (Fig. 2). Two television monitorsprovide a visual tour of the center and mediasegments of procedures and technologies pio-neered at the Juva MediSpa. The treatment areasof the center are divided into two separate butconnected sections: one for the medispa treat-ments and the other for medical and surgicalprocedures. This arrangement allows the pamper-ing and wellness-oriented environment of the spato segue gently to the safe, efficient, professional,and confidential patient treatment area.

The popularity of the medical spa is rising asbaby boomers who have discretionary incomeaggressively seek to maintain youthful looks andsearch for preventive health care services in envi-ronments that are more pleasant than the deper-sonalized medical clinic with its emphasis ondisease. Medical spas also appeal to the growingnumber of Americans who want to combineconventional and alternative medicine in theirquest for optimal health with a holistic approach.

One example shows the benefits of this ap-proach. A patient presents for evaluation andtreatment of a large port-wine stain. She receivesa consultation regarding treatment options bya staff physician. She is informed of the risks,

benefits, and side effects of the treatments aswell as other alternatives. She undergoes the lasertreatment after signing a consent form and experi-ences expected postoperative purpura. In con-trast to the traditional medical office, she then isdirected to the adjacent paramedical make-upcounter located in the spa and is advised as towhich cover-up make-up would match her skintone best while camouflaging her treatment area.This one-stop shopping makes sense and iswhat the consumer demands today.

HOW THEMEDICAL SPA DIFFERSFROM THE TRADITIONAL SPAMedical spas differ from traditional spas in severalways. At the medical spa, consumers enjoy treat-ments that have genuine medical value as well aslong-lasting aesthetic benefits. For example,depending on state law, aestheticians trained byand under the supervision of the dermatologistmay use medical devices for laser hair removaland nonablative laser rejuvenation. The aestheti-cians and physicians can consult each otherregarding patient care, and spa treatments areincorporated into medical and surgical proceduresto enhance outcomes. This collaboration con-trasts with the traditional spa where modalitiesmay be used by poorly trained technicians withoutadequate supervision. Adverse events in suchsettings have led to new legislation in certainstates restricting laser treatments to physiciansor licensed practitioners.

Because of the extensive training that dermatol-ogists, plastic surgeons, and many other physi-cians complete, treatments at medical spas suchas acid peels, lasers, botulinum toxin, and inject-able fillers can be performed safely. Sterile tech-nique always is employed when appropriate(Figs. 3 and 4), and consent forms and other

Fig. 2. Reception area at Juva MediSpa. Fig. 3. Sterilized surgical instruments.

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appropriate documentation are kept securely onfile. Patient information is confidential, and onlydirect caretakers are permitted access. Clientsfeel more confident in the efficacy of medicallysupervised treatments and are more likely toundergo more aggressive treatments such aschemical peels and microdermabrasion with anaesthetician when a physician is on site. It isimportant to maintain the consistency of proce-dures for all treatments; that is, ancillary staffshould adhere to the same treatment protocolsfor each patient to ensure a uniform, reliable clientexperience. This concept is discussed further inthe section on management.Patient and client documentation is another

important facet of the medical spa that contrastswith practice in the traditional spa. Appropriatedocumentation is required in both the spa andmedical segments of the medical spa. As men-tioned earlier, intake forms are mandatory. Theseforms include demographic information, medicalhistory, and pertinent symptoms. Consent formsare reviewed with each patient, and no proceduresare conducted without a signed consent in thechart. Ample time is provided to answer any ques-tions patients may have.In addition to intake and consent forms, flow

sheets are created and maintained for eachpatient and for each treatment modality. In thisway, previous treatment parameters (eg, settingslaser treatments or times for chemical peel) aredocumented and can be referred to for future

treatments. These forms also may include the lotnumber for injectable fillers and chemical peels,which may assist in identifying the potential causefor adverse reactions. Finally, the flow sheets canbe used to document which provider used themodality last to identify whether laser malfunctionor adverse outcome can be attributed to humanerror. This documentation is an essential featureof the well-run medical spa that also helps educatethe staff members. These forms legitimize themedical spa and help to differentiate it fromthe traditional spa, which may not use such strictdocumentation practices (Fig. 5).The creation of a pampering experience and

