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An Interview with Dr. Brent Forester by the
American Medical Student Association.

Dr. Forester is the Medical Director at the Geriatric Neuropsychiatry Unit at McLean Hospital in Belmont, MA. In February 2006, he was listed as one of Boston's top Psychiatrists in the Top Doctors List by Boston Magazine.

Dr. Brent Forester attended Dartmouth College and later went onto Dartmouth Medical School. In Boston, he completed an internship in medicine at Massachusetts General Hospital followed by three years of psychiatry at McLean Hospital in Belmont, MA. His fellowship in geriatric psychiatry was done at Dartmouth Hitchcock Medical Center.

When and why did you decide to pursue geriatric psychiatry?

I think my interest in geriatric psychiatry came about through two main factors:

I have always like older people: during family gatherings I usually found myself in the corner of the room listening to the fascinating stories of my grandmothers who lived through most of the 20th century.

In medical school I had a hard time deciding between a career in internal medicine and psychiatry. Geriatrics is the one specialty in psychiatry in which you must understand and appreciate the interaction between medical illness, neurological disorders, medication side effects and psychiatric symptoms. I most enjoy trying to figure out the many complex biopsychosocial factors influencing psychiatric problems in an older person. Geriatric patients with psychiatric issues do in fact get better and can lead a much more fulfilling and enjoyable life. Families may also be eternally grateful!

What do you find is most exciting about geriatric psychiatry?

What is most exciting is connecting with a patient who has been suffering and being able to figure out why and do something about it. I spend more time taking patients off medications that are doing harm than putting patients on new medications that may only add to the problem. This takes patience and also a fair amount of good detective work.

I also feel that with the aging of our population, there is a tremendous need for physicians who specialize in geriatrics to be treating these patients and educating other health care providers and families.

I think that in the next ten years or so we will have new understandings about the causes of and treatments for late life psychiatric disorders such as depression and dementia. This may come about through research using developing technologies such as genetics and functional neuroimaging.

What are the characteristics that a geriatric psychiatrist should have?

Traits common to all good doctors: a sense of humor, patience, a willingness to listen and explore possibilities and not jump to conclusions. I also think an interest in medicine, neurology and psychiatry is helpful. Working with families is a key part of what we do so some desire or interest in this would be important.

Are there any specific rotations/internships that you would recommend for medical students who are interested in geriatrics?

Spending time with a potential mentor who practices geriatric medicine or psychiatry would be very helpful. Evaluate patients in a variety of clinical settings: acute care hospital, geriatric psychiatry unit, community clinic, assisted living facility and, importantly nursing home settings. Many of us have our own biases about aging for a variety of reasons. Nursing homes can be wonderful places to work and this can be demonstrated through a medical school training experience with a mentor in geriatrics.

What are your greatest challenges as a geriatric psychiatrist?

One of the biggest challenges is to deal with the reality that our patients will die, sometimes sooner rather than later. Working on an inpatient unit with very sick individuals has brought this point home recently. Palliative care at end stage dementia is vital and we need to be better trained in providing this care when appropriate. I focus on quality of life for my patients and this resonates well with patients and their families.

Please describe your typical day:

Mornings start out rounding on our 18 bed inpatient unit which specializes in the treatment of patients with Dementia and associated psychiatric problems such as agitation, aggression, depression and psychosis. Out patients come to us from homes where caring for a loved one with Alzheimer's disease becomes too burdensome for families; assisted living facilities or nursing homes. My mornings are spent interviewing patients, meeting with our interdisciplinary team of social workers, nurses, neuropsychologists, physical therapist, occupational therapists and an array of consulting MDs including internists and neurologists. I am often supervising medical students during their psychiatry rotation, general psychiatry residents or our geriatric psychiatry fellows. One of the more rewarding aspects of this work environment is the help we give to families who are often at a loss to understand what has happened to their spouse, mother, father, sister or brother. It can be difficult to care for a loved-one that has been previously a high functioning member of society and now suffers from periods of agitated behavior and hallucinations.

In the afternoons, I am often seeing geriatric outpatients in our memory disorders clinic at McLean Hospital where we diagnose and treat patients with dementia and offer help to their families. These individuals are often referred from primary care MDs who need assistance with diagnosis or treatment. Other afternoons I see patients in an office in the community at a continuing care retirement community. Patients are referred to me with a variety of late life psychiatric issues including bereavement, depression, early dementia, anxiety problems and even substance abuse. Once again I rely on the input from families, staff and the nurses to get a better sense of the clinical situation in addition to the history and examination of the patient.

Throughout the week I spend about 20% of my time focusing on clinical research interests. One project is a large federally funded study being run by one of my mentors from Dartmouth Medical School where I did my geriatric psychiatry fellowship and spent six years on the faculty. This study is looking at psychosocial rehabilitation and health care management for older adults with severe mental illness (such as schizophrenia and bipolar disorder) who are still living independently in the community. The goal of this study is to provide these patients with the skills and health care assessment and education which will keep them functioning independently for as long as possible.

Another project we are about to begin will be a clinical pharmacological trial looking at a new treatment for geriatric depression. I sometimes use this research time to work with other specialties (such as neuroimaging) around McLean Hospital in an effort to develop projects which will help to advance our understanding of treatments for late life psychiatric disorders.

Dr. Forester is also an instructor in Psychiatry at Harvard Medical School.