Dr. Neil Resnick Pioneers Geriatric Care

Dr. Neil Resnick got his start in the field of geriatric health serendipitously.

Dr. Resnick received a bachelor's degree from Yale University and graduated from Stanford University School of Medicine. He did his internship and residency at Harvard Medical School.

At that time, he and his wife, Dr. Susan Greenspan (who would become an international authority on osteoporosis and direct both the Osteoporosis Prevention and Treatment Center and the Bone Health Program at Magee Women's Hospital) were two years out of sync in their medical training. Looking to "find something to do" for two years until her training was complete, he found geriatrics.

"I wanted additional clinical training, but since I had to be in Boston and didn't want to be an "organ" specialist, geriatrics was one of the only available options. Although it was a new field in the U.S., demographics suggested that geriatrics training would be valuable even if I didn't end up a geriatrician," Dr. Resnick said. "So I dove into the fellowship--and to my surprise, I loved it."

He was intrigued by his patients. Their stories, life lessons, and advice appealed to his interest in history. Their existential and ethical issues were those he'd wrestled with as a philosophy major in college, and the complexity of their medical and psychosocial issues offered a challenge and required a multidisciplinary, team-based approach.

"What was not to like?" Dr. Resnick said enthusiasticaly. "But the biggest surprise was that geriatrics expertise enabled me to alleviate and often even eliminate problems that had proved so refractory to strategies I'd been taught for younger patients. For that, my older patients were as grateful as I was."

Dr. Resnick's work to eliminate urinary incontinence in nursing home residents was historic and inspired by a patient named Joe. An immigrant, Joe had turned his trade as a cobbler in "the old country" into a successful shoe business in America. Now 89 and a widower with several chronic conditions, he'd moved into a nursing home and was one of the patients assigned to Resnick in his first month of Fellowship.

Throughout the previous year, Joe had become less sociable and family visits had become infrequent. When Dr. Resnick met him, Joe mentioned the work of Dr. Jack Kevorkian and asked that Resnick help him to end his life. After some probing, Joe divulged the source of his despair: he'd become incontinent (UI). His grandchildren had told him he smelled and stopped visiting. The odor had also caused him to isolate himself from other residents.

Knowing little about UI, but inspired by the optimism of his new field, Resnick asked Joe to give him a chance to learn more, hoping that it might be treatable. Joe agreed, the approach worked, and Dr. Resnick's trajectory was forever changed, along with his patient's quality of life.

"The transformation in his outlook was dramatic. He became more interactive with the other residents. He was overjoyed when his grandchildren resumed their visits and even took him out to dinner. I was elated. But I was also dismayed by the limited and conflicting information on UI, particularly in older adults, and wondered if I could somehow cut through the chaos in a way that might simplify and systematize the approach and maybe even enhance its efficacy," Dr. Resnick said.

To complete the research requirement of his fellowship, Dr. Resnick immersed himself in investigating UI. He immediately encountered several challenges, from having to undergo additional urological training when he was unable to find a urologist willing to serve a key role in his project, to having to respond to a firestorm when his grant application generated an ethical objection from the National Institutes of Health (NIH) reviewers who felt that the study was both unnecessary (because they believed the cause of UI in older adults was already known) and posed an unjustifiable risk as it would subject patients to infection.

Resnick was ultimately able to address NIH's objections and convince it to fund the study, which led to substantial insights and the discovery of a new disease that affected primarily older patients. Dr. Resnick notes that the study concluded without a single serious adverse event.

His research continued, resulting in new understanding that facilitated a previously impossible non-invasive approach to the evaluation and treatment of UI in nursing home residents. It also allowed for the creation of the "Minimum Data Set," which is now utilized by every U.S. nursing home as well as those in dozens of other countries. His UI experience also enabled him to apply his innovative approach to other common geriatric conditions, including osteoporosis, falls, and delirium, and even more so to the development of a proactive, pre-emptive, team-based strategy to prevent complications and adverse events in acutely hospitalized patients.

"In the process, we learned what so many others before us had also learned: change is not easy. But the effort has definitely been worth it," Resnick said.

Dr. Resnick did not realize at the time that his work on finding a cure for incontinence would determine the leadership of the newly formed Jewish Healthcare Foundation (JHF). JHF President and CEO Karen Wolk Feinstein, PhD had declined an offer to serve as JHF's first executive because, as a faculty member at Carnegie Mellon University and a Senior Vice President at the United Way, she felt she could make a bigger impact outside of philanthropy. Then she saw the Annual Report of the Commonwealth Fund that featured the work of Drs. Resnick and John W. Rowe in curing incontinence. In that moment, she changed her opinion of what health foundations could accomplish. Little did she know that Dr. Resnick would soon move to Pittsburgh and become a good friend and professional colleague.

