The Doctor is Not In

There are a number of cosmetic procedures, usually noninvasive, that are performed by RNs or nurse practitioners. In the past I have discussed the desirability of having a physician, particularly one well trained in the area of cosmetic surgery, on the premises to supervise the treatments. Recently we have been seeing a problematic variant of the undesirable situation where the patient is treated by an unsupervised nurse. What we have been seeing is a new patient coming to a cosmetic practice and being seen only by the nurse and then treated by her, without the physician ever being involved. It is possible that the physician retrospectively reviewed the patient's chart some time after the patient had departed, but this is far from optimal for patient safety.

This past week we saw a woman who went to an office to have tattoos removed on her feet. She was seen, and then treated only by a nurse. Her treatment was a substandard treatment that will very possibly leave her with visible scars and produced pain and swelling that made it difficult for her to walk for a week. The patient indicated that she expected that she would get the typical type of tattoo treatment described on various web sites. There was no attempt made to explain to her that she was getting something different or that there were other treatment options.
The reason that specialized lasers have become popular for tattoo removal is that these lasers usually leave no scarring. It has always been possible to remove tattoos by cutting them out, with a scalpel or a laser, or to burn out tattoos with heat or chemicals. The unsightly results of these procedures lead to the development of the Q switched lasers that are the treatment of choice for tattoo removal.
Of course it is possible that even if the patient had seen the physician she would have been offered the same treatment, since they may not have had the specialized laser available. This may be an example of the old saying: if all you have is a hammer, everything looks like a nail. It's unfortunate but true that there are no hard and fast rules that will guarantee that you will receive the optimal treatment. You still have to do your homework, but if you are never seen by a physician, no matter what the setting, that is a sign of potential problems.

Gerald N. Bock MD
California Skin & Laser Center
Stockton & Lodi, CA