7 days ago
Should Primary Care Physicians Offer Cosmetic Procedures?
In 2005, a patient of mine dropped out of my weight-loss program. She returned a few weeks later and said, 'I'm ready to lose weight again. My face looked older after the weight loss, so I got someone to inject Restylane.' Her statement put me in an ethical dilemma. Here's why.
I had worked to become board-certified as an internist, but during my training in Birmingham, Alabama, I traveled the state and had privileges in fourteen different emergency rooms. I loved the rush that came with working in the emergency department — the need for rapid diagnosis and the soul satisfaction of resolving life-threatening situations. So, after residency, I worked for 10 years as an emergency room physician in a busy, urban, underserved ER before finally opening my practice in 2000.
At this point, I did not think you were a "real doctor" if you only saw patients in the office. Staying true to my beliefs, I made rounds at the hospital before and after heading to the office so I could take care of my own critical care patients in intensive care. To me, radiologists were just technicians who got paid to look at the radiograph the day after it matters (while drinking a cappuccino in their dimly lit pub), and plastic surgeons were wizards when putting a face back together after trauma but meretricious in the office setting. I thought Botox cosmetic (approved by the FDA around this time) was something that no real doctor would do.
I was an asshole.
But after my patient told me that she only felt comfortable proceeding with the weight loss that would lower her blood pressure and correct her hyperglycemia once her face was injected with a cosmetic filler, my ethics were challenged: Another physician's cosmetic injection helped my patient lose weight and improve her health. I decided I should learn to do cosmetic injections.
So, I discovered the top cosmetic injector in the world at the time, Mark Baily, MD, in Toronto, Canada. He and his nurse practitioners were doing an astronomical number of injections across multiple locations. I visited him more than once to learn his techniques, and he showed me things that are still not widely known.
And Dr Baily was a family practitioner.
On both of my visits, he started his lectures with a photograph of a Canadian pediatrician who committed suicide. He said, 'This pediatrician was working night and day. He was a very devoted physician who was adored by many and prioritized patient care over paperwork. Then, he got his paperwork wrong. Following an audit, the Canadian government fined him $108,000. After this incident, he became despondent and committed suicide. If you are a primary care physician, you must offer cosmetic procedures to finance your bad habit of taking care of sick people.'
I listened. I came home and, using his techniques, became the top Allergan account from New Orleans to Destin, Florida, within the first 18 months of administering these procedures. 'After you lose 30 pounds, reward yourself with a syringe of Restylane,' I would say.
Of course, when the word was out, men and women who were not part of my weight loss program came to me for services.
A Young Woman Schools Me
Even though I was a high-volume injector, I still felt the need to justify my provision of cosmetic services by considering it "bait" to attract people to my office so that I could make them healthier.
I was still mostly an asshole.
Then, a woman in her 20s returned to my office about 3 months following a Juvéderm treatment. She said, 'I saved my money as a rent-a-maid to buy that Juvéderm syringe. I did not tell you then that 2 weeks before seeing you, I was raped. After you treated my face, it helped my confidence so much that I left an abusive relationship, got a new, higher-paying job, and have a side gig as a fitness model. I wanted to make my life match my face.'
The lights came on. 'Oh, wow. I'm such an asshole,' I thought. 'Who am I to tell someone what their pain should be? If their pain is cosmetic, I can meet them there and relieve that pain, and in turn they might become interested in my internal medicine knowledge. But even if they aren't interested, it's still a good day's work.'
After that day, I became fanatical, reading every book and attending every course I could find about cosmetic injections — and I still do. Plastic surgeons became my heroes, and to this day, I am a frequent referrer to the plastic surgeons in my area. The verdict is still out for radiologists.
Not the Only One
As I've confessed above, I had a bad attitude toward cosmetic procedures prior to 2005. But I wasn't alone in that sentiment.
Initially, Allergan focused its marketing of cosmetic Botox to plastic surgeons and dermatologists, but those specialties wanted to do surgery and rejected lowly cosmetic injections. After seeing the slow adoption of Botox by the chosen few, the company eventually relented and started marketing it to primary care physicians around 2004. Simultaneously, Allergan started pioneering powerful direct-to-consumer marketing.
Cosmetic injections were not considered standard training for plastic surgeons or dermatologists until sometime between 2015 and 2020. A 2014 report lamented the lack of standardized injection training for dermatologists, and a similar report in 2019 found that the training that was being offered was inconsistent and inadequate. Patient demand and expectations eventually triggered reformation of physician attitudes. In 2022, Objective Structured Assessment Tools were finally established for plastic surgery and dermatology residencies.
Still, then and now, you will often find the physician extender (ie, nurse practitioner, RN, or PA) performing the cosmetic injections in the office of a plastic surgeon whose website states that only board-certified plastic surgeons should do cosmetic injections.
Back to the Question & 10 Considerations
As an internist who first picked up a Botox syringe 21 years ago, I will offer a few considerations about the question, 'Should primary care physicians offer cosmetic procedures?'
