Balancing roles as full-time associate professor at Saint Louis University in Saint Louis, Missouri, serving as medical director for the Area Health Educaiton Center (AHEC), and as medical director for corrections medicine for the Saint Louis County Department of Health, Fred Rottnek, MD, MAHCM, is a family physician on a mission. Dr. Rottnek was already involved in homeless health care when the opportunity to work with corrections came up, and he said he jumped at the chance, "knowing that my population would be similar — people without resources, in particular need of health care and a bit more time." Through practiging corrections medicine Dr. Rottnek has seen patients from 8 years old to 80-plus and provided obstetric, gynecological, dental and postoperative care, health screenings and immunization services. "It always surprises me how much preventative health care we provide," Dr. Rottnek said. "We have time with people when their lives have screeched to a halt. Many people suddently realize that the priorities they have held before may need to change, and health often ranks high for reevaluation."
Q: What led you to family medicine?
Dr. Rottnek: As I entered my fourth year of medical school, I used elective time to create a family medicine rotation. We had no family medicine department at Saint Louis University at the time. I had been leaning toward family medicine or med-peds. I had already started realizing one of my professional mottos: I don’t love medicine; I love what I can do with it. During my two family medicine rotations — one at a Federally Qualified Health Center (FQHC), one a private practice — I came to realize I was much more comfortable working with people in their own communities, whether that was ambulatory care center or a homeless shelter. Working with people in their communities, with their own concerns that they identified, was a more natural fit than “doing to” people in the more patient-passive hospital environment. The day that this hit me viscerally was a day I stayed late working with my preceptor. His schedule was packed. He knew me and my skills at the time, and he knew I had been a high school teacher prior to medical school. We did a lot of tag-teaming that day, with me reinforcing care plans with patients after he made the diagnoses and plan. Time flew by, I realized I was genuinely having fun, and I found that I already was on my path.
Q: What do you love about your work:?
Dr. Rottnek: I love that I can spend my life’s energies and enthusiasm working with people to make their own best decisions about their lives, whether this is about health in a clinical setting or about professional formation and vocation in an educational setting. Both roles have a remarkable intimacy, as a physician and as an educator, because I’m allowed into people’s lives along with all the messiness, confusion, brokenness and hope. I draw insight and strength from engaging with others at various levels and in different situations. Nothing is mundane when I look at the opportunities I have, as long as I keep this sacredness at the center. Place all this in the context of other people who want to change the world on a daily basis, while displaying some wickedly funny behavior whenever possible, and I marvel that I still draw a salary on top of it all.
Q: What is your most vivid memory from medical school?
Dr. Rottnek: Unfortunately, I was so busy, stressed, and sleep-deprived through medical school and residency that I have repressed many memories (I also completely missed the Clinton presidency). While some memories are creeping back in since I came back on campus four years ago, one of my most vivid that stuck with me is that of the repeated shouting matches that occurred in the ICU when I was a student on the trauma surgery clerkship. The trauma surgeon and the neurosurgeon would literally yell and argue about a patient’s care plan in the ICU hallway during rounds! I remember being unable to process how something could be so accepted, so routine and yet so wrong at the same time. I’m proud to be part of departments, programs and an institution today that is committed to making medical school (and patient care) more humane, effective and patient-centered.
Q: What is a typical day for you?
Dr. Rottnek: I spend roughly three days per week in clinical care in corrections: Tuesdays, Thursdays and Fridays. On these days, I spend about half my time seeing patients, 25 percent doing paperwork and the other 25 percent charting and in administrative responsibilities. Since we have built an interprofessional practice in corrections, time for scheduled meetings and regular communications are central to a successful program. Also, since corrections is a nurse-driven program — they are the primary caregivers practicing at the top of their games, armed with protocols and standing orders, and above all, their clinical judgment and experience — I have quite a few nursing notes to sign off daily. I also precept our family medicine residents in their community medicine rotation. My two-plus days a week on campus are spent teaching first-year medical students, teaching in our interprofessional education program, mentoring and advising students in our service and community engagement programs, and performing other duties related to my position as the AHEC medical director. I work a lot, but I do so by choice. I liken myself to a light switch, either on or off, while my partner, Scott, is more of a rheostat. He winds down with hobbies; I wind down with a nap.
