Robert Butler’s Legacy
August 30th, 2010
 by
Christine Cassel
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Editor’s note: Earlier this summer, on July 7, Robert Butler died of leukemia. Butler was the founding director of the National Institute on Aging, a Pulitzer Prize-winning author, and one of the nation’s leading authorities on aging and geriatrics. With the essay below by Christine Cassel, president and CEO of the American Board of Internal Medicine, Health Affairs Blog is beginning a periodic series of posts about Dr. Butler and his legacy.
As he did for many people, Bob Butler inspired me to seek a career in geriatric medicine. When I was a young physician, training at a prestigious medical center and set on a career in clinical research, our teachers would ask us to find young patients with unusual diseases to discuss at our teaching rounds. After rounds, we would spend the rest of the day seeing old people with common diseases—and very few teachers were interested in helping us understand how to help these people regain their ability to live their lives, to go home and take care of themselves.
Butler described this therapeutic nihilism in his prize-winning book Why Survive? and coined the term “ageism.” He vividly described the disdain and distaste for aging in American culture, and how it has led to seriously inadequate medical and social attention to those people who would most likely benefit from advances in science and social programs.
One of the most remarkable and central facts of Bob Butler’s life and his legacy is that he started with that grim and depressing statement, and from it flowed a relentlessly optimistic and generative profusion of efforts to turn the tides of ageism and change the very culture of our society to one that respects age, commits to the science and practice of better care for the disorders that limit our abilities to make the most of our older years, and creates a previously unthinkable concept: successful aging.
Butler’s energy and optimism made possible the creation of the National Institute on Aging (NIA), the first Department of Geriatrics in a US medical school, and an international center devoted to global advances in celebrating and enhancing longevity. In each of these, he had a brilliant knack for identifying the key policy levers that could create change.
Addressing The “Inevitable” Problems Of Aging
For example, in the early years of the NIA, most people, including physicians, thought of cognitive impairment in old age as inevitable “senility.” In devoting medical research dollars to studies of Alzheimer’s disease, the NIA legitimized that research and gave a diagnosis to millions of families to understand what was happened to their loved ones. And from that, the clinical disciplines of geriatric medicine, nursing, and social work developed interdisciplinary models to better care for patients who had Alzheimer’s disease.
Butler’s example was followed by researchers who created medical models for research, treatment and prevention of delirium and falls. Before their work, the fact that many older people become confused at night when they are hospitalized was called “sundowning” and considered normal for old age. Similarly, older people were at risk for falls and disabling fractures, but before Butler’s work these were not considered medical problems.
Like many effective people, Bob Butler was a very persuasive speaker, with an amazing ability to keep both engaging personal stories and attention-grabbing statistics on the tip of his tongue. Thus, he was able to make his case compellingly in many venues and many nations, and to many—and very different—audiences. For those of us who watched his effective presentations, these speeches were themselves worthy objects of study. We realized that carrying the baton he handed to us required understanding the skills of persuasion just as much as the skills of being a good geriatric clinician or researcher.
This was an important personal lesson for me, one that I often shared with trainees, sometimes in sessions titled “Geriatrician as Cheerleader.” The geriatrician’s job is to convince young physicians in training that a frail elderly patient with multiple complex problems is, in the parlance of medical education, “a great case,” rather than an undesirable and insolvable situation. Indeed, each one is a great case because sorting out the symptoms; diagnosing subtle, complicated conditions; identifying medication interactions; making judgments with patients and families about appropriate interventions—all this requires deep knowledge of medical science, as well as great competence in communications, systems-based practice, teamwork, and medical ethics. This is one of the most demanding ands most needed of all specialties, but unfortunately too few medical students seek training in it.
Carrying Butler’s Legacy Forward Under Health Reform
Before he died, Bob Butler understood the importance of changing the health care delivery system and the methods of recognizing and paying physicians that were necessary to create this change. He was pleased to see the passage of health care reform, and if he were still alive, he would be working to make sure that patient centered medical homes and accountable care organizations include the geriatrics expertise they will need to care for the patients who most need these innovative models. Without Bob here, it will be up to the rest of us to ensure that the advances promised in the Affordable Care Act include the advances in geriatric medicine that he helped to achieve.
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