By Nora DeLigter 

When Sienna Salcedo isn’t working 12-hour shifts three times a week as a physician’s assistant at Bellevue Hospital in New York City, she’s flying down to West Palm Beach or Miami to host Botox parties. On a recent Thursday, Salcedo had a particularly trying day at Bellevue, facilitating difficult goals-of-care conversations with the families of two different patients — one would need life support in order to survive, and the other was suffering from impaired function that would alter the course of his life. When her shift ended, Salcedo had to recalibrate quickly, leaving work and heading straight to the home of a private client who had started to notice a stubborn line on her forehead and was in need of an emergency Botox touch-up.

After the injection, Salcedo rushed home to pick up her suitcase filled with supplies — mostly needles and dermal filler, which doesn’t need to be refrigerated — before heading to the airport for her flight to West Palm Beach. She made it with minutes to spare. By Sunday, around 25 plumped faces later, she was home, in time to rewatch an episode of Love Island, before waking up for her morning shift at Bellevue the next day.

“There’s this kind of a contradictory feeling for me, because there’s a big part of me that loves helping people who need it,” says Salcedo of her bifurcated life. “But being self-sufficient and independent as a young woman is very important to me, especially as the child of two immigrant parents.”

Salcedo is part of a greater rash of nurse practitioners, registered nurses, and physician’s assistants who are leaving the hospital system — or bypassing it entirely — for the greener and more autonomous pastures of aesthetics. After a 20-year growth spurt, the number of students in entry-level baccalaureate nursing programs fell by 1.4 percent last year, 9.4 percent in master’s nursing programs, and 4.1 percent in Ph.D nursing programs. “In aesthetics, it’s like breathing easy,” says Salcedo. “Because my conversations aren’t: ‘Who’s your health-care proxy?’ It’s more: ‘How was your trip to Greece?’”

This shifting workforce won’t come as a surprise to anyone working in or around the U.S. medical system in the past 50 years. Scholars have warned of a nursing shortage for decades, with many factors at play: A high patient-to-nurse ratio is just one of the many long-standing issues that nurses have faced — a concern that was only exacerbated by the pandemic. According to a 2022 National Nursing Workforce Survey, 50.8 percent of nurses reported feeling emotionally drained, 49.7 percent fatigued, and 45.1 percent burned out.

Sarah Wade, a registered nurse in New York, spent eight years working in the hospital system — first at a pediatric emergency room in Miami and then at the pediatric cardiac ICU at New York Presbyterian in New York — before making the switch to aesthetics. After COVID hit, she started considering a change. “I was still doing nights and I was burned out,” says Wade. “And the kids were so sick … in the ER, there was hope, but in the pediatric cardiac ICU, there was so much less of it.”

Wade signed up for an injectables class at Aesthetic Medical in City Hall Park, a $1,750 one-day course that promised a certification in aesthetics. Shortly after that, Wade landed a job as a surgical nurse and aesthetician at Zuckerman Plastic Surgery, where she’s been ever since. And she doesn’t have regrets. “I’ve cried with these women,” says Wade of the merits of the work she’s doing now. “The looks on people’s faces when you put your all into making sure they look their very best … it’s very rewarding.”

Somewhere between the hospital and the plastic surgeon’s office, for many nurses making the career transition, there’s the med spa. Lots of them. In the last six years, an influx of investment from private equity and VC firms like Tiger Global, Fifth Wall Ventures, and Greycroft has created something of a med-spa mill, with chains like Ever/Body, Peachy, JECT, and Skinjectables streamlining operations to reach more customers with fewer doctors (not unlike vet care and dental care). In a med spa, the physician becomes secondary, replaced by the role of the injector. To make these services accessible, med spas offer bundles and packages at affordable prices. At Plump, a med spa with seven locations nationwide, pricing for injectables is based on dosage and substance — one-fourth of a syringe of dermal filler in the lips, a.k.a. “the bee sting,” costs $425, whereas a full syringe costs $900. Memberships are encouraged and cost $100 a month, with 20 free units of Botox awarded at the end of the year.

“No one even knew what an injector was before 2018,” says Plump COO Richelle Marty, whose goal is “to become the Drybar of med spas.” To recruit its employees, Plump replicated a familiar employment package for nurses — with similar insurance plans, PTO allowances, and salaries that hospitals offered. “I had to think about how to get them to jump without thinking,” says Marty. At the end of the day, the pitch would be predicated on lifestyle: “No weekend work … and no gunshot wounds.”

Dr. Kay Durairaj, a plastic surgeon in Pasadena, California, was inspired to create an injectables program of her own after seeing how many untrained professionals were working in the industry. “It’s a very secretive industry,” says Durairaj, “and I realized early on that if we don’t share the secrets of how to do things, and if we don’t teach what we know, well, people are going to go out there and botch women’s faces.” With that in mind, Durairaj set out to create a program called Modern Aesthetic Theory and Artistry, which teaches aspiring aestheticians — most of whom are nurse practitioners, physician’s assistants, and registered nurses — how to inject. The program, which costs between $675 and $2,500, is step-by-step and instructional, with 30 different modules that cover procedures from the very basic (forehead Botox and lip filler) to the very advanced (Tinkerbell tip lift, liquid rhino injections, and Kybella injections). Since launching in 2019, she’s trained over 5,000 people.

In some states, to inject Botox or dermal filler you need to hold a nursing degree or have gotten your master’s degree as a physician’s assistant. In New York, where the regulations are more stringent, you need to have a supervising MD attached to your business. But in some states, like Nevada, for instance, you don’t need a degree at all. This means that the level of expertise can vary, depending on where you live. “It’s not a commodity,” says Durairaj. “You’re not just buying the bottle, you’re buying the expertise and the placement too. So it’s buyer beware.”

For some nurses, this pivot hasn’t come without moral quandary. On the /nursing sub-Reddit, one user describes feeling guilty for moving from bedside to aesthetics: “I have no idea why but the guilt is eating me alive!” In another exchange, one user admonishes another, calling them “a sellout” for doing PRP injections on the side. In many of the exchanges, nurses go back and forth commiserating about the stress of working in a hospital setting. “Nursing in the hospital isn’t all it’s cracked up to be,” says LobsterMac_, a RN in a trauma ICU. “Ironically … many of us are looking at trying to go the aesthetic route and looking for ways out of the hospital altogether.”

The med-spa model, though mostly profit oriented, provides this way out — opening up new pathways for RNs, NPs, and PAs, many of whom are women. “One of the statistics I’m most proud of is the fact that nearly 70 percent of med-spa owners are women,” says Alex Thiersch, founder and CEO of the American Med Spa Association. “And, considering that close to 90 percent of patients are women, and that the overwhelming majority of providers are women, the medical-spa industry continues to carry the banner for female entrepreneurs in both business and health care.”

For Amy Lee, an injector at Velour Medical, a med spa with a concierge concept that specializes in at-home treatments, it was the sense of community and the female-oriented business structures that attracted her to the industry most. “These are offices powered by women, by moms … and they’re women who are using their degrees to maintain a full-time job even after having a few kids,” says Lee. This is a meaningful disruption in a field that has historically been dominated by men. “When you have women working on women, the aesthetic bias shifts,” she adds. “Industry standards and ratios are changing, which is exciting.”

As for what Wade misses from the hospital, there is one thing: “The kids — I miss working with the kids,” says Wade. “But now I get to be with my son at night, and that’s meaningful too.”