Island Practice (16 page)

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.

Lepore doesn’t make yacht calls, only because he fears he could miss an on-island emergency. While many of Nantucket’s wealthy and prominent summer people never need pay him a visit—they have private physicians elsewhere—some are Lepore regulars even though they could see any doctor they wanted. John Chancellor, the television anchor, came to Lepore when he smacked his head into a door frame. Another patient, the author David Halberstam, liked to attend Nantucket high school football games, where he would chat with Lepore on the sidelines.

Gordon and Lulie Gund first heard “these outrageous Tim Lepore stories” from the caretaker of their Nantucket house, an old-timer named Gibby Burchell. When Gordon got the flu one summer, Burchell advised: “You gotta go see Tim.” Gordon Gund is a venture capitalist and owner of sports franchises like the Cleveland Cavaliers. He is blind from retinitis pigmentosa, and the Gunds, who also have homes in Aspen, Cleveland, and Princeton, New Jersey, are philanthropists who cofounded the Foundation Fighting Blindness.

The Gunds’ encounters with Lepore were pretty routine until August 2008, when Lulie, whom the hospital had diagnosed with Lyme disease and given amoxicillin, discovered that “my eyes had turned bright yellow.” She also “lost any much desire to eat” and “felt so grumpy.” She returned to the hospital for a blood smear, and Lepore was called. “You have babesiosis really badly,” he told her. What’s more, “because I didn’t think it was important,” Lulie, then sixty-seven, had not told anyone that she didn’t have a spleen. Hers had been removed twenty years earlier, when she’d had Hodgkin’s disease. Without a spleen, which collects damaged blood cells, a disease like babesiosis could spiral out of control.

Lepore gave her an antimalarial drug, Mepron, and an antibacterial medication, azithromycin. When she was ready to leave the island, he told her she could only go if she kept up the medication and got regular blood tests.

But soon after returning home to Princeton, Gund went to an infectious disease specialist who did a blood test that came back negative for babesia. “You’re fine,” the specialist told her. “Go off the medication.” The doctor “wasn’t familiar with babesia,” Gund says. He didn’t know that babesiosis can linger for months at levels a blood test can’t always detect, and that for a Hodgkin’s patient it may last longer. The doctor didn’t know to give her a more definitive test, called polymerase chain reaction, or PCR.

“Four days later I was so sick I ended up in the hospital with congestive heart failure and a temperature of 103, 104,” Gund recalls. “I
was having trouble breathing. I had pulmonary edema,” fluid in the lungs. “My husband called Tim.”

Lepore insisted she resume taking Mepron and azithromycin immediately. He directed Gund’s doctor to administer frequent PCR tests. He also did his own tests: the hamster protocol. He sent samples of Gund’s blood to Sam Telford III at Tufts School of Veterinary Medicine. Telford injected the blood into hamsters. “If the hamster goes belly-up, then you know there are actually live organisms in there,” Lepore said. As long as the disease was active in Gund, the hamsters died. They followed the hamsters’ progress quietly, not wanting to alarm the patient. It took six months, until February, for babesia to completely quit her system. “My God,” Gund realized recently, “I’ve never asked Dr. Lepore what happened to the hamster.”

She was also impressed when Lepore referred her to Peter Krause, an epidemiologist at the Yale School of Public Health, who studies microbial diseases. “A lot of doctors are reticent to refer you and sort of share the limelight.” Ultimately, the Gunds donated $1 million over three years to research Krause and Lepore are conducting on tick-borne diseases. Notes Lulie: “There are so many doctors who don’t realize how sick you can get.”

The Gunds know Lepore can lack the diplomatic demeanor common in their charitable and corporate circles. “I’ve heard him answer people very curtly at a public meeting if he really disagrees,” Lulie acknowledges. “The flip side is he’s so unbelievably humane when you’re with him. And it doesn’t matter if you’re not there—he always has time for you. He has so many facets, he’s like a diamond.”

“Did you notice the new rug?” Lepore asks. It’s a welcome mat in front of his office’s reception desk. Under the word “Greetings” is a homespun, tapestry-like picture of a dog sniffing the ass of another dog with a raised tail.