Island Practice Read online

  Senator John Kerry, Democrat of Massachusetts, was in Nantucket’s emergency room. It was the fall of 2003, and Kerry, then a candidate for president of the United States, had had his flesh impaled by a blood-hungry predator: he had a tick bite. He called Lepore, who interrupted a Sunday football game he was watching at home. The senator, who has had a house on Nantucket’s Brant Point for decades, was very concerned.

  “He was starting to run for president, and he was telling me that he couldn’t afford to get sick.” It was too early to know if the bite would cause Lyme disease. But Lepore advised Kerry to take a two-pill dose of vibramycin, an antibiotic, to snuff out any potential Lyme infection. “Out here, I think you really have to be aggressive. The other option would be to do a full course of treatment” with other antibiotics for thirty days, but if, as a result, “he gets diarrhea, that’s probably not a good idea, because then he gets really sick.”

  Kerry seemed hesitant. So Lepore baited him, mentioning one of his opponents, who happened to be a physician. “We can ask Howard Dean for a second opinion,” Lepore suggested innocently. Kerry “did not think it was that funny.”

  Years later, Kerry vaguely recalls Lepore’s wisecrack. “He did say something like that.” But it didn’t stop him from consulting Lepore about a subsequent case of Lyme disease and following his advice then to switch antibiotics. (Lepore told the senator the drug he had been prescribed can cause sun sensitivity, which might frustrate Kerry, an avid sailer and windsurfer.) And when Kerry came to Nantucket to recover from hip replacement surgery in 2009, he listed Lepore as his doctor “in case I keeled over and was unconscious.”

  Lepore has “treated any number of members of our family,” Kerry says. “He’s the only person who’s treated me on the island. Whether it was feeling sick, or a muscle, or a tick bite. There are not a lot of doctors who readily make themselves as available to everybody—it doesn’t matter who, what, how. He’s the real glue to the community. He’s the go-to guy.”

  Lepore is far from starry-eyed about these kinds of relationships. In fact, he considers his outspoken libertarian leanings to be the antithesis of much of what Kerry and most Democratic politicians stand for. He isn’t shy about enunciating his own politics, sometimes landing him, colorfully or controversially, in the newspaper. But when political opponents become his patients, he keeps his views to himself. “Politically I’m not on their wavelength,” but “it’s not relevant usually to what I’m seeing people for. The last thing they want if they got a broken toe is some nitwit carrying on about the Democrats.”

  “Nitwit” is not the word Kerry uses. He calls Lepore “a character,” a more neutral, senatorial term. And anyway, Kerry says, when he is on Lepore’s exam table, “we never talk about anything politically.”

  Same thing when Chris Matthews, the MSNBC television anchor who once worked for Democrats, came to Lepore with pneumonia in 2008. Matthews says Lepore was “very generous in coming into the office off-hours to treat me. As I recall, we had a great conversation about all kinds of things.”

  But not a word was said about Lepore’s appreciation of Sarah Palin or his preference for the punditry of Rush Limbaugh. “No reason to poke a skunk,” Lepore jokes. “I’m not going to convince him and he’s not going to convince me.”

  Of course, says Richards, his former nurse, political tiptoeing can work both ways. “You might need to seek out Tim even though you didn’t vote for him for school committee.”

  Rhoda Weinman considers herself “a staunch Democrat. I’m anti-gun all the way, and he’s such a big gun proponent and believes in the NRA and all that. Politically, we couldn’t be more opposite. We fight about it all the time. We’d have screaming matches on the Milestone Road while running, and I’d say, ‘We ’re going to run the next ten miles, and I don’t want to hear a word from you.’” And yet, “people are like: ‘He’s your best friend?’ Yeah, he is.”

  One particularly devoted patient belongs to one of the most prominent Democratic families: Edmund Reggie, father-in-law of the late Senator Edward M. Kennedy. Judge Reggie, as he is usually called because he was a city judge in Louisiana, has been active in Democratic politics ever since he marshaled crucial support for John F. Kennedy for president in 1960. In 1992, Reggie’s daughter Victoria married Ted Kennedy.

