At a Physician Owned Medi-Spa, is a Registered Nurse Allowed to Administer Botox Without Ever Being Evaluated or Seen by the M.D

Question

I live in CA where "Medi-Spas" are everywhere. I recently had Botox by an RN, leaving me with an inquisitive look on the right side of my face. I have never seen the physician, not even for a consult. At the same time, I had pixel laser done as well. Is this nurse allowed to perform these procedures without direct doctor supervision.....and not ever being consulted by a physician at all?

Rigo J. Mendoza, MD · Answer

That's depends on the state you live in. In Florida, Botox can only be done by a Physician or a Nurse Practioner / Physician's Assistant. A nurse is not allowed to inject Botox. Unfortuantely, a lot of Med Spas don't adhere to this.

Kevin M. Robertson, MD, FACS · Answer

As you can tell, each state is different. The tightest standards have come from states like NY, NJ, CA and FL, where supply and demand dictate legislation sooner than states like where I practice in Wisconsin. It's embarrassing to even write this, but in WI a nurse can do the injections as long as they are "under supervision", a term that is not defined. And that supervision can take place with a medical director that is within 100 miles of the clinic dispensing botox. That supervising doc can be an MD in nearly any field. Its crazy, and unfortunate. That's why we continue to push for legislation for stricter supervision, and by medical directors of the core disciplines of facial plastic surgery, general plastic surgery, oculoplastic surgery, and dermatology.

Stephen Prendiville, MD · Answer

This is a State dependent question. The best way to look it up in California is to review the CA Board of Nursing website. In Florida, injection of Botox and/or fillers is deemed the practice of Medicine and an RN is not allowed to perform these procedures even when a Physician is present. NP's and PA's are allowed to perform these procedures under protocols written and reviewed by the supervising Physician. Aside from all of this, most consumers/ patients prefer that a Board Certified Facial Plastic Surgeon, Plastic Surgeon or Dermatologist perform this procedure themselves.

Kenneth D. Steinsapir, MD · Answer

If your injector was a nurse practitioner or a physicians assistant (PA), these individuals may perform treatment independent of the supervising physician when operating under a written protocol. The notes and treatment by the PA must be reviewed by the supervising physician. I am not sure if this applies to a nurse practitioner. However, in the State of California, a registered nurse can only perform a Botox treatment if there has been a good faith examination by the physician and the physician is on the premises at the time of the treatment. If this is not the case and you had an adverse treatment, it is reasonable to report the Medspa, the nurse, and the "supervising physician" to the California Medical Board. They are understaffed and can't track down all these bogus situations without the cooperation of the public.

Harold J. Kaplan, MD · Answer

Hello.  You are correct in assuming that you should be seen or evaluated by the MD first, at least in California.

While RNs are allowed to inject Botox in California under the supervision of a physician, they are not allowed to offer a prescription.  Because Botox is a prescriptive pharmaceutical, any nurse injecting it prior to a physician exam is breaking the law.

The problem is that this law is broken many, many times every day by medi-spas and traditional medical practices every day.

The exception to this would be if your injector is a nurse practitioner or a physician assistant.  Each of these two can offer Botox and provide the prescription without the MD exam.

Jessica J. Krant, MD, MPH · Answer

Your question about whether it is legitimate for an RN nurse to inject your Botox at a California medspa without you having been evaluated even once by a physician is a great question. The answer is that state by state, laws may vary over exactly how much "supervision" of a nurse is legally required (sometimes "supervision" means the "medical director" has to have his name on a piece of paper but never be on site). This should in NO WAY determine the final decision you make about what is safest for you. Laws set the minimum standards, and in some cases, unfortunately, are formed by not fully educated lawmakers, or lawmakers influenced by many variables who are trying to balance opposing forces (spa small business interests vs. restriction of trade for safety reasons). Just because something is variably legal, does not mean you shouldn't question it when it's being done to you.

Peter A. Aldea, MD · Answer

Botox and fillers are a multi-Billion dollars business. Like all such money making opportunities, it attracted a huge number of people who are more concerned with mining as much money from an uneducated and credulent public as is possible. For their part, while the many state Medical Boards and other regulatory bodies would be expected to uphold the public's safety above all considerations, they have not really done so. I'll let you consider for a moment why that has not been the case.

	At the present time, each state has a different way of defining how much independence nurses and injectors have in performing Botox and filler injections (as well as laser procedures) and  how much supervision, real or imaginary, a doctor must give them.

	In many states, a spa must have a licensed MD as a medical director. BUT his supervision may vary from his examining each patient and then allowing the RN or injector to actually perform the procedures TO his NEVER seeing any of the patients and being "off site" collecting a check for the use of his name. I get letters monthly from spas asking me to become a medical director.

	PERSONALLY, in our practice in Memphis, TN, my partner and I do ALL of our Botox and fillers. We do not delegate it to nurses and injectors. I believe our results are superior to anything out there and our rates are competitive. I therefore cannot understand WHY would any intelligent woman be willing to get "treated" by an injector at a "MediSpa".

	Please, do your homework.

	Peter A Aldea, MD
	Memphis, TN

Steven Wallach, MD · Answer

Each state is a bit different.  A nurse can perform injections but the doctor should be evaluating the patient and discussing the treatment protocol. I inject all patients myself in my practice.

Robert L. Kraft, MD, FACS · Answer

In NY, it would be illegal for you to be treated by a nurse wtihout physician evaluation and physical presence in the location at the time of treatment.  There are many, many board certified plastic surgeons and dermatologists out there and so I must say that it is buyer beware for anyone who chooses to undergo a procedure at the hands of anyone with lesser credentials.  This constitutes the unauthorized practice of medicine in many states.

Tal T. Roudner, MD, FACS · Answer

Some states allow to have a nurse practitioner or PA inject the patients with out the doctor supervising. I personally treat all my patients myself. The decision about getting injected by a nurse or PA is up to the patient comfort with being treated by a non physican. Usually the price is lower which is another consideration. What ever you decide make sure the person is experienced and has good reviews about them.

	 

	Good luck!

At a Physician Owned Medi-Spa, is a Registered Nurse Allowed to Administer Botox Without Ever Being Evaluated or Seen by the M.D

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