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Physician and author Kate Dee discusses her article, “Medspa madness: How illegal practices are putting patients in peril” and book, Med Spa Mayhem: The Good, The Bad and the Ugly Secrets of the Aesthetics Industry, exposing the alarming rise of unregulated med spas operating without proper medical oversight. Kate highlights cases of illegal Botox and filler injections, unlicensed individuals performing medical procedures, and the increasing use of counterfeit products leading to serious injuries and even death. She details shocking incidents, including arrests in Texas and California and the tragic case of Jennifer Cleveland, who died after receiving an improperly administered IV infusion. Kate advocates for stronger enforcement, public awareness, and the need for a national certification system to ensure patient safety. Listeners will gain insights into the risks of unregulated med spas and what they can do to protect themselves from dangerous practices in the aesthetics industry.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Kate Dee. She’s a physician, and she’s the author of the book, “Med spa mayhem, the good, the bad, and the ugly secrets of the aesthetics industry.” There’s an excerpt from that book on KevinMD titled “Med spa madness. How illegal practices are putting patients in peril.”
Kevin Pho: Kate, welcome to the show.
Kate Dee: Oh, well, thanks so much for having me today.
Kevin Pho: All right, so let’s start by briefly sharing your story and journey.
Kate Dee: Yeah, well, I landed in aesthetics a little over 10 years ago, kind of serendipitously. I had friends who were OB-GYNs who had been doing it for a long time, and they encouraged me to check it out.
And long story short, it was really fun and positive in a way that my old career in breast cancer kind of was not so much. And it was very procedure-based and talking to women all day, but you made them happy. So, one thing led to another, and I kind of put up a shingle and started my own aesthetics practice, which has turned into, you know, like a pretty thriving—we have two sites now in the Seattle area.
But one thing that has been just incredibly disturbing, and I’m really happy to be reaching a greater medical audience here, is that over the last 10 years, the industry I found myself in has just exploded. It’s a 20 billion industry, just to put that in perspective. That’s like as big as the NFL. OK. And what’s spurred that growth is more and more people doing the procedures.
So, there are all these non-medical people practicing medicine without a license. There are all these people who maybe have some kind of license, like an esthetician or a nurse’s license, but they’re practicing independently, which is illegal in every state. So, there are people ordering fake product off the internet. They’re just cutting corners. There are just more and more headlines about people being injured and, weirdly, killed by these unethical, illegal practices. So, I just—I started writing about it. I ended up writing the book, and I have my own podcast too now. And I’m just trying to get the word out.
Because I feel that the more consumers know, and hopefully the more other physicians know, we can kind of tamp down the illegal practices, because there really has been no enforcement on the prosecutor’s side, and there just hasn’t been—there are no consequences for these people. We as physicians, we worry about losing our license if we do something wrong, but if you don’t have a license, you don’t have one to lose, you know? And the attitude on the enforcement side is like, well, you went to that place of your own volition, you get what you deserve. And I just think that with so many people going to get Botox and laser and other treatments, the consumers just need to be educated—like, where to go, how to know what place is legit, what place is practicing safely.
Kevin Pho: So, before talking further, let’s get everyone on the same page. For people who aren’t familiar with the aesthetics industry and these clinics that are popping up, what are some common procedures? What are some common things that one would hear about that would make them go to these clinics? So, what are some common things that you do there?
Kate Dee: Yeah, well, I mean, probably the most common thing is Botox. And you know, if you were paying attention to the headlines this last year, there were people in 11 different states who ended up in hospitals from fake Botox that people ordered off the internet. But other procedures: laser treatments for the skin, either laser hair removal or laser resurfacing. There’s a lot of RF treatments. There is a big one in treatments with PRP. So, you know, we do a lot of PRP injections in orthopedics and stuff, but PRP is used for facial rejuvenation and volume replacement.
There are places doing, you know, blood draws and stuff without any kind of medical training at all. As a matter of fact, a few years ago, there were a whole bunch of HIV cases from an unlicensed spa in New Mexico. So, yeah, I mean, it’s crazy. Oh, and the other huge thing is IV treatments. So, we know that, you know, IVs are important to treat sick people, but there are IV bars now popping up all over the country where people are sort of ordering up an IV like it’s a martini. And there was a pretty prominent case that was written about in the summer of 2023 where a lady in Texas died from going to one of these places, and the person who killed her was completely unlicensed and unsupervised and just basically hung potassium and executed this lady.
