Packed House or Ghost Town?
Buchi Neita, PA-C, and Shanna Miranti, PA-C, open their second round of "Would You Rather" with a scenario every clinic knows well: a standing-room-only waiting room versus an eerily empty one. The two land on opposite sides, and their reasoning shows how APPs manage their own bandwidth.
Neita chooses the ghost town, admitting that at this phase of her career she prefers a quieter, more subdued schedule. She notes that even when the patient count stays the same, she feels her patients' needs are greater — more questions, more counseling, more conversation — and she'd rather have fewer patients and give them extra time than apologize her way through a room full of frustrated people.
Miranti, by contrast, thrives on the packed house. She describes herself as a "master juggler" who is energized by chaos, using a full schedule to work through problems more efficiently while still taking time to connect with patients. As Neita put it, some audience members will fall firmly on one side of this.
Biologic Start vs. Accutane Counseling
Faced with initiating a biologic or JAK inhibitor for psoriasis or chronic atopic dermatitis versus doing the Accutane counseling for a teen with a reluctant mom in the room, both hosts pick Accutane — and both note these visits often get squeezed into a short, double-booked slot.
Miranti says she has the Accutane counseling "down to a science," complete with a protocol her MAs know cold and some scheduling hacks the hosts joke could fill an entire future episode. Neita agrees, describing an in-office Accutane visit that ran a full 25 minutes for a patient with severe cystic, nearly acne conglobata presentation — and felt great about it.
The appeal, Neita explains, is predictability: even with severe cystic or deep comedonal acne, she can talk patients through exactly what to expect, has no major safety surprises, and knows clear skin is coming. Both encourage providers intimidated by the iPledge system not to be scared off — as Miranti says, it's "totally worth it."
The Toughest Treatment Negotiations
Both hosts are self-described believers in shared decision-making, so the next dilemma cuts close: talk a stubborn teenager out of a 47-product, $200 skincare haul, or convince a surgically fatigued adult that a biopsy didn't clear their basal cell and Mohs is genuinely needed.
Neita takes the skin cancer patient. She leans on analogies patients understand — the lesion is like an iceberg, or it has "roots" that will regrow and cause damage if left behind — and finds most patients get on board quickly. For the rare holdout, she commits to close monitoring every six months and credits her practice's Mohs surgeons for results she trusts.
Miranti embraces the teenager, joking that she "speaks teen" thanks to her own kids. She uses a slime analogy to explain that layering many untested products together makes it impossible to know what's helping or irritating, then offers an FDA-approved, simplified regimen. Rather than banning everything, she has patients pick one favorite "security blanket" product — as long as it isn't egregious — and build from there.
The Product Bag Problem — and Reading the Ingredients
The hosts tackle the everyday reality of reconciling a longtime atopic dermatitis patient's medications: sort through a grocery bag or Ziploc of unlabeled, slimy tubes, or pull the pharmacy import into the EMR. Both acknowledge the drawbacks of each option, and that EMRs rarely talk to each other the way a perfect workflow would require.
Miranti prefers to see the physical bag—or, better, a photo of the products lined up on the counter — so she can zoom in on exact formulations and percentages. This matters especially when planning a biologic or systemic that will require a difficult prior authorization; she wants documentation of exactly what a patient has tried, since patients rarely remember drug names.
The same investigative mindset applies to over-the-counter and online buys. Both hosts stress that a marquee active ingredient means little in a bad vehicle or with harsh preservatives, and that oil-based, comedogenic products have no place on acne-prone skin. Miranti's approach: keep evidence-based medicine central, have patients start with one product, and add cautiously. Neita reinforced the lesson with a CCCA patient whose new online product — packed with oils and beeswax — was causing seborrheic dermatitis, a reminder to ask questions and investigate. (And a warning from Neita: one patient's oregano oil spilled and left her pod smelling for a week.)
The Nightmare Holiday Call: Hematoma vs. Vascular Occlusion
The final scenario splits along subspecialty lines: the dreaded after-hours call about an expanding hematoma in a beautifully closed surgical wound, or a filler patient reporting a pale, cold nose and cheek — the hallmark of a vascular occlusion (VO).
Both hosts choose the surgical hematoma. Neita, who practices general derm exclusively, says filler terrifies her because of the risk of necrosis, tissue travel, and even blindness; she feels far more confident opening a wound, finding the bleeder, and managing the repair later. Miranti, surgically trained by Mohs surgeons and having done closures for 10 to 15 years, has taken that exact holiday call and agrees the surgical problem is the more manageable one.
Miranti's takeaway for cosmetic injectors is sobering but empowering: vascular occlusions happen to the best injectors, and the more procedures you do, the more likely one becomes. She references FSDPA lecture series on VO management — including what to stock in an office emergency kit — and jokes there is "not enough hyaluronidase in the world." Her closing advice applies across every subspecialty: go in confidently, get properly trained, know who to call for backup, and review your emergency protocols before you need them.