Episode 103: Working as an Extensivist

Speaker 1: You are listening to Your Practice Made Perfect; support, protection, and advice for practicing medical professionals. Brought to you by SVMIC.

J. Baugh: Hello everyone and welcome to this episode of Your Practice Made Perfect. My name is J. Baugh, and I will be your host for today's podcast. Today, we're going to be talking about working as an extensivist, and helping us to discuss this important issue is Dr. Holly Berndt. Dr. Berndt, welcome. 

Dr. Berndt: Thank you.

J. Baugh: It's good to have you here. We're really interested in hearing what you have to say about being an extensivist, but before we get into the topic, let's hear a little bit about yourself -  maybe your background and how you came to this particular specialty.

Dr. Berndt: Okay. I'm very thankful for being here today and happy to share this because that's something I'm super excited about. But, I started out going to med school at Georgetown and I graduated in 2004, and then followed that with an internal medicine residency at Emory University in Atlanta, and finished my residency in 2007. At the time that I graduated, I was a National Health Service Corps scholar. And for that reason, I had to go to a health professional shortage area that qualified for my scholarship. 

And that led me to the North Georgia Mountains. And I had a practice - a private practice - that I owned in North Georgia - it was in Hiawassee, Georgia. And, I did basically the traditional internal medicine practice at that time. I had a full patient load in my office. I saw hospital patients and I also became involved in seeing nursing home patients at that time. Because I was the only internist in the county, and there was a transition taking place at the nursing home, I became the nursing home Medical Director. 

I remained there in North Georgia until 2015, at which time I kind of became tired of owning a business and decided to seek employment. And, it was also an opportunity for me to move back home where I am originally from - which is the Northeast Tennessee area - which is where I currently am now. When I moved at that time, I was working for a company called IPC, which was bought out by TeamHealth, and I was doing nursing home only. I was Medical Director at a couple of facilities, so I got some leadership training with that and became a certified Medical Director through the American Medical Directors Association.

That got me really interested in the leadership aspect of things and also focusing on quality control in the nursing homes. After a few years of working, particularly in the nursing home, an opportunity came up for me to work for Holston Medical Group, which is my current employer. And I began working for them in March of this year as their Primary Extensivist.

J. Baugh: Well, thank you for telling us a little bit about your background, and I'm really interested in hearing what you have to say about this idea of being an extensivist. I think that's a very unique specialty of medicine and I'm wondering, what can you tell us about this role, maybe what kind of patients you see, what type of services you provide and that sort of the thing.

Dr. Berndt: Sure. Indeed, it is a very unique specialty. I joked around with everyone when they were asking me what it was, that it was really a made up name. There is no such specialty as an extensivist. As far as I know, there's no training programs to be an extensivist. But, the way that I like to define it to people, it is providing almost like intensive care in an outpatient setting. It's not quite to ICU-level patients. However, at times I have had patients who qualified to be in the intensive care, but it's trying to provide these very intensive services in an outpatient setting, in order to provide high-quality and high-value healthcare.

J. Baugh: Well, it's interesting that you talk about this being intensive care because prior to starting this podcast, I actually Googled the word “extensivist” and I kept getting matches for intensivists. 

Dr. Berndt: Exactly.

J. Baugh: So what are some of the benefits to patients and their families, and maybe the community at large to be able to see, or to have access to an extensivist?

Dr. Berndt: Primarily, the way that I look at it, is that it is a way for these patients to stay out of the hospital, number one. Number two, it's a way for them to get a lot of the benefits that they could get in an emergency department or a hospital setting in an outpatient environment, at a much-reduced cost compared to what it would cost them if they were getting the same type of testing and services let's say in the emergency department.

J. Baugh: So there may be some physicians who did not start in becoming an extensivist, that wasn't a specialty that they initially were looking for as they began the practice of medicine, it's something that they went into a little bit later in their career. And, I'm wondering what kind of specialties of medicine might best qualify for a physician to serve in the role of an extensivist?

