SPECIAL REPORT: A day in the life of the University Medical Center at Princeton

Hospital at crossroads in 85th year, but patient-caregiver bond is still heart of the operation.

By: David Campbell
   Ask any of the doctors or nurses to describe a typical day at University Medical Center at Princeton, which marks its 85th anniversary this month, and they’ll probably tell you about one of their patients.
   They know that any given day at the hospital can bring the unexpected, but that the bond between caregiver and patient is a constant, day in and day out, week after week. You can depend on it, they’ll tell you.
   This is as true today as it was back in 1919, when the hospital was founded in a converted farmhouse on 5 acres off Witherspoon Street.
   In the beginning, there were five physicians on staff. A total of 363 patients were admitted that first year. There were 78 maternity patients and an equal number of births. Patients slept on surplus military beds bought from the War Department. If they had to be transported to the farmhouse’s second-floor operating room, they rode a ramshackle old elevator worked by hand pulleys.
   The first major operation there was on a young boy whose skull was fractured from being stepped on by a horse. That first year, an additional $15 in revenue was added to the hospital’s coffers from the sale of hay harvested from the grounds of the former dairy farm.
   Eighty-five years after its founding, the hospital boasts state-of-the art facilities as part of the greater Princeton HealthCare System. Its once modest staff has grown to include more than 800 physicians and dentists, 412 registered nurses and scores of other health-care professionals.
   Each day at the hospital now, about 2,500 meals are served to patients, employees, physicians, volunteers and visitors. About 1,565 inpatient and outpatient lab tests are performed. Each day, UMCP goes through about 4,383 pounds of linens. And every day, its switchboard receives a total of about 2,000 calls.
   The facility itself has grown to become a 310-bed acute care teaching hospital affiliated with University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. Last year, the hospital delivered 1,891 babies. It handled 35,556 emergency department cases.
   Today, as in 1919, University Medical Center at Princeton stands at a crossroads. The health-care system of which it is the centerpiece, in collaboration with the community at large, is weighing whether to grow the hospital in place or relocate to a larger campus in the region.
   According to PHCS President and CEO Barry Rabner, the grand themes that were evident in the hospital’s early days — such as growth, modernization, a standard of excellence, community participation and an atmosphere of caring — are equally relevant today.
   "These themes are still guiding us today," Mr. Rabner said. "And they’re going to guide us through the next 85 years and beyond."
   In most basic terms, it’s about the relationships between hospital staff and the people they serve.
   A day in the life of University Medical Center at Princeton, therefore, is best viewed in snapshots.
   Geri Karpiscak, nurse manager with UMCP’s cardiac rehabilitation department, said she’s had her share of emotional moments in the roughly 16 years she’s been with the unit. It’s not unlike the highs and lows anyone in a family might feel. For her and her patients, many of whom have relationships with the department that go back several years, the bonds can be lasting.
   "You get to know them, you get to know about their families," she said. "Over time, it also allows the patients to open up to us so we can help them more. You almost become like family over a period of time.
   "Over the years," Ms. Karpiscak continued, "you’ve heard about their first grandchild in kindergarten going into secondary schooling, or a child graduating from college and having their first baby. It really becomes a family experience, and a bonding on both sides."
   She added: "Is it emotional? Absolutely. I’ve been to funeral services of patients that I’ve gotten to know, because they were important to me and my life."
   Her department offers both cardiac and pulmonary rehab care services, though cardiac patients outnumber pulmonary patients. People recovering from heart attacks, coronary-bypass surgery and even heart transplants come to the unit for rehabilitation and education. So do people with emphysema and chronic bronchitis, lung-transplant patients, and people dealing with asthma.
   Typically, patients first embark upon a monitored exercise and rehab regime in collaboration with department physiologists and certified cardiac nurses that can last eight to 12 weeks. They then graduate from the monitored program to a secondary maintenance phase program in which they essentially use the department’s fitness equipment like a gym. Along the way, they receive education in such topics as diet, stress management and weight loss and weight management.