attention to service is integral to the medical spaexperience. The adage ‘‘the customer is alwaysright’’ should remain in the forefront of the mindsof staff members. Attention to detail is paramount,and employees should be encouraged to takepride in their services. This attitude, although nat-ural in the spa environment, unfortunately is atodds with that of many of today’s health care pro-fessionals who are overworked, underpaid, andoften underappreciated by patients. On otherhand, patients may view these same health careprofessionals as harried, sharp, and lacking incompassion. The medical spa environment caneliminate this dichotomy.The medical spa and traditional spa share

a serene environment. The environment of themedical spa entails both the physical setting andthe patient/client experience. Medical offices canlearn from the operation characteristically usedby traditional spas. Warmth is emphasized withlow-level lighting for common areas, soft musicon overhead speakers, and beautiful artwork.Subdued wall colors rather than the sterile beige-white should be considered. A professional con-sulting firm or spa architect should be consideredwhen developing a medical spa.At the medical spa, clients can obtain compre-

hensive skincare in a single facility that establishesthe connection between beauty and science. Thecredibility of the spa is enhanced, and the thera-peutic benefits of medically formulated agentsare passed on to the clients. This advancedprogram of aesthetic medicine can improve com-munication and relations with aestheticians andalternative medicine providers in the community.

IMPLEMENTING THEMEDICAL SPA CONCEPTBefore implementing the medical spa concept, it isimportant to understand the current trends inthe industry. Understanding these trends willhelp the practitioner tailor services appropriately,thereby meeting the needs of the targeted

Fig. 4. Waxing station.

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population. During the 9-year period between1997 and 2006, the American Society for AestheticPlastic Surgery polled 14,000 practitioners toascertain which of the following procedureswere performed most commonly: collageninjections, hyaluronic fillers, chemical peels,

microdermabrasion, laser hair removal, and botu-linum toxin cosmetic procedures.6 Of these sixmost common nonsurgical cosmetic procedures,cosmetic procedures involving botulinum toxinrepresented more than 40% of the market share.In other words, cosmetic procedures involving

Fig. 5. (A, B) Treatment modality flow sheet. (Courtesy of Juva Skin & Laser Center, New York, NY; with permission.)

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botulinum toxin tallied more than laser hair re-moval and hyaluronic acid fillers combined. There-fore, the clinician would be well advised to providebotulinum toxin cosmetic procedures as a serviceto his patients and to train staff to answer patientinquiries about these procedures and to marketthem readily in the practice.

It also is important to conduct a continued re-view of the trends in themarketplace. The previousdiscussion about botulinum toxin demonstratesthis point. Although the use of botulinum toxin in-creased in the period between 1997 and 2006,the rate of botulinum toxin use actually decreasedby 3% toward the end of the survey, whereas the

Fig. 5. (continued)

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use of hyaluronic acid filler increased by 33%. Apractitioner who did not stay current with the mar-ket trends might have missed an opportunity toserve patients appropriately, and this oversightmight have resulted in decreased profit margins.

One of the risks in implementing the medical spaconcept in a traditional medical practice is thatstaff members from varying backgrounds maynot view treatments the same way. For example,a patient presents to the spa for a facial. At theend of the facial the patient asks the staff memberabout the botulinum toxin brochure displayed inthe waiting area. Inadvertently, the staff membersays, ‘‘Oh I would never want to have a poisoninjected into my face!’’ Similarly, after a surgicalprocedure to remove a skin cancer, a patientinquires about the benefits of a chemical peel forher face. The nurse removing the sutures re-sponds, ‘‘Oh honey, you can get the same effectof a peel with many over-the-counter washes.’’One can understand how these scenarios wouldpose a problem in a medical spa practice.

Employees should be encouraged to observeclinicians perform a variety of procedures, toattend educational seminars, and to read appro-priate current literature. Clinicians should beencouraged to experience massages, to observefacials, and to listen in during make-upconsultations.