Dr. Berndt: A lot of doctors have not heard of this as a specialty, because it is not again a training specialty that we can do after a residency program. But I feel like my personal training as an intern, and particularly an internist who chose to also work in the nursing home, helped me to be a very good fit for the extensivist clinic that we have. What the extent of this clinic really does is, they serve the sickest of the sick, and they serve these patients who have multiple chronic illnesses and comorbidities. And because of that, even any primary care provider who has a mindset of what would be needed for an inpatient environment, or what might even be needed as far as rehab would be a good fit for an extensivist clinic. I believe that people who work with patients with chronic illnesses are probably the best trained to be a good fit for an extensivist clinic.

J. Baugh: Okay. So I know that most physicians do not have what you might call a typical day. Every day is different from every other day, but if you were to describe what a typical day for an extensivist would look like, how would you describe that typical day?

Dr. Berndt: That's one of the reasons I really enjoy being an extensivist is that, just like you said, I don't always have a typical day. But, my goal for what a typical day should look like would be that in the early morning, I see patients that I have already scheduled ahead, who are patients that I may be received as a referral from one of their primary care physicians, that I will follow along chronically with that patient. We also provide some chronic care in the extensivist clinic. I see these patients that are those really clinically complex patients in the nursing home setting what I call, multi-morbidity. 

These are patients who have multiple medical problems that all play on one another, and also affect their social situation in many circumstances. So, that would be the morning that I would fill up. And as the day goes on, I would receive phone calls from the primary care physicians or from the urgent care, or even some of the specialists about patients who may have an urgent problem that needs to be addressed. The patient may have hypotension and they need IV fluids. They may have hypotension and concern for early sepsis. So, I will save them to initiate IV fluids and IV antibiotics.

Sometimes I'll receive a patient that has high blood pressure that they can't control, and I can administer urgent medications to try to lower their blood pressure and actually monitor them for a few hours to make sure that their blood pressure comes down. Those are some types of things that people would often land themselves in the emergency department for, but instead within HMG, we can provide that type of care and high-value healthcare and help them to avoid just a visit to the emergency department.

J. Baugh: Yeah. It sounds like you have a lot of different situations that you have to be prepared for when you enter into the practice of being an extensivist. So let me ask you this question, what are some of the areas of potential liability exposure that you've identified and how would you recommend resolving those?

Dr. Berndt: That is certainly something that I have looked at as I have been taking care of these very sick patients, because a lot of these patients are coming to see me because they absolutely refuse to go to the hospital. They will tell me under no circumstances do I want to go to the hospital. And there are many times at which I've advised the patient that I have essentially exhausted my resources and you need to be in the hospital. And, there are times these patients are completely cognitively aware and capable of making informed decisions, and they will refuse to go to the hospital. What I do at that time is that I just thoroughly document my discussion with the patients and document their refusal, and I essentially explain to the patient that you are going against medical advice, but I will do my best to help accommodate your desires. That's one of the situations. 

The other situation is just the general fact that I am trying to care for these very ill patients that require lots of interventions. And these are interventions that indeed can sometimes be provided in a hospital environment. Where I try to alleviate the possibility of liability with those types of patients, is the time that I spend with them. That is a luxury that I have, in the extensivist clinic, is that I do have more time that I can have face-to-face with the patient, because I don't always have that set schedule like most primary care physicians have.

I sit and I spend time with the patient, educating them and educating their family about the risks of being treated in an outpatient environment compared to an inpatient environment, and the benefits as well, and the limitations that I have. I do tell them that if there's an antibiotic that needs to be given more frequently than every 24 hours, it limits what I can do in my clinic. And I really believe that that goes across the board with all specialties, that if you can spend the time with your patient and really communicate with them, that will certainly decrease the possibility that those patients are going to try to pursue any type of litigation towards you.

J. Baugh: I know that most physicians and healthcare providers really wish that they had additional time to be able to spend with patients, and I'm glad to hear that you're able to do that. So, Dr. Berndt, what kind of information do you give the patient upon discharge?