For nearly 25 years, Dr. Resnick has served as the chief of Geriatrics at UPMC, leading one of the country's largest and most innovative geriatrics programs with more board-certified geriatricians than nearly any program, a wide array of senior services, and an extensive research portfolio. He is also the Thomas Detre Endowed Chair in Gerontology and Geriatrics at the University of Pittsburgh and is a professor of Medicine and Clinical/Translational Science.

In addition to its traditional research in geriatrics, his Geriatrics Division is known for developing several innovative care models, including the first geriatric-centered "patient-centered medical home" for the ambulatory setting, the "Staying at Home" program for home-bound patients, and a fracture-liaison program for patients with acute fractures to prevent a subsequent one. The Division also devised the RAVEN (Reducing Avoidable Hospitalizations using Evidence-based Interventions for Nursing Facility Residents) model for nursing home patients, which was funded by Medicare's Innovation Center, as well as a telehealth model funded by UPMC, which evolved into a successful startup company (Curavi). Additionally, Dr. Resnick and his team showed that "gerontifying" a hospital substantially reduced complications, falls, delirium, readmissions, and costs, and they also devised a population-based model for a health plan (Golden Care). Although the models differed in their details, each was based on the same premises: that optimal geriatric care requires anticipating problems and preventing them, and that improved systems of care can help to accomplish this," Resnick said.

"I'm also tremendously proud of our faculty and staff's commitment to striving every day to provide the best personal care to patients in our community and region." He is also proud of the improvements the Division created in training for all medical students and residents, which includes innovative new "tracks" for trainees; the country's first interprofessional team-based course offered jointly to students from 10 different healthcare subspecialties; its partnership with General Medicine which enhanced training for all of UPMC's medical residents; and its Geriatrics Updates CME Course, which annually attracts hundreds of practicing clinicians from more than 20 states and even overseas, and which was recognized by a national award from the American Geriatrics Society.

Dr. Resnick notes that his generation of geriatric medicine practitioners broke important ground by dispelling many of the myths of aging, differentiating the changes brought on by aging from those of disease, discovering the underlying contributors to many geriatric illnesses, defining geriatric syndromes, and demonstrating that the same symptoms seen in younger patients were often due to different causes and required different approaches for older patients.

"We also learned that optimal care of older patients must be patient-centered and congruent with their values and goals; that cure might be less important than comfort; that the expertise of a team of non-physicians was invaluable in addressing the multifaceted challenges; and that such an approach could greatly improve outcomes, often at lower cost and with fewer adverse effects," Dr. Resnick said.

"Now we're looking to the next generation to build on these lessons and to use the breathtaking advances in molecular biology, computer imaging, gene editing, machine learning, and artificial intelligence to generate breakthroughs in our fundamental understanding of aging, as well as the causes and treatments for Alzheimer's, cancer, cardiovascular disease, impaired immunity, and chronic disease," Resnick said.

Unfortunately, although geriatricians' job satisfaction is among the highest of 50 medical subspecialties, its pipeline is among the weakest. Dr. Resnick attributes this in part to the challenges affecting all of medicine, including moral injury and burnout, as well as the lower compensation paid to primary care physicians, which is less for geriatricians despite their additional training.

"It's especially sad because the field itself is so rewarding. Yet because geriatricians are so well trained to address the growing pressures to improve the efficacy, safety, and cost-effectiveness of geriatric care, I'm optimistic that we're heading into a golden era for geriatrics," Resnick said.

Dr. Resnick is currently a member of the Pittsburgh Regional Health Initiative Board and has previously served as a Board member of JHF. Having worked with JHF since his arrival in Pittsburgh, he underscores how important JHF has been to the advancement of geriatric care. "Much of the work mentioned earlier would not have been possible without the visionary and financial support of the leadership of the Jewish Healthcare Foundation. In addition, their brilliant, out-of-the-box thinking, endless optimism and energy, and "can-do" – actually "must do" – approach has made them an inspirational "force of nature" in effecting change," Resnick said.

As he looks to the future, Dr. Resnick's hope for the field is a better understanding of and treatment for dementia and frailty, and the full burgeoning of the nascent field of geroscience, as insights into the causes of aging may facilitate much more fundamental interventions for most of the illnesses of aging and contribute substantially to improved "healthspan."

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