Clearly, as the practice transitions to the medi-cal spa, it is important to educate the staff aboutthe qualities of the new services available. Oneshould develop a standard operating proceduralmanual and make sure everyone reads it. A train-ing program for the staff should stress the consis-tency of services. One should create a proceduremanual and administer written and hands-on test-ing to ensure a high quality of service. Althoughmore staff may be better, it also is important toweed out underperforming members. The derma-tologist should test the services of the staffmembers personally and should employ secretshoppers to suggest improvements.

Secret shoppers or mystery shoppers are indi-viduals such as friends or family members thatthe dermatologist selects to visit the practice.While visiting the medical spa, the secret shopperevaluates every aspect of the staff and servicesfrom the moment the shopper makes the appoint-ment until he or she departs after the service. Theshopper comments on factors such as the staff’sprofessionalism and knowledge about products.The information collected by the secret shopperthen can be used to address any deficits oreducational holes that need improving. Patientquestionnaires also can be used to assess clientsatisfaction with services rendered in the medical

spa. Using regular patient questionnaires andsecret shopper reports can help maintain the qual-ity of services. Policies should be in place to keepservices consistent so that, when patients orclients have questions, the responses can beuniform and well informed. The importance ofinvesting in staff training and development cannotbe overemphasized.

Although training and testing staff members iscrucial, it is also extremely important to showthem appreciation. A holiday party or an occa-sional lunch or dinner is a simple way to rewardthe support team for work well done. One shouldmeasure patient and employee satisfaction levelsand also strive to increase one’s own productivity.

The learning curve of transitioning to a medicalspa may be steep and somewhat laborious forboth the dermatologist and the staff, but the endresult of proper education is a happier and moreteam-oriented group. When making the movefrom a medical office to a medical spa, everyoneshould convey a positive attitude about the transi-tion, especially when informing patients of theavailability of new treatments. One way to encour-age this attitude is to place mirrors at all receptionstations. This way, the receptionist may observehis or her reflection and be reminded to use sup-portive body language and to smile. These adjust-ments in body language and expression can beperceived over the telephone as well as in theoffice.

MARKETING THE PRACTICEMarketing is an important way to inform patientsand the public about the new services a medicalspa provides. One should plan to allocate about2% to 5% of revenues as a marketing budget topromote the medical spa. A reputable public rela-tions firm can identify the appropriate media toreach the targeted demographic group based onage, socioeconomic description, geographic loca-tion, and other factors.

Branding is the first step inmarketing a business.Branding is a concept that may be foreign to manyphysicians, but branding has been shown to im-prove recognition of services and products. Forexample, in 1999, Aflac was a zero-profile com-pany selling supplemental health insurance in theworkplace. A television advertisement in 2000showed two people sitting on a park bench tryingto remember the insurer’s name. A duck remindsthem over and over again by quacking the name‘‘Aflac’’ in the voice of comedian Gilbert Gottfried.After the introduction of the advertisement, thecompany enjoyed 90% brand awareness, a rateunheard of in its market.7 Just as branding was

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used in the television commercial, branding canhelp the new medical spa create visibility and rec-ognition. Most importantly, it conveys the positiveexperience a patient or client can expect at thespa. Branding of a medical spa starts with thecreation of a logo, which should be simple butmemorable. The logo helps personalize the prod-uct line as well as all aspects of the spa. Thelogo should be put on everything and everywhere:printed material, robes, cups, pens, and otheritems used in the facility (Fig. 6).Other important marketing concepts include

comprehensive brochures, monthly lectures,a quarterly newsletter, discounts for bringing orreferring a friend, and gift certificates. A custom-ized brochure should describe the services avail-able, office policies, and physician profiles(Fig. 7). The design should be updatable easily toinclude the latest procedures.Monthly lectures are a great way to bring new

patients into the center. At Juva Skin & Laser Cen-ter, the waiting area is equipped with a projectionscreen that drops from the ceiling for presenta-tions and visual aids. The lecture series serveseveral functions. (1) They get people in the doorand introduce them to the clinic and spa. (2)They inform and educate the public about theservices offered. (3) They allow the creation ofa database containing the contact information ofprospective clients.Perhaps the most powerful referral source for

