The Medical Director Question
What Every Med Spa Owner Needs to Understand About Proper Physician Oversight and why the physician relationship that enables your business may also be its greatest vulnerability—and how to get it right.
DISCLAIMER: This article is intended for educational and awareness purposes only. It does not constitute legal advice. The information presented here is based on Texas regulations, though every state has similar laws governing medical practice and physician delegation. Med spa owners should consult with qualified healthcare attorneys in their respective states for specific legal guidance.
A Tragedy That Changed Everything
On July 10, 2023, Jenifer Cleveland died after receiving an IV therapy treatment at a medical spa in Wortham, Texas.
According to the Texas Medical Board's subsequent findings, the circumstances surrounding her death reveal a troubling pattern that extends far beyond one unfortunate incident. The medical director for the spa was based 106 miles away in Frisco. He had been on-site at the facility on only three occasions: the grand opening in May, once in June, and then on July 10—the day of the incident. The Board noted that he had failed to implement policies and procedures, there were no protocols or standard operating procedures for IV services, and the only documentation of his relationship with the spa was an unsigned "medical director agreement."
The person who administered the IV treatment that day held no medical or healthcare license. No licensed health professionals were present at the facility.
In October 2023, the Texas Medical Board temporarily suspended the medical director's license, finding that "ordering of prescription medication to be administered by an unlicensed and unqualified delegate without adequate supervision, oversight or protocols presents a continuing threat to public safety."
This case ultimately led to the passage of House Bill 3749—known as "Jenifer's Law"—which Governor Greg Abbott signed on June 20, 2025, establishing new requirements for elective IV therapy in Texas.
But here's what every med spa owner needs to understand: this tragedy didn't happen because the law was unclear. The requirements for physician oversight and proper delegation already existed. The problem was that they weren't being followed.
The Medical Director Relationship: More Than a Signature
Let's be direct about something that many in our industry don't want to discuss openly: there exists a concerning gap between what the law requires of medical directors and what some are actually providing.
As the American Society of Dermatologic Surgery noted in a 2024 statement and noted in a recent Allure article: "Our association has, on an ongoing basis, received a number of reports from our members who have been solicited to act as medical directors in name only in a medical spa or 'med spa' in exchange for a fee."
This "rent-a-license" approach is not just ethically questionable—it creates genuine legal exposure for both the physician and the med spa owner, puts patients at risk, and undermines the credibility of our entire industry.
What the Law Actually Requires
In Texas, and every state has similar statutes, physician delegation of medical acts is governed by clear legal standards. Under Texas Occupations Code Chapter 157, a physician may delegate medical acts to a qualified person only if:
The physician believes the act can be "properly and safely performed" by that person
The act is performed in its customary manner
The act doesn't violate other statutes
The person to whom the act is delegated doesn't represent themselves as authorized to practice medicine
Most importantly: "The delegating physician remains responsible for the medical acts of the person performing the delegated medical acts."
The Standard That Actually Applies
The Texas Medical Board has been increasingly clear about its expectations. In its February 2025 bulletin, TMB President Dr. Sherif Zaafran wrote: "Your medical license is an extremely valuable commodity, and regardless of the business models that pop up, the basic rules that govern your license continue to exist and be enforced."
The Board explicitly noted that it "continues to encounter instances where individuals engaging in [med spa] business models either have no physician involvement or inadequate physician involvement." This statement should communicate to every med spa owner and physician if they are different that there is awareness of these practices at the regulatory level. Like most things, awareness is the first step toward accountability.
What constitutes "adequate" involvement? Texas Administrative Code Rule 169.26 requires that:
The physician must ensure those performing delegated procedures have "appropriate training" and there is a "signed written protocol"
The physician must be "trained or familiar with and able to perform the delegated medical act in accordance with the standard of care"
A physician, PA, or APRN must either be on-site during procedures or "be immediately available for emergency consultation"
The physician must be able to conduct an emergency appointment if necessary
A practitioner-patient relationship must be established before any delegated medical procedures
At least one person trained in basic life support must be present at the facility
These aren't suggestions. They're enforceable requirements.