1. Toxins are safe. Give pause before fillers and energy sources .
The LD50 for cosmetic botulinum toxin is about 100 times the dosages usually given with cosmetic injections. Stay away from pregnant women and those with neurologic disease (eg, Myasthenia gravis), and about the worst you can do is a droopy eyelid or a bruise. Hyaluronic acid fillers and energy (laser and radiofrequency) are trickier but can be performed safely with proper training.
2. Almost anyone can become an excellent cosmetic injector within a few weeks.
For 15 years, I have been teaching monthly hands-on workshops regarding cosmetic injections. I also wrote a textbook and have an online course on this topic. I know that with the right curriculum — and a hand and eye steady enough to put a needle in a spot the size of a pea — just about anyone can be a very good injector within a few weeks.
3. Cosmetic injections are the best, cheapest, and safest way for a primary care physician to use cosmetic procedures to help finance their medical practice .
If you are a physician, I hope the following facts disturb you: Medicare pays about $225 for a level 5 visit with a new patient and about $160 for a level 5 visit with an established patient — a visit that takes about 60 minutes and involves complicated problems where you may need to write prescriptions and you may be called in the middle of the night. Not to mention, half of what you make taking care of sick people goes to overhead. And if you make a mistake, someone could die.
The top massage at the Marriott near my home costs $680. Becoming a licensed massage therapist takes as little as 6 months of school. Plus, nobody will call you in the middle of the night, and there's very little risk of anyone dying. When you consider that someone with a folding massage table is making 2-3 times what you make as a primary care physician, I hope you will decide that you really do need — and deserve — a way to help finance your noble practice of caring for the sick.
And now that Amazon is selling doctor visits by video for $49, or a text-messaging doctor's visit for $29 , you really do need to offer something that requires a physical visit to your office if you hope to keep the doors unlocked.
4. Your patient can afford you — and her sister can, too.
Most people want and expect their insurance to pay for illness but are prepared to pay out-of-pocket for cosmetic work, especially when the procedure costs the equivalent of a trip or two to the hair salon.
5. Offering cosmetic procedures will benefit your patients with hard-to-treat medical problems.
For example, botulinum toxin is very well-supported as a treatment for bruxism. However, it is still off-label for that indication and therefore not covered by insurance. So, cosmetic injectors are typically the only providers offering this treatment. The same is true for depression and erectile dysfunction.
6 . Platelet-rich plasma (PRP) is the safest of them all.
I know, I am biased on this topic: I have developed several PRP-based procedures (ie, Vampire Facelift, O-Shot, P-Shot, Vampire Facial), trained thousands of physicians in over 50 countries, and started a supporting organization. Still, with over 18,000 papers referenced on PubMed regarding PRP, only a handful of serious sequelae are documented. It's an excellent way to get started and is a fabulous example of the overlap between medical and cosmetic care.
7. Your patients would rather see you.
If you are a primary care physician who decides to offer cosmetic procedures, individuals outside your practice may come to you for cosmetic work. However, you will still primarily treat your current patients: They want to see you, not the plastic surgeon down the street. Just be well-trained, and these cosmetic offerings will be much safer than many of your other routine medical therapies.
8. Your local plastic surgeon, if they are smart, wants you to do this .
Many patients don't consider seeing a plastic surgeon until they've experienced the confidence boost that comes from a few simple cosmetic injections. These noninvasive treatments can allow patients to feel more comfortable exploring aesthetic medicine in an environment that is much more regulated than a "med-spa." Your practice can then refer patients to local plastic surgeons after these initial positive experiences.
9 . You will have fun.
During my years as an ER doctor, a bad day could mean the death of a child. As an internist, it might involve delivering a life-altering diagnosis of breast cancer to a woman. But a bad day in your cosmetic injection practice is usually no worse than a patient getting an unsightly bruise. By offering these procedures, you get to see your patients more often when they are healthy and happy — not when they are burdened by chronic and painful conditions.
10. Do NOT buy an expensive laser or any other expensive machine .
Until half of your day is filled with cosmetic injection patients, that pricey laser will sit in the corner gathering dust, eating the money in your bank, and serving — primarily — as a table for your coffee cup. The salesperson for the machine thinks you are gullible and not a good businessperson. Do not prove them right. Start with cosmetic injections; you need a bottle, a few syringes, a centrifuge, and a little practice.
Take Care of Yourself So You Can Take Care of Others
At one time, I was the medical director of a few nursing homes. I would tell people that my 30- and 50-year-old patients financed my joy in caring for my 90-year-old patients.
When you consider that the so-called 'core' physicians who first snubbed cosmetic injections now want exclusive rights to them, you may feel a more comfortable with your own ethical dilemma and embrace my first teacher's axiom: If you practice primary care, you must learn cosmetic injections to finance your bad habit of taking care of sick people.
You will change lives for the better while having fun.