   On average, about 20 to 25 patients in the first-phase monitored program use the facility on any given day. There are roughly 70 patients in the secondary maintenance program, many of whom have been coming back to the department for several years now.
   Take Bill Jones. He’s been with the program for more than a decade. Ms. Karpiscak was his primary nurse when he first came to the unit for cardiac rehab. She said he’s watched her advance in her job from part-time staff nurse to nurse manager.
   "One of the things about Bill in particular, he has a wonderful way about him of focusing not only on what he needs to do for himself, but he’s also a great mentor of his fellow rehabbers," she said. "I consider Bill a friend now. I know his wife. I’ve seen him over the years really make a difference in his life."
   Mr. Jones, 72, is a former hospital administrator living in Montgomery Township. He said that viewed through his professional eye, the department and its staff are exceptional. He said they have been instrumental in keeping him alive.
   "That’s no joke," Mr. Jones said. "If I weren’t going there, I would never get it done. It’s the motivation, the fact that you’re going there, in a surrounding with other people doing the same thing.
   "It is very much a dynamic of mutual support," he continued. "The concern that the ladies have to take care of the patients is just wonderful, and it’s a big deal. It’s mutual support to stay on a healthy exercise program. It’s the general concern for each other."
   On Monday at about 9 a.m., UMCP’s emergency department was quiet. The waiting room’s only occupants were a woman and child sitting under a television that played cartoons. Two women were giving blood in the nearby blood-donor center.
   According to Nancy Panarella, director of the Department of Emergency Services, mornings are generally quiet, with the peak hours typically between 11 a.m. and 11 p.m.
   You could say there’s no such thing as a typical day in the emergency department. Physicians there might treat anything from a child’s lacerations to a massive heart attack. Ms. Panarella said it definitely can be hectic at times. The waiting room can be all but empty one minute, and a moment later four or five ambulances are pulling up simultaneously outside the doors.
   Staff on the floor include eight registered nurses, two board-certified emergency-medicine physicians and a physician’s assistant. The somewhat newly renovated department hosts a fast-track suite clinic for treatment of minor emergencies, and an acute emergency care suite dedicated to more serious emergency cases. Not a week goes by when the department’s beds aren’t full at some point. When they are, the medical team uses the hallways. No one is turned away.
   About 36,000 patients pass through the doors each year. The department treats about 100 patients each day. It is open 24 hours a day, 365 days a year. Given the high stress factor that can come with working there, it may be surprising to learn that the turnover rate in the department is extremely low. Why do staff stay?
   In a word, Ms. Panarella said: Dedication.
   "I think it’s stressful," she said, "but they do keep coming back because they need to be proud of the job they do."
   Dr. Chris Belardi, chairman of the Department of Emergency Medicine, said the hours can be difficult and the work physically demanding. Indeed, he said, it is very much a physical occupation.
   "You come in at 8 a.m. and you don’t sit down," he said. "You’re on your feet for 12 hours. There’s a lot of physical stuff — and I don’t think anyone gets used to working a night shift."
   He continued: "We’re frontline. We’re in the trenches."
   Dr. Belardi said emergency-medicine doctors, because they might be confronted with a variety of medical conditions on any given day, must know a great deal from a broad spectrum of medicine. He said they are problem-solvers by nature, and they are result-driven.
   "You go into emergency medicine because you get a problem to solve, and once you solve it you intervene," he explained. "You get to see people get better in real time. Is it exciting? Yeah. Any emergency physician will tell you that the real thing that drives us is the ability to intervene in a person’s life when they’re critically ill, and see results."
   Dr. W. Thomas Gutowski, who chairs the hospital’s department of orthopedics, said patients these days are more sophisticated than ever when it comes to their options in the increasingly high-tech realm of orthopedic care and joint-replacement surgery. They research surgeons’ curricula vitae online. They show up for first consultations with legal pads filled with questions. They know their stuff.
