What's a Botox Cowboy and Why You Should Worry?

The term was probably first coined by reporters in the UK when a major player in the Botox-by-proxy industry was exposed. 

• BBC undercover report in 2012

Dr Mark Harrison, the director of Harley Aesthetics, had built up a network of hundreds of nurses who phoned him on his mobile from across the UK to receive authorisation to inject patients immediately with Botox. They paid Dr Harrison £30 for each conversation.

Dr. Harrison had his GMC (General Medical Council) registration revoked for 18 months.

This Harley Street specialist bragged that his nurses had injected their customers 50,000 times. Unfortunately for them, in most instances they probably never saw him in a face-face consultation.

The problem with the situation here in Canada, and probably in most other countries, basically lies on the shoulders of Allergan, the manufacturer and marketer of Botox Cosmetic. They market a product, originally discovered by a team of Canadian dermatologists from Vancouver and the market exploded around the world.  

Even after the U.S. company was fined $600 million by the Feds in that country for encouraging off-label use of their Botox, they could care less. Why, because they have made BILLIONS of dollars on the product and its spin-offs over the long-hall.

Do they ship the Botox directly to the medical doctor, to a local pharmacist, or perhaps even to registered or practical nurses?

I personally asked Allergan  which doctors were involved in the practice of remote prescribing, and they refused to tell me. In fact, in many cases, they may not know themselves where these Botox Cowboys are really located. 

Some doctors, who have reported their concerns about this to Allergan, have been told to mind their own business. 

One of those doctors works in Ancaster, Ontario and she is a dermatologist. When her office was asked if they could help identify the name of the doctor who may be associated with a quack-filled non-medical alternative health facility in her city, she said that nothing could be done. This facility has an interesting review on HealthWatcher.net that goes back a few years.

If you go to the BotoxCosmetic.ca web site you can search for doctors near you by name or a location where injections are given by location or postal code. Members registered with the  CPSO are subject to the Medicine Act which regulates doctors from endorsing a specific drug. 

However, this is reality folks, the CPSO won't do anything to interfere with doctors who regularly do this on their own web sites or blogs. 

Do Allergan's actions actually assist doctors to violate the Medicine Act?

Scores of registered medical doctors in Ontario regularly endorse Botox, cosmetic enhancements, and procedures aimed at the worried well-off patient. It's a "three-ring circus" of sorts, and the customers are sometimes fooled into thinking that there is a "doctor in the house". When callers make an appointment after they view a full-page advertisement in their local newspaper for some classy-looking facility that promotes Botox and other enhancements they assume that it's a medical doctor that they will be seeing.

The ads usually include photos of before-and-after shots, or pics of nicely clad babes wearing a white lab coat with a stethoscope swagged around their neck. Are these the "doctors", or just a stock photo?

The pitch

At their appointment these spas sell the customers on a bevy of treatments and injections based on what? A doctor's touch you say? Most of the time, you might catch a glimpse of an image of someone who may be a doctor, or perhaps the just play one on TV. 

Skype consults are the way most of these Botox cowboys operate. The "doc" sitting at home, or in another office has to interrupt their busy day and communicate their diagnosis based on a two-dimensional assessment over the Internet. I wonder how they do it on Wednesday afternoon when they are on the 10th fairway?

That's it folks. No real medical doctor who actually sees you in the flesh. 

What goes on after this is appalling to me. The sales people then call in the nurse (either RN or RPN) to drag out their collection of vials and needles ready to attend to your furrowed brow and frown lines. Now remember, you will probably want to buy a special package for the next three-four visits just to save you a few percent. There's nothing like saving $2 a unit over the other guy down the street who may actually have a real doctor at their office.But, if the sales people do their job, you will be back for more Botox in a few months, and if they really play their cards right, they can up-sell you on some fillers, maybe more.

Allergan just does it with a two-colour double-swish

Doctors who recommend Botox-by-proxy, and some of their other products may also try to bill your insurance company for their time. After all, Telemedicine does cover other skin conditions. 

I wonder if Health Canada can please help answer some simple questions about using Botox-by-proxy in Canada.

My simple estimate is that there are probably scores of spas and salons around the country that enable the delivery of Botox injections without a medical doctor being in attendance. 

It has been going on for years here in Canada. The CPSO (College of Physicians and Surgeons of Ontario) has recently heard complaints on the subject and should render a decision in a few months. Only one other Province has been able to severely restrict who can prescribe Botox and in which setting it can be delivered. 

What other Provinces have done

The CPSBC (College of Physicians & Surgeons of British Columbia) has recently addressed this situation with a 

Guide to Non-Surgical Cosmetic Procedures

Can Botox injections be given without a physician first seeing the patient?

A physician must physically meet with a patient prior to the treatment to discuss possible risk factors ans assess contraindications.

Does a physician have to give the Botox injection?

A physician doesn't have to give the Botox injection, however, the treatment decision must be made by a physician, and that physician remains responsible for the procedure. The actual injections of Botox can be delegated to another healthcare provider, like a registered nurse, assuming the treatment is performed under the supervision of the physician, i.e. the physician must be on site during the procedure.

Can Botox injections be given in a location other than a physcian's office, clinic, or hospital?

Botox injections can be done in any setting, even a spa, provided it meets the approved clinical standards.

I was told that some Botox Cowboy RNs in BC are looking for work outside the Province because they can no longer just be injectors at spas or alternative health clinics without a doctor being there. It's the only Province that I have heard back from about this situation in their own jurisdiction. In time, this may spread across Canada. 

What can Health Canada do?

Can Health Canada do anything  to stop this abuse?  Have they ever surveyed how Botox cosmetic is dispensed? Has any regulated health profession ever asked the simple question, "Who can legally inject Botox Cosmetic?"

It seems to me that the Botox-by-proxy industry is basically out of control. Many spas have never had any medical doctor on site. They utilize nurse injectors, and Botox brings in huge profits for them, and for Allergan.

Doctor Botox Cowboys

One particular Ontario medical doctor has been associated with at least 9 different spas or clinic locations. In fact, she is almost never at their locations physically. She sees most of her patients and communicates with the injectors at the various locations via Skype. While it's better than a cell phone call from a golf course it isn't kosher as far as some experts are concerned.

According to a senior official at a major Ontario physician training centre for Botox, this has not been approved by the CPSO

Another Ontario doctor is listed on staff at about six locations around southwestern Ontario. On several of those web sites she is described as having specialty designations, and in some cases to have worked in a high-profile residency position at a major medical school. 

In reality, the CPSO has no such records, and neither does the RCPS (Royal College of Physicians and Surgeons) in Ottawa. What are the penalties for having information on web sites that are basically not true? Did she post them, or did the spas do that to help build up their clientele?

The bottom line

If your spa or alternative health facility is involved in the promotion of Botox Cosmetic there may be no medical doctor in attendance. Skype diagnosis may not be legal, and your nurse may be overstepping her allowable care guidelines. Avoid being sold a subscription in one of these spas, and demand your money back if you get sucked into a contract and there is no physician in attendance. In most, if not all circumstances, nurses can inject Botox when a physician is in the office. Anything else is just plainly and simply asking for trouble.

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