What Shared Decision Making Actually Means
Buchi Neita, PA-C, opens the episode by naming a term that gets thrown around in lectures but deserves a working definition. Their guest, Jenny Laminack, PA-C, puts it plainly: in dermatology, multiple genuinely good treatment options often exist, but the best choice isn't the same for every patient. Shared decision-making, she says, is the process of partnering with patients to choose treatment that aligns with their goals, lifestyle, and comfort with risk.
Neita ties this to the moment clinicians are practicing in. With growing medical distress, patients want a partnership rather than to be told what to do. She notes that the days of a patient walking in and saying 'just tell me what to get done' are largely behind us. Both hosts agree the payoff is practical: patients who feel like part of the plan are more likely to adhere to it, which drives better outcomes.
Their starting moves are simple. Laminack begins by asking what the patient's goals are, since the best treatment for one person may not be best for another. Neita leans on patient education and handouts, breaking down the diagnosis so patients understand why it's happening, then laying out the broad treatment categories with the risks and benefits of each. Both stress setting expectations and making the decision together.
Where These Conversations Come Up: AK, Acne, Atopic Dermatitis, and More
For actinic keratoses, Neita describes patients accustomed to liquid nitrogen every six months who just want to 'get burned and walk out.' She almost always offers field therapy, and Laminack agrees she offers it while respecting the patient's choice, even if they still end up freezing 20 lesions. Both emphasize educating patients that these precancers aren't as benign as they assume, and Neita cites a risk of roughly 1 to 10% progression to skin cancer, higher in those with a skin cancer history. They also point to aesthetic upsides — photodynamic therapy and, as Neita recently learned, topical fluorouracil cream have data supporting improved collagen and reduced solar lentigines — plus avoiding the hyper- or hypopigmentation risk of cryosurgery.
Acne is another wide-open field, with options ranging from topicals to antibiotics to hormonal therapy to isotretinoin. Neita jokes she'd give everyone isotretinoin if it were up to her, but she lays out the options and lets patients decide. She'll sometimes share what she'd choose, telling a safety-conscious patient a therapy is something she’d comfortably give a close friend or family member.
Laminack flags atopic dermatitis as the condition where these conversations have grown most, thanks to new topicals, biologics, and oral therapies. JAK inhibitors, in particular, can be a hard conversation — patients arrive having done their own research or heard the side-effect list on a TV commercial. Both hosts see this as their job: keep patients informed about the risks while also conveying the life-changing benefits. Neita adds that lifestyle, comorbidities, candidacy for oral JAKs, and insurance all factor in.
The hosts also cover hidradenitis suppurativa, where options are fewer but broader than a decade ago. Neita advises prioritizing what matters most to the patient—flare reduction, scarring, or pain— and notes data on secukinumab and bimekizumab for pain. Laminack shares a patient who is content just not needing paper towels under her arms, a reminder that the patient's quality-of-life goal drives the plan.
Don't Assume Patients Have Heard Their Options
Neita makes a pointed case for equity in options. She notes data showing patients, especially patients with skin of color, are often not offered isotretinoin, systemic agents, or biologics — a real disservice. If you're not comfortable prescribing something, he says, refer to someone who is. Her example: a 14-year-old with severe alopecia areata, two years into injections and topicals with little success, whom no one had ever offered an oral JAK.
Her bottom line: clinicians should never assume patients have already heard everything. Lay out the options each time, and if they aren't ready, you can always come back to it. Laminack agrees, and reflects on what an honor it is to have this expanded menu compared to a decade ago when the list was far shorter.
Practical Tactics for the Exam Room
The hosts trade concrete tips. Present options clearly without overwhelming the patient — a real risk in atopic dermatitis and psoriasis where the menu is long. Neita shares a cautionary story: a new patient with frontal fibrosing alopecia nearly didn't return because she gave her so much information at once. The lesson — meet the patient where they are, offer a couple of things, write it down, and bring them back to discuss more in detail.
Ask what bothers the patient most. Neita describes a Black patient on spironolactone who was frustrated it wasn't fixing her dark spots; she rewound to explain it was preventing flares, then addressed the pigmentation separately. She also invokes a 'snail or sledgehammer' framing (attributed possibly to Dr. Julie Harper) — some patients want conservative baby steps, others want to hit it hard — and she lets the patient set the pace.
Be transparent about risks and side effects so patients don't discover them elsewhere and lose trust. Factor in lifestyle: injections versus oral, ability to make in-office visits. Give patients time—don't rush the decision, provide brochures, and invite them to come back with a list of questions.
Barriers are real. Both name time constraints in tight visits and insurance limitations that can override even the best medication. Neita recounts a Medicare patient who couldn't get a branded topical cream she'd loved as a sample. Laminack adds social media misinformation, noting patients' strong loyalty to influencers can make correction a delicate conversation. Their closing consensus: patients stick with plans they helped choose, and as therapies multiply and medical mistrust grows, shared decision-making is the way forward.