   And, Dr. Gutowski said, he wouldn’t have it any other way.
   "Patients make good decisions," he said. "They’re not being led. They have ownership. They’re really an active participant now."
   HealthGrades, the nation’s leading health-care quality company, named UMCP among the top three hospitals for joint replacements in the state in 2003, the surgeon said.
   There are 28 orthopedic surgeons on staff at the hospital. There are five surgeons who specialize in procedures on the spine. Surgeons conduct more than 500 joint-replacement procedures each year. Dr. Gutowski said he himself does about 300 hip and knee replacements annually, and during any given day may have from six to nine patients in the hospital with whom he makes rounds on a regular basis.
   The specialty of orthopedics covers every bone and joint in the body, and includes sports medicine. Procedures can range from the relatively simple resetting of a fractured limb to repairing torn cartilage, tendons or muscles, to joint restructuring and spinal surgery.
   Orthopedic surgical procedures have witnessed immense advances over the last 30 years or so. Operations that once took six hours now can take little more than an hour. Patient stays in the hospital that used to run 10 days can be no more than three days today. Patients can be back to work and active again in sports and other activities in many cases in fewer than six weeks.
   A UMCP surgeon in 2003 was the first in Central Jersey to use a new, more durable ceramic implant in a total hip-replacement procedure.
   Dr. Gutowski is the only surgeon at UMCP, and one of only a handful in the state, doing an innovative new two-incision total hip replacement procedure that came out of Chicago about two years ago, and which has proven highly successful at UMCP. It brings less trauma to the body, less pain, less blood loss and faster recoveries. He said he will be training a second surgeon on the procedure in December.
   But extensive training and peer review is required before a procedure like this can be conducted, which may account for why so few surgeons are doing it at present. In addition, Dr. Gutowski added, "It’s a hard operation to do."
   It may not be for everyone seeking care, though. As the surgeon noted: "High tech is not necessarily the right option for all."
   That’s where the informed patient, in consultation with the doctor, comes in.
   And long after the surgery is finished, that consulting relationship continues.
   Dr. Gutowski said UMCP surgeons make sure to follow up with their patients every two years or so. By way of example, he cited a woman on whom he operated 10 years ago after she suffered severe trauma in an automobile accident. She was 18 when the wreck occurred. Since then, he said, he’s seen her graduate from college, raise a family, build a career.
   "You get to know these patients very well," said the surgeon, who has been a Princeton resident for almost 20 years.
   "Many of these patients are from our community," he said. "You see them on the soccer field. You see them in the grocery store. It’s very gratifying to see their lives return more to normal."
   Dr. Kathryn Robison, associate program director for the Internal Medicine Residency at UMCP, said that at some points in every resident’s training there are moments of intense stress.
   This is hardly surprising. The workload is enormous. The round-the-clock schedule can be unrelenting. The core focus of a hospital residency is patient interaction, and sometimes patients die. This is a fact of life. It is unavoidable, and one that Ms. Robison said every trainee must come to grips with during his or her training.
   Learning how to deal with it, which is only one aspect of the enormous spectrum of experiences trainees have while working UMCP’s wards and departments, is part of what the associate program director calls the "art" of practicing medicine. She said it is central to their education at the hospital.
   "A central part of our teaching here is not just the science of internal medicine, but the art of medicine," Dr. Robison explained. "The humanism and professionalism. Listening to your patient, getting the details, being there for them to console them and help them through the hard times. Putting the patient first."
   UMCP is a teaching hospital that serves as a teaching affiliate of UMDNJ-Robert Wood Johnson Medical School.
   It has programs for residencies — that period after graduation from medical school when students have earned the title of M.D. and now must earn their license to practice medicine — in surgery and internal medicine. There are about 15 trainees in surgery. Surgical residencies last about six years. In internal medicine, the residency program that Dr. Robison oversees, there are about 30. Their residency takes about three years to complete.
