When a Texas woman died in the summer after receiving an infusion at a “medspa,” an investigation followed. The doctor on record as supervising the person who gave the infusion had his license suspended by the Texas Board of Medicine.
The death is an example of a growing trend: Less-qualified medical personnel doing cosmetic treatments under the often-lax supervision of a physician, sometimes with terrible consequences.
In the Texas case, Jenifer Cleveland, 47, of Fairfield, Texas, went to the Luxe Med Spa in Wortham, Texas, and received an infusion, according to the Texas Medical Board order describing the case. She became unresponsive and died at a nearby hospital on July 10. The doctor whose license was suspended on Oct. 13 was Dr. Michael Patrick Gallagher, an anesthesiologist from Frisco, Texas.
“The Board panel found that Dr. Gallagher failed to properly supervise an unlicensed individual performing intravenous (IV) treatments, including administering prescription pharmaceutical solutions, resulting in complications that staff were not trained or prepared to manage, resulting in a patient’s death,” the Texas Medical Board press release about the suspension notice said.
Cleveland received an IV infusion with “Vit. B complex, ascorbic acid, cyanocobalamin (Vitamin B12) and TPN [total parenteral nutrition] electrolytes. TPN electrolyte solution requires a prescription and is known to cause complications due to the potassium chloride in it,” the fuller order of suspension said. Luxe’s owner was Amber Johnson, “an unlicensed individual performing intravenous (IV) treatments” which resulted in Cleveland’s death, the order said. The fuller order of suspension said Gallagher was at the medspa three times: When it opened May 6, 2023, then again on June 10, 2023, and then the day that Cleveland died, July 10.
“Respondent’s actions in improperly allowing … Amber Johnson to administer prescription drugs to the Patient without the establishment of a physician-patient relationship with the Patient present a continuing threat to the public health, safety and welfare of Texas citizens,” the order said.
Gallagher was accused of failing to practice medicine in an acceptable professional manner consistent with public health and welfare; failure to treat a patient according to the generally accepted standard of care; negligence in medical services; failure to use diligence in practice; failure to safeguard against potential complications; failure to disclose reasonably foreseeable side effects; and failure to disclose reasonable alternative treatments. His license to practice was temporarily suspended, pending a fuller hearing.
While the autopsy did not list a conclusive cause of death, the medical examiner found Cleveland died of a sudden cardiac event for which the “administration of intravenous therapy cannot be definitely ruled-in or ruled-out as contributory at this time.”
Continuing investigation
An investigation into Amber Johnson, the person who performed the infusion, is continuing, said Dr. Mary Kelly Green, an ophthalmologist in Marble Falls, Texas, who is a founder of Texas 400, an organization “promoting transparency and safety for patients in Texas.” (The Luxe Med Spa website Johnson practiced at is no longer online.)
Green said in a Zoom interview that TPN is not routinely used in a medspa or drip bar, but rather for someone who cannot use their gastrointestinal tract for some reason.
She said the order against Gallagher was unusual for the speed with which it was done. She said the board added a letter to all physicians using this business model, saying essentially “we are watching you.” She said the letter was very unusual.
To be sure, an M.D. or a D.O. often supervises a less-qualified person — say a licensed nurse practitioner or a physician’s assistant in a family practice — who is doing tasks in the doctor’s office that can be delegated to someone with lesser qualifications. But in this case, an apparently unlicensed person performed a high-level medical procedure in a “medspa” under apparently lax supervision, and the patient died.
Is this practice of lightly supervised people doing medical procedures in a “medspa” common in Texas? Green’s colleague, Dr. Alina Sholar, an Austin plastic surgeon who is also a Texas 400 member, said it’s more common than you would think. With the help of an intern, she said, they created a database for internal use of similar cases, which now has almost 500 Texas medspas that may lack adequate supervision, as reported by other physicians. “And this is just the tip of the iceberg,” Sholar said.
Physician ownership required
“Most of these procedures are done outside of the physician office at these medspas, rather than an in legitimate physician-owned facility,” said Sholar, who practices at SkinScienceSoul. “Most of these places are not owned by physicians, despite the fact that with very few and limited exceptions, medical facilities must be owned by physicians in the state of Texas. That’s another piece of the larger problem — people just opening a business and saying, ‘Hey, it’s a medspa, and I’m going to go and literally rent out the license of a physician.’ Some companies in the state actually provide a database of physicians who are willing to rent out their licenses.”
