Island Practice (36 page)

Nearly three years after moving in with the Lepores, Julie got that chance. Cathy couldn’t take it anymore.

“I find it too difficult for me to continue being the parent of a teenager . . . someone else’s teenager, specifically,” she wrote in an email in late August 2010. “I know it may sound harsh, but I just cannot give her the time that she deserves. In my heart, I am done, done, done.”

Without discussing it with Lepore, Cathy called the social worker. “She needs to go,” Cathy said. “You need to come and get her out of here.”

Cathy says the social worker understood. “I can’t thank you enough,” she told Cathy. “I was sure she was going to be hospitalized at least three times when she was with you, and she wasn’t hospitalized once.”

Lepore, on the other hand, was “upset with me because he felt like it wasn’t the right thing. I didn’t consult with him when I called, and he was upset, and he had a right to be.”

But Cathy didn’t reconsider her decision: “I don’t think he realized the effect it was having on me. He felt it was a failure on his part, but it really wasn’t at all. You think that you can bring someone into your house for three years, and you think that some of the values will rub off, and then when they don’t, it’s very upsetting. It’s like planting a tulip and having azaleas come up.”

It may be, however, that some of the seeds they planted took root after all. More than a year after she left the Lepores, Julie, seventeen, living with her father in New Hampshire after a couple of unsuccessful foster placements, said she has “definitely changed a lot.” She has experienced more tragedy—her brother committed suicide in April 2011. But she said she was attending a high school program in the evenings and getting As and Bs.

Julie doesn’t fault the Lepores for ending their foster care arrangement: “I’m not blaming anybody but myself,” she says. “I got really lazy when I was living with them. I was just slacking off. I don’t really have too many regrets about staying with them. They did teach me a lot, and they taught me the value of education and how important it is and stuff like that. I have a lot of respect for them, you know.”

For a meeting of Nantucket Cottage Hospital’s board of trustees, Tim Lepore prepared a PowerPoint presentation. It started off innocuously, with a map of Nantucket, a steel-gray island floating in an ocean of midnight blue. The second slide was a bucolic photograph of a foggy inlet braceleted in scrub oak.

But once Lepore presented his title slide, “Keeping My Finger on the Prostate of Medicine,” any pretense of decorum was tossed aside. He showed a photograph of an ivory-billed woodpecker, a creature so prized and rare that scientists have offered rewards for finding one. Lepore explained that a solo general surgeon on an island—someone, as it happens, like himself—is like the woodpecker, “much talked about, seldom seen.” Small wonder, he noted, that this special woodpecker is sometimes called the “God Bird.”

So much for humility. Lepore had things to say. “I was the skunk at the family picnic.”

The family, in this case, had morphed in recent years, adding what Lepore considered a stodgier, less permissive set of in-laws. The hospital 247
had, in 2007, relinquished its independence to merge with a much larger Boston medical system, Massachusetts General Hospital and its parent company, Partners HealthCare.

It was Nantucket’s attempt to make its hospital more efficient and financially viable. But to Lepore, it was also a capitulation of sorts to Big Medicine, a world of health care by cost code and corporate-driven consistency.

“I always felt it was better to date larger institutions than marry them” is how Lepore puts it. “When the giant sneezes, the little guy gets a cold.”

At the meeting, Lepore wanted to warn the hospital not to get its priorities wrong. “Whether the patient needs something or not is a clinical decision. You deal with the financial decision later. To do it ass-backwards is bad medicine.”

Lepore shifted from rare birds to rock bands. “Rolling Stones,” read one slide. “‘Let It Bleed.’ Dr. Tim says: ‘Great song, bad public relations.’ Nantucket Cottage Hospital is on an island, but not an island. We have to listen to our customers.” Customers want a hospital that treats them well.

Lepore said the hospital was charging much more than the mainland for MRIs, CAT scans, and lab testing, creating hardship for islanders without insurance or with copayments that are calculated as a percentage of a procedure’s cost. He said he had “brought this up again and again” to billing officials, “and they were treating me like Mickey the Dunce,” he said. Told some prices were erroneously high because of computer glitches, he replied, “Fix it, and then make sure you call the people back that paid for it.”

But Lepore also told the trustees something that might sound odd for a surgeon. Some board members had discussed adding a second operating room, but Lepore said there wouldn’t be enough additional surgical cases to justify the cost of extra anesthetists and nurses to staff
another OR. “Where,” he wondered aloud, “are you going to get these cases from? We don’t have nuclear medicine. We can’t really do biopsies for breast cancer. If I can’t do what the state of the art is, I don’t want to do it.” He was not concerned, as some people thought, that a second OR might lead the hospital to hire a second, less maverick surgeon. “If another surgeon came out, great. But I know there isn’t enough surgery to keep somebody busy. Plus you got to be a little bit crazy.”

There was more. While the hospital is hoping to raise money for a new building, Lepore said some things needed upgrading now. The decor reminded him “of the Soviet era” and was “vaguely reminiscent of Cedar Junction,” a Massachusetts maximum security prison. “It is difficult to attract the carriage trade and put them in a barn.”

Lepore’s last slide was a map showing the hospital and his house, both on Prospect Street, roughly one hundred yards apart. His point was beyond dispute: “This is my vocation and avocation. The hospital is my career and my home.”

For Lepore, the big hospital’s incursion has been a less-than-seamless work in progress. “It’s a pure and simple culture clash,” says Margot Hartmann, the hospital’s CEO. “I live with it every day. They know that he’s outrageous. They would like him to be a party guy. But they also understand that that will never be Tim.”

As if to underscore that point, during his board of trustees presentation Lepore displayed the hospital’s longtime logo: a silhouette of the island inside a life preserver. Mass General had changed the logo to a shield with a scallop shell on it to homogenize it with the shield logos of other Partners hospitals.