  “You go to Dr. Lepore,” Reggie was told about a decade ago by a Boston urologist treating him recurrent bladder tumors. Reggie, who with his wife, Doris, lives half the year in a charming, airy house in Nantucket’s Shimmo section, had no idea how significant the relationship would become. First, whenever Reggie had tumors scraped off in Boston, he visited Lepore, who administered catheters of bacillus Cal-mette-Guerin, BCG, an inactivated tuberculosis bacterium that triggers the immune system to battle tumors. Lepore used the occasions to “talk to him about Huey Long.”

  Then, when a New Orleans doctor perforated Doris’s intestine during a colonoscopy and sewed the tear with heavy sutures, she, in extreme pain, “immediately went to see Tim.” Lepore removed the sutures, joking that they were of such a heavy gauge they “could have landed a fish.”

  Next, Edmund came in with chest pains, “trying to have a heart attack,” as Lepore put it. Lepore wanted to get him to Massachusetts General Hospital but was told no beds were available. “If I want something, that’s not an answer I want. Whatever I have to do to get the answer I want, I’ll do.”

  “Do you know who he is?” he prodded the hospital. Then he informed Ted Kennedy’s office, and eventually, “mirabile dictu, they found a bed.”

  Remarks Doris: “Once you’re his patient, you’re his patient forever.”

  But, says Edmund, “the big enchilada was what he did for me on my crucial night.” It was July 2009, and the Reggies had been entertaining friends, including Louis Susman, the Democratic fundraiser who was the new ambassador to the United Kingdom. That night, Reggie recalls, he felt “extreme back pain. I got up in the night, and my legs were weak, shaking. A little while later, around 3:30 AM, I fell, and I couldn’t get up.”

  “Well, let’s call Tim,” Doris said.

  “No, it’s the middle of the night,” Edmund replied.

  “We waited on the floor because I didn’t want to wake him up,” he recalls. “The man works so hard. He had given us his cell, and I didn’t want to use it.”

  They finally called Lepore at 6 AM, who, without even seeing Reggie, ordered a jet ambulance to ferry him to Boston from Nantucket’s hospital. While awaiting the jet, Lepore ran a CAT scan and blood tests. The hospital’s visiting MRI service wasn’t there that day, and Reggie says he was later told by other doctors that “a person who needs to be more studious might wait longer and say, ‘Stay overnight,’ and wait till the MRI came.”

  But Lepore, who thought Reggie, then eighty-two, might have compression of the spinal cord, didn’t want an MRI anyway. “You can’t take someone who is not stable and put them in there.” And with spinal cord compression, “you have a very finite period of time before you have permanent damage. If you put pressure on the cord, you damage the cord so you can’t get electrical impulses across it.”

  Lepore “scooted me off the island,” Reggie recalls. “The doctors in Boston told me, had he not called a jet so quickly, had Dr. Lepore delayed my situation, I wouldn’t have been able to walk. My legs were dead. I couldn’t move them at all.”

  Boston doctors performed surgery immediately, and with rehab, Reggie recovered. “Your rapid response is what saved my legs, and how can I thank you for that?” he wrote Lepore. “This grateful patient will always be in debt to you—always!”

  A year later, after Reggie visited Lepore for leg pain and a hamstring tear, a package arrived at the Lepore house: peaches picked fresh in Louisiana and overnighted to Nantucket. “If Tim Lepore left this island, to replace him we would need four to six more doctors,” Reggie mused in his light-filled living room one summer afternoon. “He does everything for Doris and me. Tim is my doctor.”

&n
bsp; Some doctors are more inclined to wait and see how a patient’s condition evolves or deliberate with a team of physicians before recommending a treatment. But while Lepore regularly consults with mainland specialists, on Nantucket he is his own team. His nurse, Katie Pickman, says, “He will instantly pull things together, getting them to a specialist if necessary, in a ridiculously quick amount of time for being on an island.” Ridiculously quick for anywhere actually. “If someone were in Boston, it would take them three months.”

  Lepore owes his confidence to the vast array of cases he’s seen, to his voracious habit of reading about illnesses and treatments, and to his assertive, unequivocating personality. “It isn’t always wonderful because sometimes he’ll just throw the orders at you,” admits Shelley Foulkes, a visiting nurse. “But I do admire that he is able to do that.”