Many of these medspas are not in compliance with the Texas administrative code’s stipulations in Rule 193.17 on “Nonsurgical Medical Cosmetic Procedures,” she said. Requirements include writing policies on how to avoid complications, and what to do in the event of an adverse event, and various similar protocols. In many medspas, she said, that is not happening.
The rule says, in part: “The purpose of this section is to establish the duties and responsibilities of a physician who performs or who delegates the performance of a nonsurgical medical cosmetic procedure (hereafter referred to as ‘Procedure’). These procedures can result in complications and the performance of these procedures is the practice of medicine. This rule shall not be interpreted to allow individuals to perform procedures without either a physician or midlevel practitioner being onsite, or a physician being available for emergency consultation or appointment in the event of an adverse outcome.”
Sholar said: “People just kind of run amok in the name of having a business, and the unsuspecting public doesn’t know that there’s no doctor around and nobody’s watching what’s going on. They feel like they’re safe, because they don’t know the difference.”
“When you look nationwide at studies, we see that the complication rates of medspas versus physician offices that are doing the same procedure are vastly different.” For example, a study showed 71 percent of laser skin surgery lawsuits involve non-physicians, she said.
Skirting the law
Physicians are skirting the laws to let others practice under their licenses, Sholar added.
“The statutory code allows physicians the ability to delegate to anybody, however, the physician has some responsibilities with that delegation,” she said. “They themselves have to have been trained adequately. But what is adequate? Well, I’m a plastic surgeon, therefore my training is very adequate for aesthetics. But does a family practitioner have adequate training for aesthetics? Obviously not. But they do these weekend courses, and they call themselves credentialed.
“Texas does not want to restrict what physicians do. Let’s say, we have a physician who’s retiring and wants to kind of pivot their practice, we want to give them the leeway to do it. So you don’t want to restrict what the physicians are doing. But the physicians have the responsibility to ensure that they are trained properly, and that who they’re delegating to is trained properly. Therein lies the problem as well — a nurse practitioner or a [physician assistant] or a nurse or a lay person is not going to be trained the way a plastic surgeon is trained. So it’s up to the physician to determine if that if that person is able to perform that procedure safely or not, under their guidance.
“Texas has has rules in place. Some people would say that that because Texas gives the ability to the physicians to determine who’s qualified, that that may be a little too lenient. But we’re kind of an independent-minded state. And we think that people can make good judgments. Most of them do, but some of them don’t. And that’s where we need to work, especially on the enforcement side.”
Green pointed out that she and other M.D.’s learn new procedures frequently — though they are building often on a basis, for instance, in her case, of eye medicine. “But PA’s and NP’s can switch specialties on a dime,” she said. “We have to go back and do a residency to switch. So the question of adequate training comes up a lot.”
“I guarantee that most of these physicians are supervising in name only” she said of the medspas — whereas she, in supervising someone in her ophthalmology practice, is following stricter rules.
Seeking transparency
The Texas 400 and Texas Physicians for Patients, its political action committee, say on their site: “Our mission is to ensure that all Texans are able to see a physician (MD/DO) when they have a medical problem. We seek transparency for all practices so that patients will know whether they are being seen by a NPP (non-physician provider) or an actual physician (MD/DO) and will have the right to choose physician-led care.”
The groups are lobbying in the Texas Legislature to pass legislation, doing media outreach and conducting legislative bootcamps to train doctors to further their goals in the legislature.
Gallagher, the doctor in the Luxe Med Spa case, was also involved in a lawsuit in 2021 related to a death of Kimberly Ray of Arlington, Texas, at a Coppell, Texas, wellness center, according to a local news report from KCEN-TV.
“Though Cleveland’s case is not directly connected to this 2021 lawsuit, Gallagher was the Chief of Anesthesiology at Integrity Wellness Center, 920 S. Belt Line Rd. in Coppell, Texas, according to Attorney Michael G. Sawicki, who is representing the family of … Kimberly Ray,” the TV station reported. “According to the lawsuit, Ray from Arlington, Texas, died following a routine rhizotomy procedure at Integrity Wellness Center on April 19, 2023 that was performed by certified registered nurse anesthetist (CRNA) Joseph Scott Houghton, who misrepresented his qualifications to Ray.”
