The Last Country Doctor

by: John Stanton

photography by: Nicole Harnishfeger

Eccentric? Sure. He once took payment for a hernia operation in a batch of oatmeal cookies. He has been paid in lobsters. He once showed up at my barn on short notice to stitch up a horse named Dr. Who, after a misunderstanding with a fence led to a gash in his flank. At the time, it did not seem unusual to call our family doctor to tend to our horse. He has a red-tailed hawk named Ajax.

Independent? Yes. During a debate on whether construction of the new hospital would destroy a quiet place sometimes used by patients to contemplate their diagnosis, he told The Inquirer and Mirror that he would lie down in front of the backhoe if the plans didn’t change. The optics of the hospital’s chief of medicine protesting were not something anybody in charge was anxious to see. And nobody thought that he wouldn’t do it.

The thing is, truly eccentric people never think they are eccentric at all. It just makes sense to them. In fact, what might be the most eccentric thing a 21st century physician can do makes perfect sense to Tim Lepore, MD. His personal cell-phone number is included in both the newspaper and radio ads for Addiction Solutions, his clinic for addicts.

It should come as no surprise that he thinks it makes perfect sense.

“I give out my cell-phone number,” he said. “It’s not a usual thing, but nobody can say they got the secretary and couldn’t get an appointment. They get me. And if people want to get off opiates, we meet in the office, talk and get a plan. Then we see them at the clinic on Wednesday evening or Friday morning.”

Instead of mentioning a doctor to explain his philosophy, he mentioned Keaton Goddard, the local bladesmith who recently won an episode of the History Channel’s “Forged in Fire” show.

“It’s like what he does,” Lepore said. “You heat up the metal and there is just the right moment to hammer it. If people want to get off opioids, that is the time to meet them and talk to them. Right then, not later. We meet at my office and we talk and we set up a plan.”

The bottom line is that Tim Lepore may be the last of the old-fashioned country doctors. He calls his own shots, takes responsibility and knows his role in the community. There are, of course, other doctors on Nantucket, but most people know Lepore as the island’s doctor.

“This is what I enjoy doing,” he said. “If I didn’t, then I wouldn’t do it. And they’re my neighbors, so what the hell. They’re my neighbors and if I can do something to help them, then good.”

Lepore has his opinions on health insurance, but he does not seem overly worried about it when his patients do not have insurance. It takes money to run his office, and he likes to get paid as much as the next guy, but he does not let it stand in the way of doing his job.

“I think I feel, because of the opportunities I’ve been afforded to be in this position, I should help people when I can,” he said. “That to me is the payoff. Still, hopefully I’m not going to go broke. But the house is paid off, the kids all went to good colleges and got good jobs. What are you going to do, put leftover money in your coffin? So, I have what I need.”

He is the island’s general surgeon, the medical examiner, and as the high school’s athletic doctor he often spends fall Saturdays on the sidelines of the football game. When the opioid crisis washed up on island, he decided to do something about it. He began a clinic and runs it to help people deal with opioid and heroin addiction. But what Lepore finds most rewarding is simply taking care of patients.

“What I really like is seeing if I can help people,” he said. “Sometimes I can. Sometimes I can’t. But you can always help people whether you can make them live longer or not. You can take them out of pain, and you can make them feel valued. It can even be rewarding to help someone die well.”

He is the son of a doctor who came home from the second world war and moved from general practitioner to surgeon. His path went the opposite direction. He graduated Harvard and Tufts Medical School. After his residency, he ran the emergency room and did surgery at Roger Williams Hospital in Providence.

In the summer of 1983 he came to the island with his wife and three kids to work at Nantucket Cottage Hospital, 24 hours on/48 hours off. When he went back to Roger Williams, he told people he was moving to Nantucket. Nobody believed him. Why would he step off the ladder? Why would he let his career stall? Didn’t he want to end up at Massachusetts General Hospital? He arrived on-island with his wife Cathy on New Year’s Day.

There is something about life on Nantucket that got under his skin. You could get involved in things you might not ever think of doing on the mainland. One day he treated a patient who was a master falconer.