Five Questions Every Med Spa Owner Should Ask
If you operate a medical spa, IV clinic, wellness clinic or are considering starting one, here are the questions you should be asking about your medical director relationship—honestly:
1. Does Your Medical Director Understand Your Services?
The physician who provides oversight for your practice should have genuine competency in medical aesthetics. Under Texas law, a physician can only delegate procedures they are "trained or familiar with and able to perform... in accordance with the standard of care."
This doesn't mean every medical director must be a board-certified dermatologist or plastic surgeon, though those specialties offer the most relevant training. But it does mean that a physician who has never performed neurotoxin injections, laser procedures, or IV therapy shouldn't be delegating those procedures. It is also important to note that a 4-hour training is likely not enough training to satisfy this requirement. Why do we say this?
Ask yourself: Could your medical director step in and perform the procedures being offered if needed? Can they recognize complications and guide treatment? Do they understand the nuances of facial anatomy, laser physics, or the contraindications for the medications being administered?
2. Has Your Medical Director Evaluated Your Team?
Before delegation can occur, the law requires that the physician ensure those performing procedures have "appropriate training and competency." This isn't satisfied by reviewing résumés or verifying licenses.
True evaluation means understanding each provider's:
Clinical training and experience with specific procedures
Competency performing the procedures they'll be delegated
Understanding of contraindications and complications
Ability to recognize and respond to adverse events
3. Is Your Medical Director Actually Present?
The days of "reachable by phone from 50 miles away" as adequate supervision are ending. Texas's new rules require that a physician, PA, or APRN be "on-site during the procedure or immediately available for emergency consultation" with the ability to "see the patient for an emergency appointment." The question open to further clarification is, What does immediately available mean?
Well, let’s look beyond legal minimums, and consider what genuine medical leadership looks like: A medical director who is regularly on-site can observe procedures, coach providers, identify training needs, and build relationships with both staff and patients. They can catch small problems before they become big ones.
A 2023 study published in Dermatologic Surgery found that more than 80% of med spas reviewed in the greater Chicago area didn't have a physician on-site. While being on-site every minute of the day is not necessary or required (recall “immediately available”), that statistic should concern anyone who cares about the reputation and safety of our industry. Reason being that it is likely that many overseeing physicians have NEVER been on-site.
4. Are Your Protocols Real—and Being Followed?
The law requires written protocols, standing orders, or prescriptive authority agreements that document what can be delegated, to whom, under what circumstances, and with what oversight.
But here's the question: Were these protocols actually developed by your medical director based on their clinical judgment? Or were they downloaded and signed without meaningful review?
Proper protocols should reflect:
The specific procedures offered at your practice
The training and competency requirements of your specific providers
Appropriate patient selection criteria
Clear procedures for handling complications and emergencies
Documentation requirements
5. Is There a Real Relationship—or Just Paperwork?
The prescriptive authority agreement requirements in Texas law include provisions for "periodic meetings" that must include "the sharing of information relating to patient treatment and care" and "discussion of patient care improvement."
These meetings must be "documented" and occur "at least once a month."
This isn't bureaucratic box-checking. It's the mechanism by which genuine medical oversight actually happens. If your medical director hasn't met with your providers this month, you're not just out of compliance, you're missing the entire point. Additionally, how do you or your medical director expect to defend yourselves God forbid something happen?
The Consequences of Getting This Wrong
The consequences of inadequate medical director oversight aren't theoretical. They're real and they're serious.
For Physicians
Medical directors who fail to provide proper oversight face disciplinary action from the Texas Medical Board, which can include:
Temporary or permanent license suspension
Public reprimand
Restrictions on practice (including prohibition from supervising or delegating)
Administrative penalties and fines
Requirement for additional training or monitoring
Dr. Michael Gallagher, the medical director in the Jenifer Cleveland case, had his license temporarily suspended in October 2023. While it was later modified to allow him to practice anesthesiology, he remains restricted from supervising or delegating to others in all circumstances—effectively ending his ability to serve as a medical director.
