When Dr. Bruce Katz scanned the list of attendees to the Medical Spa Expo and Conference in Miami last fall, his eyes stopped on one name. A neurosurgeon.

VERNON BRYANT/DMNDr. Sheila Calderon applies a wrinkle-reducing laser to Valerie Rothdeutsch as a tube above blows refrigerated air on her face at Elite Medspa in Frisco. Until recently, Dr. Calderon had been an internist for years in East Dallas.

In the seven years since Dr. Katz has been involved in seminars for aspiring spa doctors, he had tutored his share of obstetricians, family physicians, even dentists.

VERNON BRYANT/DMNDr. David Fein applies Botox at his Rejuve Medspa. 'As our managed-care reimbursement gets cut more and more, people don't understand how tight things have gotten for physicians.' Dr. Fein says the spa helps him maintain his first love of delivering babies and tending to women's health.

"I was floored by that," said Dr. Katz, a New York dermatologist and leader in the medical spa industry. "I never thought I'd have a brain surgeon come to a medical spa meeting."

Offering doctor-supervised cosmetic procedures in pampered surroundings, medical spas are no longer the personal empire of plastic surgeons and dermatologists. The reason? Money. Wrinkles and blemishes can be a lucrative undertaking, bringing payment with the swipe of a credit card. No more waiting on an insurance check.

This influx of so-called "non-core providers" - those outside dermatology and plastic surgery - into medical spas has helped transform them into the fastest growing segment of the spa industry, with the International Spa Association reporting that the number doubled between 2002 and 2004.

"I think that society should be very concerned about this trend," said Dr. Larry Fields, an Ashland, Ky., practitioner who is president of the American Academy of Family Physicians. Since the academy began offering yearly instruction in chemical peels, Botox, and lasers in 2003, the classes have quickly filled each year and gathered waiting lists.

Dr. Fields worries that spas have become a patch for an ailing health care system. As the amount in insurance reimbursement falls, more doctors are floating their practices on Botox. It is not a sideline that some enter enthusiastically.

Dallas obstetrician Dr. David Fein is frank about the motivation behind his move to cosmetic medicine. With a spa on the side, Dr. Fein says he can maintain his first love - delivering babies and tending to women's health. "In 15 minutes, I can generate $800," he said.

"As our managed-care reimbursement gets cut more and more, people don't understand how tight things have gotten for physicians," Dr. Fein said. "I would love to say I'm doing this to pay for my vacation home and drive a Porsche, but I don't own a vacation home and I don't own a Porsche."

"They end up with big houses in Highland Park and big mortgages," he said. "They get into a cycle where they have to have an expensive lifestyle."

Mr. Girards doesn't fault doctors for wanting to make money, as long as it is not at the expense of their patients. As hurriedly trained practitioners take up cosmetic procedures, he says, he gets more calls from people experiencing beauty gone awry. Damage caps make such cases not worth pursuing, he says.

Plastic surgeons and dermatologists themselves say they are skeptical about the training of some of their fellow providers. Even with a medical degree, physicians are not adept at everything.

"You have to know how the human face works," said Dr. Katz, who is president of the Medical Spa Society. The courses his society organizes are an effort to give non-core physicians additional expertise. "You have to understand the art of being a cosmetic physician."

Dallas plastic surgeon Dr. Rod Rohrich, a former president of the American Society of Plastic Surgeons, agrees. "Just because they're a physician doesn't mean they know how to do Botox," he said. "To do these things correctly, it's not easy." He says that he doesn't mind other specialties getting into the cosmetic business, as long as they have the skill.

Not all traditional providers are so welcoming. A Florida law went into effect this summer restricting satellite spa operations to plastic surgeons and dermatologists. "I think it is going to change practice in Florida quite a bit," said Francesca Plendl, director of government affairs for the Florida Medical Association. Any doctor can provide cosmetic procedures in their own offices, but they cannot operate spas unless that is where they primarily see patients.

Dallas' Dr. Fein believes that limiting spas to the oversight of plastic surgeons and dermatologists would not necessarily address patient safety, that the deeper problem is spotty standards in general in the medical spa industry. He himself has taken extra classes in cosmetic procedures. At his Rejuve Medspa, he acknowledges that he does not perform all procedures personally, but voluntarily requires his personnel to undergo training far beyond what's required to be in business. His spa is safer, he contends, than one owned by an absent plastic surgeon who leaves the treatments to inexperienced technicians.

The reality of uneven quality means customers shouldn't judge a spa by its aromatherapy-filled waiting room. Internist Sheila Calderon, owner of Elite Medspa in Frisco, cautions that the enticement of spas has attracted both the careful and the sloppy provider. "It's a mess," she said.

A recent marriage brought Dr. Calderon to Frisco after taking care of a generation of patients with heart disease, diabetes and other standard internist fare in East Dallas. Even before she left her medical practice, she had developed an interest in removing precancerous blotches after her mother and aunt were diagnosed with melanoma. Though she now operates a spa full time, she still considers her work lifesaving; perhaps the blotches she removes could morph into cancer.

Yet in a time when more than 46 million Americans have problems getting basic care because they lack health insurance, some medical ethicists are uneasy with so many doctors eager to cater to the better-than-well.

"It's not clear that Botox and smoother skin with less wrinkles are really about promoting the health and well being of patients," said Dr. David Magnus, director of the Stanford Center for Biomedical Ethics. Doctors' flocking to the spas "says something about medicine that we should be concerned about."

But should doctors even have to explain themselves? Perhaps only because a physician's time says something about all of us, said Jonathan Moreno, director of the Center for Biomedical Ethics at the University of Virginia.

"We have this tension of what we expect doctors to be," Dr. Moreno said. Society generally has a romantic view of physicians as servants of the greater good.

"We agree they should make a decent living, but somehow they should preserve this ideal," Dr. Moreno said. Doctors as blatant entrepreneurs are not being unprofessional, he says, only unbecoming to the archetype.

Still, medical spas would not stay in business if people did not support them. "I think the diagnosis goes to the society," he said. "We get the medical profession we want."

This is cache, read story here