“I said I was always interested in raptors,” Lepore said. “So, I apprenticed with him. I learned. I took the test. And that allowed me to trap a hawk. And now I fly the hawk. That is something else I would have never gotten into unless I moved out here.

Lepore likes to say he is just the guy who picks the ticks off deer at the weigh-in station during hunting season. But he is a nationally-known tick-borne-disease expert.

“I also stumbled into the tick stuff. Working in the emergency room I got to meet the fifth patient who had babesia out here,” he said. “I got involved with Andy Spielman, who was at the Harvard School of Public Health, and then I met all these other guys and I got involved in tick research. That is amazing to me. Because any other place I probably would have been sitting at home or playing golf.”

There is a very obvious difference in the way Lepore practices medicine and the way it is practiced on the mainland. The temptation is to say that he is allowed to do his own thing, but nobody allowed Lepore to do anything. He just does what makes sense to him.

“I think it’s important that you know your patients,” he said. “I had a situation yesterday, where somebody (at the hospital) wanted to do something to one of my patients and I didn’t want them to. So, I told them to screw. I just said, ‘Stop talking. We’re not going to do it.’ It’s a different way of practicing. You don’t see it anymore.

“Medicine is depersonalized these days. You take a look at stuff that comes back from Boston. First, it seems like they always put down Martha’s Vineyard on the chart and that annoys me.

Most of the stuff on the computer is crap because they just cut and paste. The intellectual part of it is about three sentences. You’ve got to go through this trash where everybody repeats the same damn thing day after day as far as diagnosis. It’s just garbage in, garbage out. And nobody’s responsible. It’s all diffused. If I have a patient I operated on, then I’m responsible. I want to take care of my patients the way I want to be taken care of.”

He is prone to unvarnished opinions. It is often best to stay out of the way and simply listen. And so, let’s shift the style of this story to a sort of modified Q&A.

On the importance of continuity in healthcare.

“When I was in Providence and just doing surgery, I would see a patient. Operate. See him once or twice after. Then they were off into the ether. Here I see a patient, I probably know him before I operate on him. And I follow him along after. I see whole families which you get involved with. I think that is fascinating. It is not something that shows up on the computer, but it is extremely rewarding.”

On telemedicine, which is gaining traction because of the COVID-19 pandemic and the talk is it might become the new normal way of doing medicine.

“It’s a cheap trick. You can’t effectively do medicine that way. First, you can’t do a physical exam. You miss a lot of cues that you can get from the patient in terms of how they are sitting, or what they are doing with their hands. There is just nothing that beats being able to touch a patient. That is why stethoscopes don’t have six-foot tubes. Because you gotta get close. You gotta use all your senses. You gotta listen to them, you gotta talk to them, you gotta smell them, you gotta touch them, you gotta put all those things together. You can’t do that on a Zoom. You just can’t. Anybody who says they can do an adequate assessment on a patient on Zoom is blowing smoke or has money in Zoom. You can’t do it. I think hospitals will go to that, however, because it is cheaper for administrators.”

On serving on the School Committee for over 30 years.

“I got on the School Committee because my mother got on the School Committee when she was 21. And I always thought that was sort of interesting. So, I got on the School Committee and I was learning stuff. I enjoyed it. I found it very interesting. My exposure to collective bargaining was zero until I got on the School Committee. Then I learned by keeping my mouth shut and my ears open. I think it is just fascinating.

Collective bargaining, to science fair, to interscholastic athletics, to the performance of teachers, I think it is all fascinating. I think my kids got a great education here. I have a much better understanding now as to what’s going on behind the curtain.

I’m just starting a three-year term. So, God only knows when I will retire. I’m not sure what the record is, maybe somebody from 1812 or something.

Nobody gets on the School Committee that doesn’t figure they know how to do it right. But it’s tricky and there’s a lot of wheels moving. You get involved in collective bargaining and that’s a whole different world. Social-political and social-emotional, those are all tricky issues and fascinating ones. I enjoy it. Depending on who else is on the committee they can be a little long-winded, but I’ve done that myself. The sound of your own voice can be a siren’s song.”

On reopening schools in the face of a pandemic.