So, yeah, I mean, it’s crazy, and there are so many laws that regulate medicine—and we all know about that—but nobody is going to enforce these in these outpatient, you know, cash-only businesses. And it’s crazy, so I’m—you know, it’s important for consumers to understand what they’re getting. And people walk into a medical office, they think that it’s regulated, and we are highly regulated. But nobody is regulating these, you know, pseudo-legal or illegal practices.
Kevin Pho: So, tell me a little bit about your transition from being a physician to your aesthetic clinic now. What kind of preparation, what kind of training did you undergo in order to open up your own aesthetic clinic?
Kate Dee: Yeah, well, you know, as you probably know, there’s no residency in aesthetics, right? So, I was in practice at a breast center for 16 years. I was a board-certified radiologist—I still am—and did, you know, breast biopsies, wire localizations, MRI, ultrasound, mammograms. And so, I looked around for a good training course. There are lots and lots of training courses; they’re kind of everywhere, and there are actually new ones popping up all over the place.
The first one I did was all physicians, and it was, you know, less than a week, and we learned how to inject Botox, how to inject filler, laser physics—actually, that was the most fun part for me because, you know, radiologists are physics geeks—but, you know, chemical peels, skin care, and all that. And the way these courses work is, you know, you take a course and you’re supposed to go back and practice on family and friends and then come back and do a more advanced course, which is what I did. Then you learn a little more advanced techniques, and basically you have to kind of learn it on your own. There’s really no residency, and if you look at—I mean, I don’t know exactly how old you are; I am 57. I graduated from med school in 1994. You know, none of my colleagues who went into plastic surgery or derm did any aesthetics in their residency because it didn’t really exist back then. There’s reconstruction, you know, but—and cosmetic surgery basically, but there was really no Botox cosmetic; it wasn’t FDA approved till 2003, and everything else has come along since then.
So, the industry is, you know, just over 20 years old. But even now, if you look at derm and plastics residencies, there’s very little of that, if any, in those residencies. So, how do you get training? You know, like everything else we do, back in residency, see one, do one, teach one. So, I mean, I went through all of that in 2013, 2014, and, you know, just kind of practiced on friends and family and then, you know, slowly kind of got more experience. And unfortunately, there really isn’t any other, you know, kind of formal training.
As a physician, at least we are extremely well trained in anatomy and physiology and all of that. If you look out there, though, and just Google, you know, “Botox course near me” or “injectables course,” there are courses all over the country that offer a weekend, two-day course to anyone. You don’t have to have a license. So, you can be an unlicensed person.
This is really common in several states where there are laws allowing non-licensed providers to practice under a physician as long as they have a medical director. So, the one that’s the most commonly cited is Texas. So, Texas—you know, it’s not legal to practice independently as a non-medical person without a medical director, but there are these courses where you go for a weekend, and they teach you basically how to inject Botox, right? Then they say they guarantee that they will find you a medical director. So, there are people who are completely unlicensed, learn over a weekend, get some person on paper to be their medical director so they can order Botox, and now they’re practicing completely independently. And it’s not legal, but those courses are popping up—they’re everywhere. And the people who pay for the course and go through that training think that they’re allowed to do this, but they’re not, right? And so that is kind of rampant and spreading all over the country.
So, there’s actually—there’s not a state that doesn’t have illegal people injecting things in people. And they may or may not even know that what they’re doing is practicing medicine without a license, but, you know, that’s a felony as far as I know in every state.
And there was a young woman who I interviewed on my podcast, and she’s got her own YouTube channel after what happened to her, but she went to an unlicensed medical spa in California about four or five years ago. And long story short, this person had no medical training, had ordered fake deoxycolic acid off Alibaba, and injected this girl all over her body with tainted product that had mycobacterium in it. So, she almost died; she was in the hospital for over three months.
