Island Practice

  Table of Contents

  Title Page

  Dedication

  Foreword

  CHAPTER 1 - A NICE QUIET ISLAND

  CHAPTER 2 - WHY ARE WE LEAVING?

  CHAPTER 3 - CUT, SEW, AND TIE

  CHAPTER 4 - Moby-Tick

  CHAPTER 5 - IN THE BLOOD

  CHAPTER 6 - MUTINY ON THE BOUNDARIES

  CHAPTER 7 - ARMS AGAINST A SEA OF TROUBLES

  CHAPTER 8 - WE CAN HANDLE WEIRD

  CHAPTER 9 - FAMILY PRACTICE

  CHAPTER 10 - UNMOORED OFFSHORE

  CHAPTER 11 - THE FOURTH DIMENSION

  CHAPTER 12 - THE LOST

  CHAPTER 13 - WAIFS AND STRAYS

  CHAPTER 14 - THE LIFE PRESERVER

  Acknowledgments

  Copyright Page

  For my mother and father,

  whose extraordinary love, encouragement, emphasis on honest effort,

  and empathy and respect for others inspire me to strive for originality

  and integrity and to approach the world with wonder, laughter,

  a sense of adventure, and the hope of making a difference.

  FOREWORD

  In the decade before the American Revolution, the writer St. Jean de Crèvecoeur traveled to the island of Nantucket, which was already on its way to becoming the whaling capital of the world. Despite being well removed from the eastern seaboard, Nantucket was a place of intense economic activity, sending out whaleships as far as the west coast of Africa and the Falkland Islands. Crèvecoeur spoke with the leading physician on Nantucket, Doctor Benjamin Tupper, who claimed that most of the women on the island, whose husbands and sons were often away for months if not years at a time, used opium. Tupper was himself a user and told Crèvecoeur that without his morning jolt of the drug, he would not be able to “transact any business.”

  Two hundred and fifty years later, Nantucket has a doctor who is also an addict. But unlike Tupper, Dr. Timothy Lepore, the subject of this book and my personal physician for the last twenty-five years, is a teetotaler. Instead of drugs and alcohol, Tim is addicted to being a doctor, and he is always, and I mean always, on call.

  Being a writer with an interest in history who doesn’t get out very much, I tend to know more about the past than I do about the present day, especially when it comes to the island I call home. Much in this book by Pam Belluck comes as a revelation. Some of it is fascinating; some of it is hilarious; and some of it is sad and very troubling. In Island Practice, Belluck has created a remarkable portrait of a physician and the island community to which he remains steadfastly devoted.

  Islands have a way of exaggerating life. When things are good, they are great. When they are bad, they are terrible. The middle ground—the emotional range where most of us prefer to spend our daily lives—is harder to hold on to in a place like Nantucket, where fog can transform a crystal blue sky into a blanket of gray in a matter of seconds.

  The Wampanoag Indians who named the island Nantucket (which means “faraway land”) attributed its discovery to a mythic giant named Mashop. Mashop, it was said, pursued a huge bird that had scooped up a child in its talons and flown out across the waters to the south of Cape Cod. After wading through the shallows of Nantucket Sound, Mashop came upon an island he’d never seen before. Underneath the branches of a large tree he found the whitened bones of the dead child. Mashop sat down for a contemplative smoke and created the fog that still frequents the island to this day.

  I live fairly close to the hospital on Nantucket, and I often hear the rotors of the MedFlight helicopter as it hovers over the church spires and roof walks of this historic town before descending into the sprawl of nondescript buildings that comprise the island’s one and only medical facility. Soon the helicopter is climbing back into the sky and is gone. Inevitably, I think of Tim, the physician who, in all likelihood, made the decision to summon the helicopter and has already turned his attention to the next patient. This is the story of Nantucket’s modern-day Mashop.

  —Nathaniel Philbrick

  Nantucket Island, February 2012

  CHAPTER 1

  A NICE QUIET ISLAND

  “There’s a trail somewhere,” Dr. Timothy J. Lepore huffs. “I know there’s a trail.” A seemingly impenetrable forest rises on all sides, and Lepore, sixty-seven and battling bad knees, is submerged in tangled branches and tightly twisted trunks. He can’t see anything beyond the brambles, and from the dirt-and-sand road near Hidden Forest, it is impossible to see him. But he can be heard coughing and breathing heavily.