a center is the happy, satisfied patient. Happy pa-tients also are the least expensive way to promoteservices. A recent article suggests ways to useone’s current client base.8 An excerpt from thisarticle begins: ‘‘Mrs. Jones, thank you for yourkind words. You know I’d like to have more peoplejust like you. Would you tell some of your friendsabout us?’’ The article continues by advising one

to reward Mrs. Jones for the referral by sendinga note of gratitude with a gift card toward some-thing she has been buying or a procedure shewants to have done (Fig. 8). Capitalizing on theseencounters or ‘‘bring-a-friend’’ discounts areeasy ways to cultivate the existing client base.A quarterly newsletter is a very cost-effective

form of advertising, and suppliers’ advertisementscan reduce the cost of printing and postage(Fig. 9). These newsletters can be sent or emailedto current clients or to prospective clients whocame to a monthly lecture. One exposure usuallyis not enough. Most people forget what theyread, and they also may be slow to move. Peoplemay need up to five or six contacts before theydecide to come in for a procedure. Other market-ing strategies include a complimentary productat the initial visit.

MANAGING THEMEDICAL SPARevenues from a medical spa can realize a profitmargin of 20% to 30%, which can be twice thatof a traditional spa. This kind of profit margin canbe achieved only with good management, how-ever. Good management is the key to success.One should hold regular meetings with the staffand keep minutes of the proceedings. It is ex-tremely important to review the minutes from theprevious meeting to make sure that new policiesand procedures have been implemented. Oneshould be explicit in delegating tasks and shouldbe sure to state the obvious. What may seemobvious to the director may need to be explainedto members of the staff.Regular business reports should be assembled

to show important financial parameters of themedical spa. These reports include revenuesfrom procedures (broken down by providers), rev-enues from products, overhead expenses, payrollcosts, and staff productivity. Product sales shouldprovide approximately 30% to 40% of revenues,with the balance coming from services.Benchmarking is another important practice

that should become a routine part of the business.What is benchmarking? Benchmarking is processused to ascertain the best practices that will leadto superior performance. By benchmarking onecan measure the performance of the methods,procedures, products, and services of a practiceagainst those of other practices that consistentlydistinguish themselves in the same measurementareas. Statistical comparisons include charges,revenues, expenses, and gross/net collectionpercentages. For example, most practices spenda certain percentage of their revenue on staff. Ifa practice is spending 30% of revenue on staffFig. 6. Branding: JUVA mug and robe.

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salaries and benefits, and the industry standardspends 15% (half the amount), the leader of themedical spa should strive to achieve this targetand make adjustments where necessary to ensurethe greatest profitability. One should benchmarkthe finances of the practice frequently and makepractice planning a routine.

One should watch the business trends carefullyand investigate numbers that do not make sense.For example, several years ago at Juva Skin &Laser Center, the number of patient/client visitswas increasing, but income was dropping. What

could have been the reason for this? After severalweeks’ investigation, it was realized that the staffmember responsible for appointment schedulingwas scheduling extra time for new patients andprocedures, padding the schedule so that the staffmember could to leave the office earlier. This staffmember was terminated. A meeting with the restof the staff alerted them that such practices wereconsidered as sabotaging the medical spa andwould not be tolerated. To achieve optimal perfor-mance, it is important to have good informationto make good business decisions. One must

Fig. 7. Customized brochure. (Courtesy of Juva Skin & Laser Center, New York, NY; with permission.)

Fig. 8. Juva MediSpa gift certificate.

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surround oneself with people one can trust, butone also should verify changes personally.Although the example given previously could be

explained as an innocent mistake in which the staffmember did not realize how her actions mightaffect the bottom line, other more disheartening

examples of staff theft, dishonesty, and even as-sault have been reported. To enhance the safetyand security of the medical spa (for the director,for staff, and for patients), many offices use secu-rity cameras. These cameras, installed in publicareas and not in patient rooms, are a valuable

Fig. 9. Sample newsletter. (Courtesy of Juva Skin & Laser Center, New York, NY; with permission.)

