Geriatrician and author Robert Butler, MD, has long been involved in activities that have changed the way the U.S. medical establishment and the public view aging. He gained national recognition after receiving a Pulitzer Prize in 1975 for his book, “Why Survive?” which documented the social and medical challenges and improvements in the lives of millions of older people. He established the first geriatrics department in a U.S. medical school at the Mount Sinai School of Medicine in 1982. He also helped establish the National Institute on Aging at the National Institutes of Health. More recently, he has focused on positive aspects of aging as the president and CEO of the International Longevity Center USA.
Dr. Butler's experience is especially pertinent today as baby boomers move towards old age and the nation grapples with how to care for a burgeoning elderly population amid insufficient resources and a dwindling supply of geriatricians. Dr. Butler talked to ACP Observer about demographic trends, why geriatrics has not been a popular career choice and how the advent of longevity medicine might change some of these forces.
Q: What's driving the surge in health care needs of the aging population: longevity, medical advances or higher quality of life expectations?
A: People are living longer. By 2025, 20% of the population will be 65 and older, compared with almost 13% now. Also, the data show they have fewer disabilities until a great age, so they are also healthier. There's also great improvement in technology to diagnose and treat; that adds to the costs. Innovations like drugs and technology drive the costs much more than the population's aging does.
Q: As the baby boomers age, how would you expect the health needs of older people to change?
A: The baby boomers are the fattest generation in American history, unfortunately, and they are contributing enormously to the prospect of diabetes and heart disease. The baby boomers are not healthy. They have a reputation as though they are all exercising, but that's not true. They're going to be a costly group.
Q: Do you think that more people might continue working past age 65, and could this have an effect on health care for older people?
A: Most Americans don't quite realize they're no longer going to get their Social Security at 65. It's slowly being phased up to 67. So I think as it dawns on more and more older people that they aren't going to be able to afford their retirement, they are going to stay in the work force longer. And that's actually mutually advantageous as far as health is concerned. It seems like people who have something to get up to do are actually more likely to be [healthy].
Through medicine and through the good work of doctors and the health care system, and if we could really get health promotion underway, we could have a healthier population. If they then worked longer, it would be a huge benefit to the Social Security system, to the cost of Medicare, etc.
Q: What can medical educators do to encourage more medical students to choose careers in primary care and geriatrics?
A: Only about 30% of doctors in our country are engaged in primary care medicine. It's 50/50 in most of the rest of the world. Doctors, when they graduate from medical school, have an average of $150,000 in debt, so it's very attractive to go into a procedural specialty. The future of medicine is going to have some shift that moves us into more primary care, or we're going to see the further development of nurse practitioners, and nurse practitioners are going to become the primary [providers].
Q: Is it only salary issues that make it unpopular?
A: I think that's part of it. It's also scary to some people. With aging, you think of deterioration, depression and dementia. It takes a while for medical students and young doctors to appreciate that even modest medical and social intervention can make an enormous difference in the life of a person and give you satisfaction. But it's not quite the same as some of the more heroic tasks that we doctors might be able to do in surgery, in the emergency room. I don't think it's just money, I think some of it is fear and uneasiness.
Some of it is that we only have 11 departments of geriatrics in 145 medical schools, and we have divisions and programs in another 40 or 50 at most. So there aren't too many models for the medical students to follow.
Maybe the [baby] boomers will get politically [active], and because they will make up one out of every five Americans, and about one out of every four voters, they may be more demanding of better medical care, better trained doctors, nurses, and social workers … so they might have a very salutary effect. I hope they do.
Q: Other than Medicare, are there any other federal health care programs working to provide better health care for the aging population?
A: I think the Veterans Administration system has been pretty good. And the National Institutes of Health provides grants which help bring new knowledge about aging, about Alzheimer's disease, about a variety of different topics that are relevant to the better care of older people. The Agency for Health Care Research and Quality has a small budget and provides some efforts.
Q: What is longevity medicine?
A: Geriatrics, as I see it, is an effort to maintain people's function to overcome the kinds of problems that may come about as a result of multiple complex illnesses that unfortunately characterize at least a significant proportion of older people, especially the older they get.
Longevity medicine is an effort to maintain health through vigorous health promotion and disease prevention efforts like not smoking, moderate alcohol intake, physical aerobic activity, muscle strengthening and a reasonable diet. Longevity medicine is the positive force of keeping people alive, functioning, and going, whereas geriatric medicine is the repair method.
Q: Is it possible that as more students and residents find out about the positive aspects of longevity medicine that there might be more interest in caring for the elderly?
A: I hope so, but I think as you pointed out earlier, if they also are compensated a little more fairly compared to procedural specialties [interest in longevity medicine could increase].