  “You all right?” a companion calls. “Yeah, I’m just bushwhacking,” Lepore barks, swinging at the forest with his fists. His shoes are untied. His bald head is swamped in sweat. He peers through perspiration-fogged glasses. “Stay right there until I see if there’s a trail.”

  Lepore is on a house call—not your average house call, even for doctors who still make them. But he is determined to find the home of one of his patients, and if this is what it takes, this is what it takes. Finally, Lepore manages to force some branches apart and locate the remnants of an overgrown path. Slivers of water from Stumpy Pond can be seen at the bottom of a ridge, and turtles sunning themselves on rocks pull their heads in at the commotion.

  Lepore trudges up a hill, clambers over roots, tears through thickets of scrub oak, and stops.

  “Come up,” he calls with triumph in his voice. “What do you see?”

  At first there is nothing but forest. Then, through the trees, light glints on a dark green plastic tarp. Underneath is what looks like an igloo that has been intricately woven out of tree branches, grapevines, and reeds. It is about eight feet long, barely five feet wide, and a little over six feet tall. There is a door—wood framed with a large pane of one-way mirrored glass—and Lepore has a key.

  “Tom,” Lepore calls as he cracks open the door. Calling out is hardly necessary—it’s a tiny structure—but it represents a touch of conventional good manners in this very unconventional setting.

  Lepore may be the only person who has been invited to visit this house and one of the few people aware that its owner, one Thomas Johnson, has not completely fled the island.

  Most people here know of Johnson as Underground Tom, and they think he is long gone, chased away after the discovery of another one of his secret lairs—dug deep under land that belonged to a Boy Scout camp. It was revealed only after a deer hunter stumbled on the black tip of a stove pipe sticking out of the ground.

  That home, too, was a phenomenon of makeshift engineering, Lilliputian craftsmanship, and camouflage. It was also quite illegal, so Underground Tom was uprooted. After authorities discovered a tree house and a brush-covered log cabin he had built in other trespassed patches of land, he was, as far as most people knew, driven off the island.

  Lepore’s island, Nantucket, is much more than a charming tourist destination or a summer haven for the exceedingly wealthy. It may draw more than a million visitors a year, and be known the world over for its cobblestone streets, lovely beaches, and whaling industry nostalgia. It may be a magnet for hedge fund managers, media personalities, and the political elite.

  But its roughly 10,000 year-round residents experience Nantucket in an altogether different way. They know the allure and liabilities of living in a place that is not always easy to get to or to get away from. Mystery has a way of drifting ashore, like the scrim of fog that can crease Fat Ladies Beach. And longtime residents are the first to say that this boomerang-shaped island—just fourteen miles long and three-anda-half miles wide at its widest point—seems to host more than its per capita share of outliers: eclectic, independent-minded, occasionally slippery or up to no good, often just aiming for a little reinvention.

  “If you’re going to make i
t here, you’ve got to have something that’s different. People have to be characters who live here,” asserts Peter Swenson, who runs Family and Children’s Services of Nantucket. It’s a quality many islanders acknowledge with shrugged shoulders and a touch of pride.

  “Nantucket attracts the kind of person who has some flaws, who in the real world would become a problem, but here they’re welcome,” explains Chris Fraker, Lepore’s longtime neighbor. “It’s safe out here. You’re one step removed.”

  A sign in the Nantucket town clerk’s office puts it plainly: “Thank You for Not Discussing the Outside World.” “We print it up on fancy, bordered paper,” the town clerk, Catharine Flanagan Stover, pointed out to Lepore one day.

  Thirty capricious miles of Atlantic Ocean stretch between Nantucket and its closest contact with the continent, the southern base of Cape Cod, Massachusetts. But the metaphorical distance can feel much greater.

  Some people here call the mainland “America”—not wistfully, or in any way unpatriotically, but as a place they have happily, if only slightly and inconsequentially, seceded from.