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investment. They can be installed so that the areascan be viewed online even when one is not physi-cally in the office. Employees are notified of thecamera’s presence, and this knowledge helpsdiminish dramatically the impulse to take productsfrom the office. The film also serves as a possiblerecord of any criminal offenses.

As noted earlier, it is important to attract goodstaff and to train them properly. How does onedo this? Before hiring a staff member, it is crucialto have an established training program. Onemust create a training manual that details jobdescriptions. The practice manual should stressconsistency of services and responses to variousclinical and nonclinical scenarios. One shouldinvest the resources in retraining current staff andencourage the pursuit of continuing medical edu-cation credits. One should establish patient ques-tionnaires to evaluate staff performance. Oncethese building blocks are in place, one shoulduse various recruitment methods, including wordofmouth and advertisements in newspapers, med-ical journals, and perhaps on radio and television.

When an applicant is invited to visit the practice,one should make sure to include staff members(eg, the office manager, the head nurse, the patientcare coordinator, front desk manager, and evencompeting assistants) in the interviewing process.Doing so helps ascertain the ‘‘best fit’’ for the prac-tice. Also, during the interview, the intervieweeshould be asked to perform tasks relevant to thejob description. Even though applicants maydeclare they have proficiency in various programs,they sometimes exaggerate their skills. Oneshould ask the applicant to demonstrate his orher knowledge during the interview by workingwith the practice’s programs. Another method ofassessing a suitable applicant is role-playing.One can provide various scenarios and evaluatethe applicant’s responses. Factors predictive ofgood development include energy, potential, moti-vation, loyalty, and intelligence.

This discussion underscores several importantpoints. It is important (1) to investigate when busi-ness numbers do not make sense, (2) to hire theright staff and invest in staff training, and (3) toweed out the underperforming staff. Also, andperhaps most importantly, one must recognizeand embrace the role of the leader in the practice.

DISPENSING SKINCARE PRODUCTSThere are several advantages to dispensing cos-meceuticals from the medical spa. Kligman9

coined the term ‘‘cosmeutical’’ to indicate a topicalpreparation that is sold as a cosmetic buthas performance characteristics that suggest

a pharmaceutical action. This group of agentsis difficult to categorize because of the well-established practice of media hype and becausethe publication of the preparations’ true pharma-cologic actions would require reclassification ofthese agents as drugs. These factors make it diffi-cult to distinguish fact from fiction. Despite thesedifficulties, in the first half of 2002 the sales of cos-meceuticals increased by 83% while overall salesfor skincare products increased by only 1%.10

Rokhsar10 summarized the agents that show themost promise. These include vitamin C, alpha-hydroxy acids, retinoids, and growth factors. Vita-min C improves skin texture and pigmentation byacting as an antioxidant. Vitamin C is a knowncofactor in collagen synthesis and has beenshown to stimulate new collagen production. Al-pha-hydroxy acids improve dyspigmentation andfine rhytids by accelerating exfoliation, resultingin increased epidermal turnover. Growth factorsregulate fibroblasts and other mechanismsinvolved with wound healing. The end result isimproved pigment, texture, and rhytids.10

Retinoids have been shown to be the most effi-cacious of these products. Retinol is the maindietary source, transport, and storage form ofvitamin A and is found in many over-the-counterproducts. It is marketed as an anti-aging agent.In the body, retinol is converted to the biologicallyactive form, all-trans retinoic acid (tretinoin).

Several studies have confirmed the efficacy oftretinoin in improving fine lines, mottled pigmenta-tion, roughness, and laxity. Although retinol is20-fold less effective than tretinoin, and the cuta-neous concentration of tretinoin is 1000-fold lessin topically applied retinol than in topically appliedtretinoin, recent studies have shown efficacy.11

One study of 24 patients using 0.15%, 0.3%, and0.6% concentrations over a period of 6 monthsshowed histologic and clinical epidermal improve-ment in all patients using the two higher concen-trations and in 40% of those using 0.15%retinol.12 Incorporating the use of products thathave higher concentrations of retinol into the prac-tice is something to consider. The use of someform of retinoid should be a mainstay of treatmentin most patients’ skin care regimen.