Dr. Berndt: We have a standard clinical instruction sheet that we give to every patient that comes through our clinic, regardless of what they were there being treated for. The first thing, it is very clear as to what we believe that we were treating them for. At the very top, it says today you were treated for X problem. And then, it actually goes on to the next line and says what treatments we gave. We have a thing that will mark whether we give them IV fluids - particular IV antibiotics - because we want that to be available to the patient, that if by chance they do get sick or after they leave my clinic and have to present to the hospital, that they've got this sheet that says what they were given. Particularly if they were given an antibiotic or some type of other parenteral medication.

I also add to that specifically what home regimen changes that I want them to do. And I give them specifically when they are going to have a followup with me or their primary care physician. I make sure that every patient has a followup appointment scheduled. So to make sure that these very sick patients and these very complex patients don't fall through the cracks. And at the very end, there is a disclaimer that reminds them that our clinic is only open five days a week, Monday through Friday - we're open from 8:00 to 6:00 - but I give them instructions as to how to reach someone after hours.

J. Baugh: So, if we have any listeners who are healthcare professionals that are considering going into a field - such as being an extensivist - what kind of advice would you give to someone who might be pursuing something like that?

Dr. Berndt: You know, a moment ago you asked me about what specialties would best be suited, but I really think we look at it more as, what types of experiences in medicine would best suit a provider for this type of clinic.

J. Baugh: Okay.

Dr. Berndt: Because for me, what I feel like has shaped me into being able to do this role in a better way, is the different types of experiences that I have had. Because I owned my own practice and I know what it's like to try to run an office and stay on a very tight schedule, and try to see patients and make sure you don't make the person who's next in line angry because you're delayed. I understand that perspective. I also understand the perspective of what it's like to be a nursing home physician and what types of patients need rehabilitation, and when they come out of the hospital, when they would be better suited to go home versus in the nursing home.

Where I have had hospital experience, it very much makes me aware of what types of experiences the patients have in the hospital, how much downtime there is in the hospital when there's not a lot of things going on for those patients, which allowed me to kind of shape what I was coming into the extensivist clinic with. So, a person who is a provider who may be experiencing burnout, which is kind of in a place where I was for a while and I was looking for something different. This really allowed me to integrate my skill sets, and to realize that I'm going to be seeing a lot of these same types of patients, "the internal medicine patient" or “the geriatric patient” that I saw in the nursing home. And how can I best serve that patient in the environment that they're in? How can I keep them out of the hospital? How can I keep them out of the nursing home? If they are at home and I feel like they're unsafe, how can I keep this person off the floor of their home, prevent them from falling?

And so, all of these different experiences that I've had helped me to be able to come into the extensivist clinic with a mindset of, "Okay, I'm going to do everything I can to provide high-quality and high-value healthcare for these people." I saw that in the nursing home that we could provide IV antibiotics without having to send a person to the hospital. So, knowing that, I also came into the extensivist clinic thinking, "Well, I can provide IV antibiotics here and we don't have to do that in the hospital.” So, if you can just sort of have a wider perspective, then the area of medicine that you are particularly working in right now, I think that those types of things could prepare you well to be an extensivist.

J. Baugh: So as we bring this podcast to a close, are there any tips or advice that you would like to leave our listeners with?

Dr. Berndt: I just think that the idea of an extensivist clinic is so valuable in a healthcare system where costs are just escalating and escalating. The really nice thing that I have is, I can even order certain procedures to be done as an outpatient. I can order home health when it extends beyond what I'm able to do in my clinic. I can arrange for the patient to go back into a rehab facility if they have recently been discharged from the hospital. And it is just a really nice environment to really be able to thoroughly parse through the patient's medical problems in order to help them avoid hospitalization, which in the long run will lower healthcare costs as a whole.

J. Baugh: Well, it certainly sounds like the specialty of extensivists is something that ought to be considered more, because you're able to spend more time with your patients and you're able to do it at a lower cost than say the patient there may go to the ER. So, that sounds like a win-win for everyone when you can spend more time with less cost, that's really great to hear. 

Well, Dr. Berndt, we want to thank you for your time talking to us today about the specialty of being an extensivist. It was very helpful and very informative so thank you a lot. 

Dr. Berndt: Thank you very much for having me. 

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect, with your host J. Baugh. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast. 

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