  “I spent ten years in America; I paid my dues,” says Richard Ray, a native Nantucketer who heads the health department for Nantucket, which, including the tiny islands of Tuckernuck and Muskeget, has the unusual distinction of being both its own town and county.

  Lepore himself decamped nearly three decades ago from Rhode Island. An emergency room doctor tired of shots being fired outside his Providence hospital and the nightly parade of urban gore gracing his gurneys, he was tantalized after a summer shift at Nantucket’s bite-sized hospital. With its rows of cedar shingles and white-railed widow’s walk coordinating neatly with the island’s graceful architectural simplicity, the hospital seemed quirky without being chaotic. Nantucket would offer an easier lifestyle and would be a great place to raise kids, he and his wife, Cathy, a nurse and school counselor, reasoned.

  Lepore became the island’s general surgeon, the head of medicine at the island’s hospital, and the island’s medical examiner. “So maybe I can cover up my mistakes,” he suggests archly. He is the school physician and the high school football team doctor, and he has been reelected to serve on the school committee for more than twenty years straight. He has bootstrapped himself into becoming a nationally recognized expert on tick diseases, a special scourge on Nantucket.

  Although he has no psychiatric training, he provides cut-to-the-chase, profanity-perfused psychological counseling. He acts as an occasional Dr. Doolittle, treating a run-over deer, an ailing sea gull, a postpartum sheep.

  When crisis has enveloped the island, as with a string of teenage suicides in recent years, he is one of the people called upon to try to hold things together. And he and his wife have repeatedly taken in teenagers who are in trouble and others needing a place to stay, sometimes fraying the fabric of the Lepore family in the process.

  Lepore’s family practice accepts all comers. He is not just a sawbones to the summer rich. Sure, he’ll handle Jet Ski collisions and overboard yachtsmen. Even a little Botox now and then. Once in a while, a vacationer will show up dangling a bluefish from his head or torso, the hook having snagged not only the fish, but the fisherman. But Lepore also sees many working-class people and foreign laborers whose jobs undergird the luxury life: construction workers with sawed-off fingers or ears, lobstermen with chests crushed by winches, the firefighter’s son who shattered a finger launching fireworks.

  An equal opportunity malady is something Lepore calls “cobblestone rash”—injuries from falling (or stumbling drunk) on Nantucket’s picturesquely uneven streets. There are also moped injuries galore, described with delicacy and decorum by the island doctor: “I’ve told people if they wanted the moped experience they could just let me hit them with a bat and then go over them with a sander.” Bedside manner á la Lepore.

  Driven by his own irrepressible volition, Lepore works constantly, never drinks on-island so as not to blunt his reaction time, and rarely goes off-island. “Hundreds of people would have died if he wasn’t there, if not thousands,” claims Richard H. Koehler, a surgeon on the mainland who comes over to cover for Lepore if he steps off Nantucket for even a day. Koehler figures Lepore “must have coronary arteries the size of the Holland Tunnel”—surgeon-speak for a big heart. “Literally, I don’t know how he does it.”

  There are a handful of other year-round doctors, including three family practitioners, an internist, an orthopedist, a radiologist, and an emergency department director. And there are off-island specialists who visit at various times. But islanders, including other physicians, routinely describe Lepore this way: If you are sick or hurt on Nantucket, Lepore is the person most likely to be there to keep you alive. He is everywhere, and one of a kind.

  “His is a job that very few people want to do, and nobody’s doing it like he’s doing it,” says Diane Pearl, an internist on the island, who grew up here. “The fact of being limitless like Tim is—I couldn’t do that. This is his kingdom.”

  Still, to the extent that Lepore is a medical monarch of sorts, he can be controversial. He can talk in brash assertions or unfiltered barbs that he sees no point in editing into more anodyne expressions. He can irritate or confound people who expect him to advocate a particular position. He has a passion for guns, hunting, and other conservative and libertarian issues, but will also perform abortions and supply patients with marijuana cookies. He has stirred tension by proclaiming that the only way to solve Nantucket’s tick disease problem is to kill more deer. And he is not known for an especially cuddly bedside manner.