In making other products available to patients,one should consider the following parameters:

1. Choose noncomedogenic formulations, espe-cially for products that will be used on theface and neck

2. Make sure products are fragrance free to avoidpossible allergic contact reactions.

3. For patients who have sensitive skin, the prod-ucts should be hypoallergenic.

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4. The ideal product should be pleasing to thepatient when applied. In other words it shouldnot feel greasy or leave a residue or film. Theproduct should be ‘‘cosmetically elegant.’’

One rationale for and advantage of dispensingproducts in the medical spa is obtaining knowl-edge about and control over the products patientsare using on their skin. In the authors’ experience,patients present to the clinic after using numerousover-the-counter or Internet-purchased products;usually these patients are using toomany products(often incorrectly) that have no proven efficacyafter spending tens, hundreds, and sometimesthousands of dollars. By dispensing productsfrom a line that one has chosen personally, onecan provide the patient with efficacious, reliableproducts that are customized to meet the patient’sspecific needs. Patients who obtain products fromthe medical spa will avoid confusion from the useof other products and will obtain more compre-hensive care. Convenient one-stop shopping,minimizing irritant or contact dermatitis, andreducing issues of noncompliance are addedadvantages. Finally, repeat sales at the officeand Web site improve profit margins.As mentioned earlier, it is important to brand the

products. When branding the office pens, paper-work and brochures, one should consider brand-ing some or all of the topical agents. Brandingthese products adds to the medical spa’s exclu-sivity and visibility. Existing private-label linescan be used, or product formulations can bedeveloped with a cosmetic chemist. To keep theproduct line simple, one can organize it by skintype (eg, aging skin, sensitive skin, and oily skin).Products also can be organized by ingredients.With this method, one can provide comprehensivecategories such as cleansers, sunscreens, mois-turizers, eye creams, and body lotions. Key ingre-dients may include glycolic acid, antioxidants,botanicals, and alpha-lipoic acid. The productsshould be exclusive and difficult to find elsewhere.The packaging of the products is important.

Packaging provides 60% to 70% of productappeal and should be nicely styled but not flashy.The products should be presented in one location,in a highly visible area. The shelves should beopen, and testers should be available so cus-tomers can try the products. A staff person shouldbe nearby to monitor and answer questions. Allstaff, including physicians, aestheticians, nurses,and front-desk staff, should be educated abouteach product. Financial incentives may be givento all staff for selling products. One should testthe staff’s knowledge about the products andundertake a periodic analysis of sales by staff.

Some physicians may feel uncomfortableabout selling products from their practice. Sev-eral articles detail the various opinions, pro andcon, surrounding the ethical issues of physi-cian-office dispensing.13–16 Those who opposephysician dispensing claim the selling of nonpre-scription products in the office is driven solely bythe profit motive and creates an inherent conflictof interest. Proponents of physician dispensingdiscuss the convenience for the patient, im-proved compliance, and physician expertise.Although the decision to dispense is a personalone, Gormley14 suggests eight facets of ethicaldispensing:

1. The product must confer a true benefit.2. Risks, benefits, advantages, and disadvan-

tages should be discussed.3. The product must be sold at a fair price.4. There must be no misrepresentation of the

product.5. No pressure tactics should be used.6. Patients must not be encouraged to discard

existing stocks of similar products.7. Products should be sold with a replacement

guarantee.8. In the unlikely event of an adverse effect, man-

agement for the problem must be provided freeof charge.

One also should analyze the economics for thepatient and the profit for the medical spa whileavoiding pressuring the patient to buy the medicalspa’s product rather than other retail products. Toachieve this goal, the products should be pricedbelow comparable retail products. This pricingshould ameliorate the ethical dilemma of dispens-ing skincare products. In addition, one canimprove customer service and patient satisfactionby providing full refunds if a client is not completelyhappy with the product.