  When a bartender came to him with inflammation of the penis, Lepore was concerned. One possibility was balanitis, in which the foreskin becomes red and inflamed. But “this was unlike any balanitis I’d ever seen. To me it was obvious it was cancer.”

  Lepore sent the bartender to a mainland urologist, but “the urologist thought it was just an infection, so he watched it for a while. It wasn’t getting better.” Finally, the urologist conceded it was cancer and removed affected areas of the penis, a potentially avoidable approach if he had confirmed Lepore’s suspicions sooner and tried cancer treatment instead of surgery. The operation was unsuccessful because the tumor had already spread, so the urologist ultimately removed the entire organ. “The guy’s alive, but he’s gone through a lot of surgery, radiation. He’s got some cancer in his lymph nodes,” Lepore laments. “You can sit around and fool around,” but “I just think you have to be aggressive and get after these things.”

  Nathaniel Philbrick, the best-selling author of Mayflower and In the Heart of the Sea, has been on the receiving end of his nimble diagnoses. “He is a man of action, and I think that’s the only way you can survive and become the figure he is,” says Philbrick, who lives on Nantucket year-round. “It’s so easy to sort of ask for another test.” But hesitating can be hazardous, “given the state of care here and the time-bound realities he, and everyone, is operating under. That puts a lot of pressure on him—to just sort of come up with that diagnosis and go with it. He has the courage to make those kinds of calls, to do something rather than waffle.”

  When Philbrick was bitten by a tick one Saturday, “I didn’t want to go to the ER, so I just called Tim up, as do a lot of people. He just called an antibiotic into the drugstore, one big pill. It’s almost prophylactic, if you don’t know you have Lyme disease. I hadn’t come down with the symptoms.”

  And when Philbrick’s wife, Melissa, needed an emergency appendectomy, “that was traumatic. If Tim hadn’t been there, I don’t know what we would have done.” In fact, “everyone on the island has a story that without Tim there, who knows what would have happened. Everyone thinks of Nantucket as this wealthy summer community where everybody’s drinking gin and tonics all the time. It’s not. It’s an island where you can’t get in a car and drive away.”

  Especially for a doctor, Philbrick reckons, “that’s got to be extremely stressful. When you’re trying to do everything, you always feel slightly incompetent. You always know there’s someone else who could do it better. Out here, you just don’t have that luxury.”

  Which helps explain Lepore’s no-holds-barred brand of doctor-patient relationship. Philbrick’s medical visits often blossom into discussions that help him with a project. For Abram’s Eyes, about the history of Native Americans on Nantucket, Philbrick chatted with Lepore, whose passions include Indian bows and remains found at construction sites and burial grounds. Lepore had deduced, for example, by examining an unearthed partial jaw bone, that island Indians used shovel-shaped teeth to eat food mixed with sand. He’d spoken at a Nantucket Historical Association program on Indians, where Lepore, identified as “chief of medicine at Nantucket Cottage Hospital and enthusiastic amateur archaeologist,” conferred excitedly with a panelist with an only slightly more exalted title: Slow Turtle, Supreme Medicine Man of the Wampanoag Indian Nation.

  With Philbrick, Lepore discussed an illness that ravaged the Indian population in 1763. “Maybe they picked up yellow fever,” Lepore speculated. “But none of the whites got sick. Hepatitis? Nah. Measles? No. And it couldn’t have been anything carried by a flying insect because whites would have gotten it.” Lepore finally concluded the mystery disease was louse-borne relapsing fever or louse-borne typhus.

  When Philbrick was writing In the Heart of the Sea, about the sinking of the whaling ship Essex, he consulted with Lepore about dehydration. To help Philbrick understand how some marooned sailors survived by eating people, Lepore and Cathy’s sister Beth Tornovish, who studied nutrition, estimated “the nutritional value of a human: how much protein, how much fat?”

  And for The Last Stand, about Custer and the Battle of Little Bighorn, “I’m in my johnny, and Tim said, ‘You got to see what I have here,’” Philbrick recalls. Lepore led Philbrick out of the exam room to the semipublic nursing station and showed him a topographical map of the Custer battlefield. Little did Philbrick know that Lepore was a card-carrying member of the Little Bighorn Society.

  “There’s these great unsolved mysteries where an entire unit was wiped out,” Lepore mused. “Were the other officers all drunk? Did they hate Custer? Did Custer make a tactical mistake splitting up his troops? Was Custer betrayed?”