So, the problem is that there is nobody, you know, regulating. I mean, there are all the laws, regulations, right? But there’s nobody looking to actually enforce those laws in this kind of wild west of aesthetics. So, there are some really fantastic med spas—I don’t want to take down the whole med spa industry; I’m in it. What we do is, I think, pretty amazing. And I’m not a typical beauty consumer at all, never worn makeup in my entire life; I probably wouldn’t have ever had Botox had I not kind of stumbled into the industry myself. But we really do so many great things, but for every really high-quality, you know, doctor-run and doctor-led med spa, there are so many of these shoddy places that are cutting corners. So, I’m actually really interested—and this is just in my brain idea stage—but I’m really hoping to found a national nonprofit that would certify med spas, not rate them or anything, but be able to look at, you know, their qualifications, their licensure, their medical directorship, and their corporate structure, and make sure that they’re actually operating legally. But that doesn’t exist yet, so I’m working on that.
Kevin Pho: So, for those consumers that are researching med spas, the fact that a med spa is founded and run by a physician, is that a crude measure of quality? Can we be sure that just because a med spa is run by a physician, they’re not ordering things from Alibaba, like you said?
Kate Dee: It’s probably the best proxy we have because, you know, as a physician, I mean, you just do not want to lose your license, and the chances of losing a license or being sued for malpractice are so high if you’re a physician. You know this—for instance, this lady who almost killed this girl in California, right? She had no license. She had no malpractice insurance. She never got prosecuted because the prosecutor told this girl, well, you went there on your own, and what do you expect? And did she say she was a doctor? You know, no. But also, she couldn’t get sued. She tried to sue this woman, and no lawyer would take her case because there was no money to be had. She didn’t have any money. She had no insurance. So, you know, I would say 99 percent of physicians really want to operate legally and take care of patients and actually care about those things. But yeah, it’s a crude proxy. Could there be some very corrupt physicians out there? Sure.
Kevin Pho: So, in general, when we’re talking about these med spas, what percentage approximately are, in fact, run by physicians?
Kate Dee: It’s actually pretty small. I don’t have an exact number. I know that AMSPA, which is the American Medical Spa Association, points to at least 15 percent having no medical director at all, but that doesn’t address ownership. So, legally, in most states, a non-doctor can’t own a medical practice, right? There are corporate practice of medicine laws. But very few people know that when they get into the business. So, there are a lot of new entries into this space where it’s illegal ownership and also just illegal practice. But it’s really hard to know what that total number is.
Kevin Pho: So, for those consumers, again, researching med spas, what are some of the things that they should look out for to make sure that it’s being run by a physician, or any red flags they should be looking out for?
Kate Dee: Right. Well, the first thing is to find out who am I seeing and what is their license, and actually look them up. So, if they’re a nurse, at least make sure they actually have a nursing license, OK? And then always ask who is the medical director, and look them up, and find out if they know anything about aesthetics. So, if that is, you know, an anesthesiologist who works in a hospital 100 miles away, chances are they’re not there at the clinic, right? The other thing you can do is ask to get an appointment with the medical director because if they actually have a presence in the clinic, you will at least be able to get an appointment with them eventually. They might be really booked out—I mean, I’m kind of booked out, right? But you can get an appointment with me at my place. So, those are like the top two questions. And always, you know, a good faith exam has to be done. So, a doctor can do that, but also a nurse practitioner or a PA working under a doctor can do a good faith exam. But if you’re walking into a place and it’s just an RN, they can’t make medical decisions or do a good faith exam or make an assessment and plan. So, you know, just walk out. And if it’s not even an RN, like if it’s an unlicensed person or an esthetician, that’s completely illegal. They can’t do that, right, on their own at all.
So those are the top questions, really. As far as ownership, that’s really hard to tell, OK? I think that’s beyond the scope of people’s sleuthing. But that’s why I think that trying to create this med spa board that would certify, like, yep, this is all legit—at least it would slap a label on it that would be identifiable, like this place is legal.
You know, kind of like how Certified Organic popped up years ago when organic became a thing. You know, in the beginning, people didn’t really know what it meant, but now you know what you’re buying, and you’ll actually pay more for a certified organic vegetable. It has that meaning, and I’m sort of hoping to create this kind of label because I don’t think that any change is going to happen from the regulatory side.
Kevin Pho: In general, med spas that are run by physicians, is there a price disparity compared to clinics that aren’t run by physicians?
Kate Dee: Right now, not a lot, because prices are being undercut by all these people cutting corners. And so, if your prices are a lot higher than that, then it’s hard to compete because people can’t tell the difference. Yes, there definitely is a little bit. There should be, honestly, right? But I think that hopefully with education, people will be able to see that and know that they’re going to a legit place. And I don’t think that identifying these corner cutters is going to eliminate—there’s always going to be someone who’s going to go for, like, the cheapest thing possible, you know, the people who fly to other countries to have surgery because it’s cheaper there. But if you’re a knowledgeable consumer, most people don’t want to go to those places that are dangerous.