For Med Spa Owners
If your practice is operating without proper physician oversight, you may be engaged in the unlicensed practice of medicine, which is a serious criminal violation.
Beyond criminal exposure, inadequate oversight creates massive civil liability. When something goes wrong, plaintiffs' attorneys will examine whether proper protocols existed, whether the medical director was actually involved, and whether the delegation was appropriate.
"Med spas are really good about consent," one dermatologist noted in the recent Allure article. Their consent forms may be detailed. But consent doesn't protect against claims that arise from practicing medicine without proper authorization or supervision. Such behavior may constitute negligence.
For the Industry
Every high-profile incident damages our entire industry. The Allure article titled "Med Spa Nation," published in November 2025, detailed consumer concerns about safety and oversight—concerns that affect every practice, even those operating properly.
The med spa industry has an extraordinary opportunity to provide valuable services that help people feel better about themselves. But that opportunity depends on maintaining trust—and trust requires genuine commitment to patient safety.
What Good Looks Like: Best Practices for Medical Director Relationships
Moving beyond compliance to genuine best practices, here's what a proper medical director relationship should include:
Active Clinical Leadership
Your medical director should be a clinical leader, not just a signature on a document. This means:
Regular on-site presence—not just minimum requirements, but genuine involvement
Direct interaction with providers and, when appropriate, with patients
Leadership in developing and refining clinical protocols
Participation in case reviews and quality improvement
Availability for questions and consultation
Rigorous Provider Evaluation
Before any delegation:
Verify credentials and training thoroughly
Observe the provider performing procedures
Assess clinical judgment and complication recognition
Document the evaluation and establish competency thresholds
Comprehensive Protocols
Develop protocols that are:
Specific to your practice and your providers
Based on current clinical evidence
Clear about patient selection and contraindications
Explicit about documentation requirements
Reviewed and updated at least annually
Clear Communication Channels
Establish:
24/7 availability for emergencies (this is required, not optional)
Regular scheduled meetings (monthly at minimum)
Clear escalation protocols for concerns
Documentation of all communications
Transparency
Be open about your medical director relationship with:
Staff (who should know how to reach the medical director)
Patients (required by Texas law)
Regulators (be prepared for audits)
A Different Way Forward
The med spa industry is at an inflection point. We can continue down the path that leads to tragedies like Jenifer Cleveland's death, increasing regulation, and erosion of public trust. Or we can embrace a different approach—one where proper physician oversight isn't viewed as a burden to be minimized but as a genuine commitment to patient safety.
For med spa owners, this means:
Choose medical directors based on competency, not convenience. A physician who understands aesthetics, who will be genuinely involved, who will hold your practice to high standards—this is worth paying for.
Build real relationships, not paper ones. The monthly meetings, the chart reviews, the ongoing communication—these aren't just legal requirements. They're what makes a medical practice genuinely safe.
Invest in your team. Proper training, clear protocols, ongoing education—these cost money. But they're far less expensive than a lawsuit, a license suspension, or a tragedy.
Operate in the light. If there are aspects of your medical director relationship that you wouldn't want a regulator, or a journalist for that matter, to examine closely, that's a sign that something needs to change. Be a leader. Be the lamp on the stand and let your leadership light shine among your peers and the industry.
The Bottom Line
A medical spa is, fundamentally, a medical practice. The procedures offered—neurotoxin injections, dermal fillers, laser treatments, IV therapy—carry real risks. They require real medical oversight. This becomes more and more the case as we see med spas offering peptides and hormone replacement therapy.
The law has always required proper physician involvement. The difference now is that regulators are paying attention, enforcement is increasing, and the public is becoming more aware of the gap between how some med spas operate and how they should operate.