A minor change, one might think. But symbols matter. “They didn’t ask us,” says Mary Monagle, a nurse. “That’s still a huge bone of contention.” In fact, in 2010, when Hartmann became CEO, the logo still rankled enough that she made up mugs with the old logo on one side
under the words “Honoring the Past,” and the new logo on the other side with the words “Celebrating the Future.”

For Lepore, though, the changeover is about much more than logos. The new administration wanted Nantucket physicians to join the Massachusetts General Physicians Organization, the MGPO. MGPO doctors get salaries and pay a certain amount to cover management costs. They are subject to rules concerning billing, hours, supplies, and procedures.

The other doctors signed up, but Lepore said no. “I want my employees answering to me. I want to work as hard as I want to work. And if I don’t belong to the MGPO, I can stand up and say the emperor has no clothes.”

Lepore acknowledges that the MGPO provides “some pluses”—good retirement benefits and malpractice insurance—and some processes can be helped by economies of scale. But there are downsides, like scheduling patients. “If I have a divorced couple, I’m probably not going to schedule them at the same time. That may happen with the MGPO. And nobody’s coming in every twenty minutes to tell me that I’m done.”

The hospital tracks MGPO physicians’ “relative value units” or RVUs, a dollar amount assigned to patient visits, used to calculate how physicians get paid. To Lepore, that’s like asking a doctor, “Did you make enough widgets today? I am sink or swim on my own nickel—hopefully swim, just not with sharks.”

T.J. Lepore worries the MGPO arrangement could irreversibly cramp his father’s style. “It makes it more difficult to get paid in cookies. It’s very one-size-fits-all, and Nantucket is a place that doesn’t fit all.” Tim Lepore is skeptical of the big medical company’s impact on Nantucket’s scrappy hospital, which he describes as “like a real hospital, except shrunk, Sanforized.” The merger, he feels, “is like a Great Dane and a Chihuahua trying to get it on.”

And he has bridled as things become more rules-oriented—more Boston Proper, less Wild West. “He always had that free hand, and I
think with Mass General, it kind of brings corporate America to the hospital, and with that kind of oversight and stuff, it makes it difficult,” T.J. says.

“All of a sudden employees have to sign in,” Lepore groused. And when he was told, “Dr. Lepore, we don’t want you getting packages at the mail room,” his response was, “Hey, bite my ass.” When a portable cardiac ultrasound machine was sent over from Cape Cod, a technician complained to Lepore that the patients had not yet been registered. Lepore confronted “the guy in charge of registration, and the son of a bitch wouldn’t stop eating his breakfast burrito. He did not view it with quite the intensity that I did. I like to see things made easy for patients because they come in, they are anxious, they have a life.”

Lepore also objected to “restricted hours for residents and interns. Sounds good, but do you want to have a guy who actually knows the case and follows it along or do you want to have twelve people do a hand-off because you can only work so many hours?”

It used to be simple, Monagle says, to “call down to the lab and say, ‘Dr. Lepore wants you to add on an extra tube of blood.’” Or, if an older patient was scheduled for a colonoscopy, Lepore might admit him to the hospital the night before to make sure he followed the pre-colonoscopy regimen and did not eat or drink the wrong things. “We know the patient lives alone and his daughter has a full-time job, and this way we’re able to watch him like a hawk,” Monagle recalls. But lab tests and discretionary hospital admissions cost money.

Monagle left in 2011 partly out of frustration with the merger: “Why don’t we embrace what makes us unique? What makes us unique is that we are a country hospital. If I wanted to work for Mass General, I would have gone to work for Mass General. I wanted to work with Dr. Lepore, the way he does it.”

The way Lepore does it has earned him respect from many in the community. “Sometimes he plays role of canary in the coal mine, so
when he sees something he doesn’t like that the administration is doing, he can be vocal about it,” says Michelle Whelan, executive director of Sustainable Nantucket.

“He would like to see the hospital be better than it is, offering more things,” says Louise Hourihan, a patient, whose husband, Bill, a bank executive, is on the hospital board. “He’s controversial because he doesn’t sugarcoat things and he’s very opinionated.”

Some board members have learned to take Lepore on his own terms. “That’s Tim. He doesn’t want anybody to pay his salary and tell him what to do,” says Bruce Chabner, a board member who, as director of clinical research at Mass General’s Cancer Center, has followed the merger from both sides.

Chabner remembers Lepore’s board presentation as “a little distasteful” and says some trustees and hospital officials “think he’s an unusual sort of person. He doesn’t want to be fenced in. But he’s a respected clinician. I don’t think anybody says he’s not a good doctor.”

In fact, says Chabner, who has summered on Nantucket for decades and whose wife has been treated by Lepore, “the first years I knew Tim, we had a sort of cool relationship. Politically, he’s on the other end. He likes guns. He’s sort of a swashbuckling character. But I respect him as a doctor, so I got to know him. And I wouldn’t hesitate to send a patient to him.”

If hospital officials object when Lepore becomes what he calls “the archetypal loose cannon,” he doesn’t care. “They are not ordained. I didn’t see tongues of fire on their heads. I have to say what’s on my mind. If people don’t like it, they don’t like it.”

No one is more involved in choreographing the Lepore–Mass General pas de deux than Margot Hartmann, who has known Lepore since 1999,
when she was a summer visitor feeling disgruntled about her primary care practice in a Boston suburb.

“He likes to say that I walked slowly past the hospital and he reached out,” Hartmann says. “Actually I think I reached out to him.” She began working in Nantucket’s emergency room and remembers when she first called Lepore to get his opinion on a complicated patient. She presented the facts over the phone in the rubric physicians learn: medical history, symptoms, test results, etc.