Gallagher was terminated from his position after the death, the report said. In January, he “provided his deposition to Sawicki for the lawsuit. In it, he admits that he is not a board certified anesthesiologist, despite being the Chief of Anesthesiology for the wellness center. He continued to say he wasn’t present at Integrity Wellness Center the day Ray died and that he never reviewed her records of care or spoke to EMS about her care.”
Supervision and licensing
The Luxe Med Spa case was discussed extensively on Reddit, on the r/Noctor subreddit, for “Not a Real Doctor.” The subreddit is described as “as a repository of sources and a place of discussion regarding INDEPENDENT midlevel practice. It is designed to highlight the differences between a medical doctor and midlevels in areas including training, research, outcomes, and lobbying. ‘Noctor’ refers to midlevels (NP, PA, CRNA, CNM, etc.) who pretend to be doctors. This is not a sub for discussing nurses acting in a nursing role.”
Rules for supervision of aesthetic procedures or of non-aesthetic procedures vary greatly from state to state and situation to situation.
In Texas, Sholar said, there are statutory and administrative codes regarding this. “There’s the general delegation rules regarding physicians with N.P.’s and P.A.’s, and then there’s also very specific rules for medspas,” she said.
An ongoing debate in medicine has the M.D. and D.O. community sometimes pointing out that less-qualified practitioners are not as well-trained and skilled as a full doctor, and that they make mistakes. In response, nurse practitioners and physician assistants say that doctors are trying to protect their income, and that lesser-qualified medical personnel are by and large professional and responsible. Research and argument is rallied on both sides. Specialty-specific graphics documenting the amount of training for M.D.’s and midlevels are collected and disseminated. Meanwhile, a shortage of doctor appointments nationwide shows no sign of abating, which drives more demand for midlevel practice.
Statute vs. enforcement
Back to medspas specifically: Both Green and Sholar agreed that the statutes are one thing, and enforcement is another. The Texas Medical Board does not have hundreds of investigators and enforcers on staff; rather, the procedure relies on reports coming to the T.M.B., they said, and a lot goes unreported.
Doctors are required to report possible wrongdoing whenever they see it, Green said.
“I had to deal with the doctor in my town that I, unfortunately, had to report to the medical board, ” she said. “I didn’t know until I went and read the medical board rules that I was actually required to report, if I saw that there was care that wasn’t meeting the standard of care. As a licensed physician in Texas, I’m required. It’s not optional. Those doctors don’t know that either. I didn’t know it until I went and read the rules. And I guarantee you, doctors are not reading Texas admin code 193.17.”
Related: Rules are in place, but they are routinely ignored.
Sholar said: “Some transparency rules are in place. For example, whether it’s an N.P. or P.A., a nurse, layperson, aesthetician, they’re supposed to wear a badge in the medspa that has their name and their title. They’re supposed to have posted in the medspa in the treatment room and in the lobby in a conspicuous place, who the delegating physician is. These rules are already in place, but they’re not happening.”
Green added: “There’s not a giant throng of state employees who can drive around every month looking at medspas.”
Sholar added: “The physicians are the gatekeepers, the physicians are the policemen here. We don’t have enough gatekeepers keep engaged — they’re letting the cows out of the pen. It’s hard to wrangle them back in once they’re out. So that’s that’s what we’ve got to correct here: Getting physicians back on track and and making sure that we’re all doing what we’re supposed to do to keep patients safe.”
Doctors’ roles
I have seen traffic online (on Reddit, for example), with doctors explaining that they have seen a transgression but that they will not report something because they fear damage to their reputation, or they don’t have the evidence to follow through on a case, or … they thought about it and decided not to.
One Redditor wrote of an online video: “Throwaway account. Random plastic surgeon here. This is likely illegal. Awful technique. I can’t file a complaint because of the risk of damage to my practice. you have to give your name, and the online hoard can cause a nightmare for me. Anyone who might be interested in filing a complaint: This is the form: https://pr.mo.gov/boards/nursing/375-0168.pdf“
The topic of midlevels practicing not as an independent but rather under supervision is increasing, too, as hospitals and others seek to cover medical needs. Medical professionals who view this as taking work away from doctors, or expanding the role of midlevel practitioners beyond their skillset, say that the practice is a slippery slope and can lead to unqualified medical professionals doing things they are not trained or licensed to do.