“Teachers are often in the bad demographic. But kids get sick, and while there hasn’t been enormous mortality among kids it is still a concern. So, what percentage of parents are going to say let’s go with hybrid and how many are going to say let’s go with the distance model?

Eventually, we could switch over all the way to the distance model. That has its own problems. But now we have had time to consider (distance learning) and how to more correctly do it. I think there are considerations about going about it correctly. It isn’t the best. But for a period of time it may give us some breathing room.

Elementary-school kids probably aren’t super-spreaders. I mean, that remains to be seen. But when you get into high school they probably can be super-spreaders. So, the concern is teachers getting sick. Nobody knows yet what’s going to happen.

How are you going to do distance learning in kindergarten or elementary school? I think those are problems and we have to think about a better way to address them. But it would be nice to see the hybrid model buy us some breathing room, see where we are in November, then see what’s realistic. I don’t want to see kids losing two years of school. It’s a huge balancing act.”

On Addiction Solutions.

“I saw a problem. I had handed out diplomas to kids and now they were addicted to opiates. So, I took the course. Got certified to prescribe suboxone (used to treat opioid and heroin addiction). So, I said OK, let’s see how this goes. I met Aileen Womack and we started working together. Aileen is a kid who grew up here but has 30 years of experience at San Francisco General in emergency psychiatry and addiction.

There are two people on this island licensed to give suboxone, myself and my daughter Meredith, who is a nurse practitioner. But I’ve always thought counseling was a key part of it, not just writing prescriptions. I think it’s a real need.

Even though we do a good job there are still mortalities. It’s a real problem. It has not leveled off, but there is more Narcan (used to reverse overdoses). Two things changed the game: Fentanyl kills people and Narcan saves people.

But there are still a lot of people using. They get involved in drugs and then there is fear and shame that is part of it, and we like to provide an opportunity to get past all that. If you’ve got a problem, we’ve got a solution. We’ll work with you. We don’t let insurance, money or anything else get in the way.

This problem goes across the whole island. We see people making a million bucks and people sleeping in their cars. If people want help, we can help them. But we can’t want it more than they want it.”

Cathy Lepore, retired school nurse and counselor, with her daughter Meri Lepore, the nurse at Nantucket Elementary School, holding her son Henry Peel.

Walk into Lepore’s office and along with the jackalope and enough skulls and fossils to make the place seem like an exhibit at the Museum of Natural History, including a giant rat killed at the dump, you see photos of a young doctor.

The young doctor is sometimes with his wife and young family. That doctor is now 74 years old. His wife is retired. Cathy Lepore, a nurse and social worker, recently stepped down as school nurse and counselor. His son, TJ Lepore, is a doctor, an OB-GYN, in the western part of the state. Meredith is the Nantucket Elementary School nurse, and worked for her father this summer. His youngest son Nick is a lawyer in Seattle.

“I met the right woman, Cathy, and she is a great mother and still likes to have me around,” Lepore said. “Sometimes we’ve had arguments over what she would like to see as my role, but it’s worked out.”

The sentiment goes along with his “one thing just led to the next” way of looking at life.

“If I were at MGH or Roger Williams Hospital, I’d be circumscribed at what I could do,” he said. “You always have some administrator breathing down your neck. We may be heading that way here, but we’re not there yet. And so, I can be proactive, the way I enjoy, and do what I want. I can call my own shots, win or lose.”

It is a rare thing to find a job that describes who you are, one that you can shape into an imprint of who you are, one that is part of you. It is rarer still to find your way into the heart of a community through the way you go about doing that job. Whatever happens to island healthcare when he leaves, Tim Lepore will be the last country doctor.

It is late in the afternoon, after office hours, and he is sitting in a chair shaped like a giant moose, made by island artist Clara Urbahn. He is counting on his fingers.

“I start counting up the things I enjoy,” Lepore said. “Addiction Solutions is going to go on until they carry me out feet-first. The tick stuff I really enjoy. Then I start saying, you know I really like my practice. So, all of a sudden, I’m back to where I am. I enjoy what I’m doing. You think you might pare it down. But you just end up going back to the things you like.” ///

John Stanton is a writer, documentary filmmaker and story editor of Nantucket Today.

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