  The story of Tim Lepore is in part a tale of a most unusual person who is central to the health and life of a community in ways that rarely occur these days. (Even the pronunciation of his last name is unexpected—not for him the more common “LehPOOR.” Lepore rhymes his name, appropriately enough, with “peppery.”) Against the background of a changing, churning American medical landscape, a physician like Lepore has become an outlier and a maverick.

  His patient-focused approach, once much more the norm, now strains to survive in towns and cities across the country as health care costs skyrocket, medicine becomes more corporatized and monetized, and extended face time with doctors is an increasingly vanishing commodity. This is true in Lepore’s own community as well. Nantucket’s small hospital was recently swallowed by a big hospital company, forcing Lepore to struggle, not always successfully, to continue practicing medicine his way.

  Lepore’s island practice also provides a glimpse of the inner life of a place famous for its elite reputation but rarely understood in the human, warts-and-all way that Lepore experiences it every day.

  There are many such places in America, some literally islands, others isolated by other geographical realities or by demographic transformations. They might be vacation havens like the Outer Banks or Aspen, Stowe or Sun Valley, places with hardy year-round populations that take on a different identity when visitors flood in each year. They might be the hundreds of less notable small towns dotting the Midwest, the Plains, the South, and the Northeast that have seen their populations whittled as industries leave or contract, or have confronted change as immigrants or other newcomers move in. They might even be neighborhoods in tourist cities like New Orleans or San Francisco, places that outsiders surmise to be a certain way but can never really understand as the locals do.

  Lepore’s Nantucket, with its saltbox houses, windy moors, and sea-stung sands, may be more offbeat than people would expect. Yet it is also more emblematic of America—in all its diversity, social strain, and economic division, but also in its scrappiness, creativity, and gumption.

  Nantucket turned out to be a place that would let Lepore be Lepore. His idiosyncrasies and hobbies are quixotic even by island standards. Anyone for Siberian throat-singing or dog-hair knitting? How about scooping up roadkill or carving prehistoric spear-throwers? His comments, whether uttered in public meetings or patient exam rooms, can be just as colorful:
a shot-from-the-hip political incorrectitude here, an arcanely acerbic aphorism there.

  “He’s peculiar,” observes Jim Lentowski, who heads the Nantucket Conservation Foundation, “but we all are peculiar living on this island.”

  Pam Michelsen, a friend who teaches high school English, particularly Emerson and Thoreau, thinks Lepore could have “walked off the pages of Walden Pond. He is a nonconformist.” In fact, both of these nineteenth-century Transcendentalist thinkers gave lectures on the island, which Emerson dubbed the “Nation of Nantucket.” Notes Michelsen: “Emerson said, ‘What I must do is all that concerns me, not what people think.’ Well, that’s Tim Lepore.”

  Part of the island’s attraction for personalities of this sort stems from the challenge of living here year-round. Sure, Nantucket has some of the most expensive houses in the country—the median home price in 2011 was $1 million, making Nantucket the only U.S. county with half the homes costing at least seven figures. But those houses belong mostly to summer visitors. For the people who live and work there—teachers, police officers, waitresses, landscapers—those seven-digit numbers serve mostly to make everything, from gasoline to groceries, a lot more expensive.

  There are no big-box discount stores, no Wal-Mart or Target. And because rain, wind, or hurricanes can suddenly make it impossible to leave the island, there’s no guarantee that provisions from the mainland will always be accessible. Or that someone needing medical care could get off-island to receive it. “There’s a certain amount of risk inherent in living on Nantucket, enshrouded in fog sometimes to where even the Coast Guard can’t get in,” Lentowski explains.

  Sean Kehoe, who spent his teenage years on the island, leaving for New York as an adult, feels that “the amount of work that’s involved, and sacrifice just to live here, after a while it’s just exhausting. You see people move away. You see people just recede into themselves.” But “people like Lepore who occupy the character role, who are a little bit eccentric, who are not flamboyant—people are just glad he’s here. They trust him because he just wants people alive.”