The American Medspa Association, in a blog post, wrote of the Wortham medspa death: “As tragic as this situation is, it can serve as a reminder to other medical spas about the need for proper supervision and delegation when administering medical spa treatments such as IV therapy.”
It then cited another blog post with a roundup of state regulations on IV services, saying: “One of the most important takeaways from these rules and regulations is to remember that just because a provider may be qualified to administer IV services, this by itself does not mean the provider can form and own an IV bar or business performing IV therapy. Each state has its own rules and regulations outlining who may do what and who may own what. Be sure to check your state’s requirements before you start.”
More Texas cosmetic cases
The problem of cosmetic practitioners operating without proper qualification seems to be common in Texas.
A Houston man was arrested and charged with practicing medicine without a license recently after a botched breast surgery at a plastic surgery center, KTRK TV in Houston reported.
The Texas Medical Board listed on its website a series of “cease and desist” orders from Oct. 13, 2023, relating to medspa and cosmetic offices, in a press release detailing disciplinary actions. These press releases are issued monthly, cataloging disciplinary actions related not just to medspa and cosmetic procedures, but also to other medical practitioners.
”Brea, Helena, No License, Frisco — On October 13, 2023, the Board and Helena Brea entered into an Agreed Cease and Desist Order prohibiting her from acting as, or holding herself out to be, a licensed physician in the state of Texas. The Board found Ms. Brea asserted that
she is certified as a ‘Medical Aesthetics Physician, M.A.P.’ and ordered lab tests and treated multiple patients.
“Dimas, Christine, No License, San Antonio — On October 13, 2023, the Board and Christine Dimas entered into an Agreed Cease and Desist Order prohibiting her from acting as, or holding herself out to be, a licensed physician in the state of Texas. The Board found Ms. Dimas treated two patients for injection fillers without she and the medical director meeting rule requirements as detailed in Rule 193.17.
“Forsberg, Dianna M., No License, Dallas — On October 13, 2023, the Board and Dianna M. Forsberg entered into an Agreed Cease and Desist Order prohibiting her from acting as, or holding herself out to be, a licensed physician in the state of Texas. The Board found Ms. Forsberg, on her med spa website, identified herself as ‘Dr.’ where she is also pictured wearing scrubs with ‘Dr.’ followed by her name embroidered on her top. Ms. Forsberg’s website does not include any health professional, such as a physician, physician assistant or nurse practitioner.”
What can you do?
Patients should be sure to check the credentials of any medical practitioner — do they have a license to practice? — with the relevant medical board.
Along with records of licensing, many states have a public record of disciplinary actions from an oversight organization. This is one for Texas; here is one for Nevada.
To complicate matters, a state board of nursing is likely to have a different set of disciplinary actions; here is one for Texas nurses and here is one for Nevada nurses.
These listings may be klunky or hard to navigate. It’s also well-known that most states do not list a mere complaint against a doctor or other practitioner; only completed disciplinary actions are listed in most states.
As basic as it seems, the recommendations of friends and neighbors can be very valuable. Ask around, but don’t take everything you learn at face value.
Check the online presence and web documentation for a provider. If the site looks seedy and is full of misspellings, you might want to move on.
A Google review search or Yelp visit can be informative — though again, don’t take everything at face value. Here’s the Yelp page for MyShape Lipo., a Las Vegas clinic. Notice that Yelp’s average of the reviews can be less informative than reading the actual reviews. In this case, there is also a large number of “not currently recommended” reviews; Yelp doesn’t explain what that means, but it’s sometimes worthwhile to look. Also a large number of reviews were “removed for violating our terms of service.”
A huge number of online reviews are fraudulent. Here’s our story about that.
Check the physical setting; if the building looks seedy and dirty, move on.
If you don’t want to see a physician assistant or a nurse practitioner, say so. For example, your doctor’s office might say “Dr. Smith is booked through the end of the month — but I can get you in with our PA.” You can say no.
