Medical spas, also called medspas, are the newest craze. They combine facials, massages, and seaweed wraps with medical procedures such as microdermabrasion, chemical peels, and even Botox and laser hair and laser spider-vein removal. Some even whiten teeth.There are about fifteen hundred medical spas in the United States, bringing in about $1 billion annually, according to the International Medical Spa Association. These numbers increased threefold from 2004 to 2006. Medical-type treatments now make up over half of spa revenue.Medspas are supposed to be physician supervised. Even though the doctor is meant to be on site full-time, the level of supervision varies widely. Some physicians use their names and medical licenses to allow other personnel—a nurse, an aesthetician, even an unlicensed worker—to perform procedures. The profit motive at medspas is tremendous, not only on the part of the spas, but also for the companies that manufacture their equipment.There have been at least two deaths at medspas. Yes, deaths. In December of 2004, a 22-year-old woman seized after a lidocaine numbing cream was applied to her legs prior to a laser hair-removal appointment at a North Carolina spa. She died the next week. The lidocaine reached toxic levels and poisoned her.The medical director, an ear, nose, and throat doctor, had his license suspended for six months because he did not take a history and perform a physical prior to prescribing the anesthetic.  Apparently, nonmedical personnel at the spa were selling 10-percent lidocaine gel without a prescription. This tragedy is strikingly similar to one that occurred in Arizona in January 2002. A woman suffered a seizure after applying anesthetic cream to her legs and lived in a coma for two years before dying in November 2004.The American Society for Dermatologic Surgery found eight patients in 2001 who had complications from nonphysicians performing cosmetic dermatologic surgery procedures. And that was before the boom in medspas. Imagine how many people have been injured now.When one chooses a physician, the educational background of the doctor is paramount. Procedures such as laser hair removal, microdermabrasion, and chemical peels have well-known side effects that are respected by physicians.Careful examination of the backgrounds of nonphysicians performing these procedures in medspas can reveal some shocking facts. Nurses receive minimal or no formal training in skin care in nursing school. Skin care specialists, specific types of aestheticians (cosmetologists), receive six hundred total hours of training in New Jersey, including training in facials, makeup application, and waxing. Their training is often during high school. Education in skin physiology, biochemistry, and the use of lasers and drugs on the skin is minimal. Why would anyone undergo medical treatment by minimally educated, unsupervised, nonmedical personnel? Because the fees for a nonphysician are a fraction of those for a doctor. But it is better not to have a procedure than to have one that is botched. The cost of treating complications such as scarring, pigment changes, or more serious medical problems, could dwarf the cost of the original procedure.According to David Goldberg, M.D., dermatologist and director of Mount Sinai Medical School’s dermatologic laser research, nurses and physician’s assistants should be able to perform these procedures under the direct supervision of physicians. This means that the doctors are ‘‘on site and immediately available,’’ he says. Problems occur when there is no physician in sight. Dr. Goldberg’s patients indicated in a survey that they would rather be treated by a physician at a higher fee, than by a nonphysician at a lower fee. Another problem occurs, he says, when physicians such as gynecologists, family practitioners, or even dentists take advantage of their licenses and perform procedures they are not properly trained to do.MORE: Watch Out for “Wannabe” Plastic SurgeonsThe Most Dangerous People Are Those Who Don’t Know What They Don’t KnowA California company will now send a physician assistant to your business office to inject Botox or wrinkle fillers! Seemingly minor procedures can result in disastrous complications, and even the lightest peels can result in scarring. Allergic reactions can be immediate and deadly, with no time to call the ‘‘supervising physician’’ at his office across town. Shame on state medical boards that allow unsupervised medical procedures. And shame on physicians whose greed gets in the way of good medical judgment. My advice? Insist on a physician—you deserve no less.