I take my responsibility as role model seriously, although I don’t always take myself that seriously. In doing so, I remind students you don’t have spend as much time as I do in work-related activities. For me, folding my avocations and vocation into my work time is a good fit. Other people need more boundaries between work, service, fun and other stuff. That’s part of the joy of family medicine, academic medicine in particular: you have the opportunity to tailor your life to your values.
Q: What has been the greatest challenge you have faced as a family physician?
Dr. Rottnek: My reach exceeds my grasp. I don’t think I’ll ever have the time to do all that I’d like. While that is generally a good problem to have, I can also allow myself to be overwhelmed by what I perceive as so much need through the lens of my familial-hypertrophied sense of responsibility. Finding joy and contentment in the state of the way things are, despite all the imperfection, is my greatest challenge.
Q: How have things changed since you entered the field?
Dr Rottnek: Somehow, though don’t ask me how, we got through medical school without the Internet! I am thoroughly wired into the Internet now through electronic health records (EHR), medical resources, Google everything, email communications with peers and administrators, etc. Also, in a short 16 years of practice, I’ve noted hospital stays grow shorter and shorter, and sicker and sicker people are sent home without adequate resources for themselves and their families. A very positive change is that our society is far more vocal today about issues of health care and access for those with little. Society was not yet ready to engage in the discussion of health care as either an issue of the common good or national security during the early Clinton administration. Today, it ranks high in every discussion of local and national policy. Finally, another great improvement is the explicit recognition of interprofessional practice in health care delivery. Physicians cannot, and should not feel they should, be responsible for all aspects of patient care. By improving team skills for all care providers, we are improving patient outcomes and safety while we are having more rewarding and enjoyable professional experiences.
Q: What motivates you to be involved in community service?
Dr. Rottnek: The well-being of all of us depends on the well-being of those of us with the least. I was raised by a working class family, and I was the first of the family, ever, to go to college, much less graduate school. I was modeled the values of caring for others and taking responsibility for those with less. Since I did not have the benefit of growing up in a “medical” family, my role models were different from many physicians. Much of my greater comfort in community settings springs from this. Also, I have a very public record of living with major depression and some spectacularly odd self-defeating career choices until I came to understand the role of therapy and medication in my well-being. Perhaps, because of all this, I am never far away from the thought that life is hard. Working with others to alleviate that-which-sucks is good.
Q: What do you wish you knew when you were in medical school?
Dr. Rottnek: I would have trusted myself more. A book we give our cadre of first-year medical students who are accepted into a four-year longitudinal service distinction program is Parker Palmer’s Let Your Life Speak. In his own life’s story, Palmer describes his true happiness and vocation came from him uncovering/revealing his authentic self. It took me many years to begin this process, that of discovering the Authentic Fred. I think the Authentic Fred many have enjoyed, and remembered, more of his medical school experience. And he would have had more fun along the way.
Q: What surprised you most as a new physician?
Dr. Rottnek: Sometimes, doing your best just isn’t good enough. Growing up, I had developed the impression that, if you worked hard, cared deeply and applied your learning, good would result. And it often does, particularly when you are working with like-minded people. But health care is one situation when so much is out of your control: health care systems are complex, many people are involved in an individual’s care, you have only a tiny amount of time to influence someone’s health beliefs and behaviors, and you and your patient may functionally come from different planets. If I work obsessively to control any situation, I will likely have little effect in primary care. I initially underestimated the power of relationships and communication in effective patient care. With great joy — and the guidance of an extraordinary behavioral therapist in our residency program — I learned to trust myself and my patients to move clinical care agendas forward. And I also learned to enjoy being a physician.
Q: What do you tell undecided medical students who are interested in family medicine?
Dr. Rottnek: What tools do you want for your professional life? While there are many similarities in the types of practices you can build in all areas of primary care, family medicine training gives you more tools that you can use over the course of a career. Some tools, just as those associated with procedures or specific patient populations, can be set down or picked up when your practice or interests change. But importantly, with family medicine you always have the ability to walk into any situation and be a patient and family advocate; you know your way around. For example, I've been able to translate information for patients and their families in the intensive care unit (ICU) and in social situations. I can relate to their concerns through the lens of the family and their relationships because my perspective isn't limited to an age group or a specialty. Through our unique training from community sites to behavioral medicine to practice management, we all gain confidence in the broad issues that patients have outside of the hospital and the exam room. This allows us the ability to not only exchange information, but also build trust and relationships that are effective and long-lasting.
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Medical School & Residency
In Their Own Words: Family Physician Q&As
Dr. Fred Rottnek