   The Medical Center also hosts about 40 medical students in their second, third and fourth years of medical school.
   Internal medicine trainees work in rotations of shifts that can run from 7 a.m. to 8:30 p.m., and from 8:30 p.m. to 7 a.m. Dr. Robison said it is not uncommon for residents to spend a full 24 hours in the hospital, but said that nobody works a full 24 hours.
   She said trainees are taught by the entire staff of the hospital, which she said is a mutually beneficial relationship not only for the residents and the physicians, but for the patients as well.
   That’s because in an academic environment such as this, teaching doctors are encouraged to keep abreast of the latest developments in medicine, which means that patients receive treatments that can be on the cutting edge of science. UMCP also brings in regular speakers to teach residents and staff at the hospital to make sure everybody is current, she said.
   A typical day for a resident at UMCP is a long one. It includes rounds with patients in consultation with the attending physicians; teaching sessions on patient care; lunchtime lectures; and patient admissions from the hospital’s emergency department. Trainees also work at UMCP’s indigent clinic, where they provide supervised care for patients there. In addition, they do some outpatient work with private practices.
   Professionalism falls under the art of medicine, and it, too, is taught at UMCP.
   It involves learning to recognize and appropriately reflect a doctor’s standing in society. This includes making sure to act and dress professionally; treating colleagues, patients and medical staff with courtesy and respect; honoring patient privacy. It also includes community service. Dr. Robison said all residents are called upon to provide free care to indigents and others in need.
   Medicine is an art as well as a science. Clearly, it also bears the weight of civic responsibility.
   Dr. Robison has a unique perspective on the unique benefits of a residency at UMCP. She did her own internal-medicine training there from 1992 to 1995.
   She said it is commonly held that medical residencies have to be at big, urban university hospitals like ones in Philadelphia, New York City or New Brunswick. She said the value of rotating to a community hospital like the one here in Princeton is often underestimated.
   Because in practice, she explained, only about 5 percent or fewer of doctors will end up working at the big-city hospitals. The majority will end up building their careers in community hospitals like UMCP.
   And those careers, she said, like the very nature of residency education, ultimately come down to the patient-doctor relationship. She said that having part of your training in a community setting can bring invaluable benefits.
   "I really valued my (residency) experience at Princeton for teaching me that doctors have long relationships with patients, and patients really benefit from having their doctors know them so well," Dr. Robison said.
   University Medical Center at Princeton stands at a crossroads.
   In a sense, it is starting fresh, just as it did 85 years ago when the hospital saw its humble beginnings in the wards of a converted farmhouse. Will it grow where it began, nearly in the heart of Princeton at its current site off Witherspoon Street? Or will it relocate to grow nearby?
   Either way, PHCS officials say, the Princeton community plays an integral part in that decision, and, they say, can trust that it will continue to be served by the hospital for many years to come.
   What better symbol for new beginnings is there than the birth of a child? A day in the life of the Medical Center would not be complete without a visit to the maternity department.
   At 4 p.m. Tuesday, Stacy Booher gave birth to baby Allison Nicole. Beaming a generous smile from the bed of her labor and delivery room on Wednesday, with her newborn daughter in her arms, Ms. Booher was surrounded by several close friends. That’s because the nurses in the department there are her co-workers. She works on the ward, and now has brought a new member of her family into the world there.
   Assistant Nurse Manager Julie Greenfield, looking on from the door, said working in the department is akin to having an extended family. She said the work she and her coworkers do is extremely gratifying. There are an average of 1,800 births there each year. On Wednesday, the ward’s 21 labor and delivery rooms were full.
   Husbands may stay with their wives during the births and afterward during recovery. Siblings and grandparents and other family are encouraged to visit as well, the nurse manager said. Indeed, a family atmosphere pervades the place.
   "It’s a very positive, happy area," Nurse Greenfield said of the department. "Just being part of a birth is most gratifying."