But I just had a patient a few months ago now who is a lawyer who was coming to me for the first time, and I was like, oh, where’d you go before? And he’s like, oh, there’s this girl down the street from my office. And I was like, oh, you know, a girl—like, what was she, a nurse, or what was her credential? And this lawyer had no idea. So, I’m like, oh, I didn’t even realize I had to ask that. So even lawyers don’t realize that there are people doing this illegally.
Kevin Pho: Now, if you were to create this certification board, how would you certify practitioners to be legitimate? Would you have them pass exams? Or what basis would you certify them on?
Kate Dee: I think it’s—no, I mean, this is really not certification on their education or their training. It’s really just are they operating legally? So, it would be voluntary. It would be some kind of nominal fee that would make sense to everybody who is operating legally and would want to get certified so they could advertise, yes, certified legal or whatever, and it would be documenting that everybody is licensed, there’s a good faith exam done by somebody who’s qualified to do that, the medical director has some kind of expertise in aesthetics, and that they have a presence there—there’s actual medical directing going on. And then it’s legally owned. And hopefully, yes, that they have contracts to get legal products with the major companies.
And so it really isn’t about rating them or, you know, proving that one place is better than another. It’s really just being certified as operating legally and ethically. And, you know, I mean, I came from the breast cancer world. We had to go through annual certification. Every place you can get a mammogram in America has to certify every year. That was a lot of hoops to jump through. I’m sort of hoping to make it very simple and straightforward so people will want to get certified so they can just advertise that on their website and all the things, and just to publicize also that it matters because I think that most people who—oh, they go to their hair salon, and they’ve got some RN who comes there once a month to do Botox—you know, so many things are wrong with that. And I just think people have no idea that that’s a problem.
Kevin Pho: We’re talking to Kate Dee. She’s a physician, and she’s the author of the book, “Med spa mayhem, the good, the bad, and the ugly secrets of the aesthetics industry.” Kate, let’s talk about your book. So, what are the main messages? What are some of the audience targeting that you want people to read your book about?
Kate Dee: Well, you know, I originally wrote that book with the target audience of consumers of aesthetics. So anybody who’s ever had Botox or laser hair removal or a facial even. But what I’ve found since I published it is that it’s had a pretty broad appeal. So even people—so a lot of people in medicine—are just astounded by it. I mean, all my friends in, you know, traditional medicine just can’t believe this stuff is going on.
There are a few doctors who are kind of crusaders for this movement, even having nothing to do with aesthetics. But there’s a doctor I know in Texas who, you know, is very interested in changing the way all these non-medical people are practicing. Then also, amazingly, people who are in law, and in a lot of—you know, I have to say most of the aesthetics industry is women. I mean, most of the consumers; it’s 90 to 95 percent women. But a lot of men and a lot of people who are non-consumers are just kind of like, you know, astounded by it, and their reactions are like, well, you know, see, I told you so; this stuff is crazy.
But I’m really trying to make it so that the industry self-corrects, because I really see a lot of value in it. And it’s not just for people who are vain. It’s not about that, right? It’s not just Hollywood stars. And I think that it’s become more and more just accepted in mainstream. A lot of people consider their skin care and stuff as kind of like a haircut. You know, it’s just part of their maintenance routine of their skin and their body and their hair.
So, I really want the danger to be kind of taken away from it. But, you know, honestly, I think that it’s a pretty quick read and pretty entertaining for just about anybody.
Kevin Pho: And finally, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Kate Dee: Yeah, well, I really encourage people to check the book out and the podcast—the podcast has the same name, Med Spa Mayhem. And anybody who has ever consumed these things, ask those questions. If your best friend asks you, you know, where do you go for Botox, make sure they ask all these same questions. And, you know, reach out to me if you have any interest in helping me with this or if you have questions about the industry or you want to hear something on the show. I’m really, really interested in talking to other physicians who actually care about these issues as well.
Kevin Pho: The book is called “Med spa mayhem, the good, the bad, and the ugly secrets of the aesthetics industry.” Kate, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Kate Dee: Oh, thanks so much for having me today.