  Lepore’s enthusiasm didn’t stop at maps. “Inevitably he’d show up to my physicals with a replica weapon for me to look at,” Philbrick says. Lepore had replicas of every gun used in the battle, and he and Steve Tornovish, a detective, took Philbrick to the police shooting range, letting the author fire Lepore’s Trapdoor Springfield rifle and 1873 Colt revolver. For extra verisimilitude, Philbrick recalls, amazed, “he actually made the gunpowder and put together cartridges of black powder for all these shots.”

  This is not the way other Nantucket doctors work. “I am not on call twenty-four hours, seven days a week, which he is, because I think that creates a lot of burnout and resentment,” says Diane Pearl, a longtime Nantucketer and internist. “For most people it would not be healthy, and it can almost be pathological if taken to a certain degree. Unless you thrive on that, which Tim does.”

  When Margot Hartmann, now the hospital’s chief executive officer, began working with Lepore a dozen years ago, she was shocked. She tries to draw the line because in a place where everyone sees everyone regularly, it’s hard to carve out personal time when people are not asking for your medical opinion.

  “You’re sitting eating your oatmeal in a café, and someone pulls their hair back—‘This thing is growing on my forehead. Could you take a look at it?’” Hartmann says. “You have to be able to say, in a way that doesn’t prevent them from seeking care another time, ‘I would so like to help out with that, but I’m just at breakfast.’ It’s not Boundaries 101 living in a small community—it’s Advanced Placement Boundaries.”

  Lepore sees things differently. Patients, he says, “all have faces, and particularly on a small island like this, you see them again and again and again. In some places, you can call it a one night stand—you meet a patient, operate on them, discharge them, and they go back to their other doctor. I operate on somebody: I know their wife; I know their brother; I know their kids. Here, they don’t go away, and you don’t go away.”

  In most places, surgeons primarily perform surgery, often encountering patients after several other doctors treat them. “Once a patient’s better, unless there’s a complication, I never see them again,” notes Richard H. Koehler, a Plymouth, Massachusetts, surgeon who covers for Lepore on the few occasions he leaves Nantucket. Lepore’s protean perspective sets him apart.

  “Unfortunately most stuff isn’t stuff we can operate on,” he knows. “Most stuff is a whole series of stuff that is nonsurgical, maybe even non-medical. Even a guy with a
hernia has a job, has a life, came from somewhere, is going somewhere. Unless you sort of understand that, I don’t think you can provide good care. You probably can in Boston, where you’re surrounded by residents. But here I’m the one taking care of that patient, and I want to understand that person and understand their life.”

  So Lepore typically follows his patients from start to finish, even after they have been treated, released, or transferred elsewhere. Sometimes he’ll run to Boston to reassure a hospitalized patient. He always calls doctors at other hospitals to keep tabs. “Two reasons: I want to make sure my patients are getting good care, and I want to be ready for the next one. I want to know what they did in case I get another case like it.”

  At Nantucket’s hospital, Lepore hounds other staff to move things along. Lab technicians at the hospital will inevitably see him at their door “’cause I want the damn lab tests done. I get itchy.”

  With radiology, he sticks his head in, asking to see the films. “Am I pain in the ass? Sure I’m a pain in the ass. But we get an answer right away. If I got a patient in the emergency room, I don’t want to sit and wait for an hour for a goddamn X-ray report. I don’t.”

  Once Lepore thought David Goodman, a patient and local columnist, needed an ultrasound, but the machine was booked all day. “Sorry, he’s getting in there now,” Lepore told the technicians. “He pushed them aside,” recalls Goodman, who, as a thank you, installed tile in Lepore’s house.

  When the Lepores were scheduled to go to Ireland to visit their son T.J. in medical school, a breast cancer patient Lepore had operated on years earlier began experiencing a recurrence of cancer, in her lungs this time. “She was desperately ill, and there was nobody that could take care of her like I felt I could,” Lepore believed. He told his wife he couldn’t make the trip, and “Cathy went bat shit, but I was not going to go while this woman was dying.” As it happened, bad weather made off-island travel impossible for several days. By the time the weather cleared, the woman had passed away.