HEALTH ANDWELLNESS SERVICESIn addition to cosmeceuticals, several otherservices should be considered for inclusion in themedical spa. Health and wellness services area natural extension. Associating with other healthcare professionals such as nutritionists, physicaltherapists, acupuncturists, psychotherapists, andothers can provide an edge over the competition.Canyon Ranch has used this multitiered approachsuccessfully. For example, working with a regis-tered dietician who can advise clients about therelationships among food and health, fitness, andweight loss may help a liposuction patient fine-tune her posttreatment goals. Employing body

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therapists who offer massage, herbal wraps, andwater treatments will underscore the importanceof the pampering environment.

The presence of a holistic physician with anorientation toward disease prevention and main-tenance of a healthy lifestyle will add to themedical spa’s cachet. This provider can be aninternist or a general or family practitioner. Oneshould select colleagues who are excellent com-municators and who value prevention anda healthy lifestyle. Patients can be referred toan acupuncturist for pain management or to a chi-ropractor for musculoskeletal issues. Patientsseeking anti-aging treatments can meet witha psychotherapist for stress reduction or smokingcessation. Those interested in liposuction or cel-lulite treatment can consult a personal trainer foran exercise regimen. A consulting relationshipwith a cardiologist for stress testing and othernoninvasive studies can complement the medicaland spa services.

INNOVATION AND CUTTING EDGEThe medical spa concept is new and exciting.Patients, clients, and physicians have recognizedthe desire for effective and convenient aesthetic-based services, and the emergence of themedical spa meets this desire. Providing theappropriate spa services and creating a pamper-ing care environment is adds value for a dermatol-ogy practice. When incorporating medical spaservices into the practice, the dermatologistshould remember that he or she is the leader,and the entire team must support the transition.One must demand consistency of services fromthe staff and promote continuing education andtraining. Assertive marketing, branding, and man-aging of the medical spa are crucial componentsof long-term success. Diligent management withrapid response to changes in the marketplaceand continued innovation will ensure the successof the medical spa.

REFERENCES1. DeVierville JP. Spa industry, culture and evolution:

time, temperature, touch and truth. Massage &

Bodywork 2003;18(4):20–31.

2. Frost G. The spa as a model of an optimal healing

environment. J Altern Complement Med 2004;

10(Suppl 1):85–92.

3. Frosh WA. ‘‘Taking the waters’’—springs, wells, and

spas. FASEB J 2007;21:1948–50.

4. Routh HB, Bhowmik RK, Parish LC, et al. Balneology,

mineral water, and spas in historical perspective.

Clin Dermatol 1996;14:551–4.

5. International Spa Association web site. Available

at: http://www.experienceispa.com/ISPA/. Accessed

October 2007.

6. American Society for Aesthetic Plastic Surgery sur-

vey. Availabe at: http://www.surgery.org/download/

2005stats.pdf. Accessed October 2007.

7. Lauer C. Branding lesson. Mod Healthc 2006;

36(29):26.

8. Fairfield JC. Refined marketing. Advance for Healthy

Aging 2007;3(3):27–9.

9. Elsner P, Maibach H, editors. Cosmeceuticals and

active cosmetics. Boca Raton (FL): Taylor & Francis

Group; 2005.

10. Rokhsar KC, Lee S, Fitzpatrick R. Review of photore-

juvination: devices, cosemeceuticals or both?

Dermatol Surg 2005;31:1166–78.

11. Kockaert M, NeumannM. Systemic and topical drugs

for aging skin. J Drugs Dermatol 2003;2:435–41.

12. Kligman CH, Gans EH. Re-emergence of topical reti-

nol indermatology. JDermatologTreat 2000;11:47–52.

13. Miller R. Dermatologists should guard their patients’

purse, not pick their pockets! Arch Dermatol 1999;

135:255–6.

14. Gormley D. There is nothing wrong with dermatolo-

gists selling products to patients! Arch Dermatol

1999;135:765–6.

15. Goldbar J. Point: dermatologists should promote

treatment products. J Cutan Med Surg 1999;3(3):

145–6.

16. Gratton D. Counterpoint: the things you do for

money? J Cutan Med Surg 1999;3(3):146–7.

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