For med spa owners who are doing this right, those who have genuine medical director relationships with qualified physicians who are actively involved, this is an opportunity. You can differentiate yourself in an industry where many competitors are cutting corners. There are many benefits to behaving in a fully compliant manner:
Legal & Risk Protection:
Reduced malpractice liability exposure
Protection from TMB/state board enforcement actions
Lower likelihood of criminal prosecution for unlicensed practice of medicine
Potentially better insurance rates and coverage availability (some carriers won't cover non-compliant operations or will deny claims)
Protection of your medical director's license—which protects your ability to operate
Business & Financial:
Higher practice valuations (beyond just acquisition—applies to financing, partnerships)
Ability to attract and retain quality medical directors (reputable physicians won't risk their license)
Ability to recruit top provider talent (skilled injectors want to work in compliant environments)
Premium pricing justification (compliance is a differentiator)
Sustainable, scalable business model
Reputation & Market Position:
Protection from negative publicity (one bad headline can devastate a practice)
Credibility with referral sources (physicians, other providers)
Stronger patient reviews and word-of-mouth referrals
Competitive differentiation in a crowded market
Industry standing and professional respect
Clinical & Operational:
Better patient outcomes (proper oversight catches problems early)
Consistency of care across providers
Clear protocols improve operational efficiency
Better staff retention (employees prefer working somewhere "above board")
Stronger documentation supports continuity of careanxiety free operations
For those who have been operating with minimal physician involvement, the message is clear: the status quo is no longer sustainable. The time to build a proper relationship is now—before a complaint, before an incident, before a tragedy.
Jenifer Cleveland's death was preventable. The failures that led to it were not subtle or ambiguous, they were obvious violations of basic standards that already existed. Let's honor her memory by ensuring that every medical spa operates the way it should have from the beginning: with genuine physician oversight, proper protocols, qualified providers, and an unwavering commitment to patient safety.
Action Items for Med Spa Owners
If you're a med spa owner or operator, here's a practical checklist for evaluating your current situation:
Regarding Your Medical Director:
Is your medical director trained and competent in medical aesthetics?
Can they actually perform the procedures being delegated?
How often are they physically present at your facility?
When was the last time they met with your providers?
Do you have a signed, current prescriptive authority agreement?
Are your protocols developed by or with your medical director?
Regarding Your Team:
Has each provider been evaluated for competency by your medical director?
Is that evaluation documented?
Does everyone understand the chain of communication for questions and emergencies?
Is there always someone trained in BLS on-site?
Do staff wear identification showing their name and credentials?
Regarding Your Operations:
Is your medical director's name and license number posted in public areas and treatment rooms?
Is information about how to file a complaint with the Texas Medical Board posted?
Are your protocols current, accessible, and actually being followed?
Do you have documentation of monthly meetings with your medical director?
Are you maintaining proper medical records for every patient?
Regarding Transparency:
Would you be comfortable if a regulator audited your practice tomorrow?
Would you be comfortable if a journalist examined your medical director relationship?
Are there any aspects of your operation that rely on "no one will check"?
If any of these questions give you pause, that's not a reason for panic—it's a reason for action. Consult with a qualified healthcare attorney in your state. Have honest conversations with your medical director. Make the changes necessary to operate properly.
The alternative—continuing to operate with inadequate oversight—isn't just legally risky. It's dangerous for patients. And it's ultimately unsustainable for your business.
Resources
Texas Medical Board
TMB Guidelines for Medical Spas
Standing Delegation Orders — Chapter 169
tmb.state.tx.us
American Med Spa Association (AmSpa)
State Regulatory Resources
americanmedspa.org
Legal Counsel: This article is for informational purposes only and does not constitute legal advice. Consult with a qualified healthcare attorney in your state for guidance specific to your situation. Need a recommendation? We can help you find the right counsel for your practice. And, this is a complimentary offer, as we would rather you be compliant and your patients be safe than earn a fee for a simple referral.
About the Author
Randy Stepp is the owner of B.A.R. Aesthetic Advisors, providing strategic consulting and competitive intelligence for medical aesthetics and wellness practices. With extensive C-suite experience in the medical aesthetics industry, including scaling a medical aesthetics franchise to become a national brand, he works with private equity firms and individual practices on market analysis, operational optimization, and business development.
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