THE ISLAND DOCTOR

IN THE NANTUCKET PRACTICE OF TIM LEPORE, MEDICINE AND CARING ARE DISPENSED IN EQUAL DOSES.

rom the ferry, it’s only a short walk before the Nantucketness of Nantucket comes into view. Up Broad Street you go, past the bike rental shops, a few restaurants, and the whaling museum. Swing a left onto Beach, where the crowds thicken, the traffic too, as beat-up trucks jockey for position with pricey SUVs and uncertain pedestrians. Different lives, different destinations.

Some are headed to the stores that line wide, cobblestoned Main Street; others to the big homes just beyond, symbols of the island’s privileged lineage. It’s a mix of classes and backgrounds, heritage and fortunes. Here is a carpenter. There is a hedge fund manager. Here is a schoolteacher. There is a Fortune 500 CEO.

BY IAN ALDRICH

PHOTOGRAPHS BY MARK FLEMING

Beyond the draw of the island itself, the single biggest connection that the local, the visitor, and the rich and famous all share can be found about a mile from downtown, on the campus of Nantucket Cottage Hospital. There, in a small gray-shingled building, you can find the island’s only surgeon and primary care physician. The one place, the one person that Nantucket residents, whether a former secretary of state or a land squatter everyone calls “Underground Tom,” go to when they’re injured or sick.

It is the office of Dr. Tim Lepore.

On a Thursday morning, around 8, in early September, that office is starting to fill with patients. Lepore, who is dressed in beige pants, a blue buttondown, and sneakers, is in the back part of the building, shaking his head.

“Doris!” he barks, addressing a woman in her seventies who’s sitting in front of a computer. “The penguin.” He gestures toward a large plastic bird on the floor near the refrigerator. “You were supposed to put it outside. What happened?”

Doris, who is working her way through a stack of patient documents, is not having any of it. “I didn’t have time,” she shoots back, continuing to work. “I’ve got a lot to do.”

Lepore, who may stand 6 feet on his tiptoes, has a cleanly shaved head, a neatly trimmed gray mustache, and glasses. He lets out a single-note highpitched laugh and grabs the bird by the neck. “You’re disappointing me, Doris,” he says. “You know that.”

He pushes open the back door, steps outside, and places the penguin next to his other plastic pets: a chatty frog, a set of pink flamingos, and a big goose. They face out toward the hospital’s main building, allowing them to both greet new visitors and poke at his bosses, who don’t always share his levity. “There,” he says, looking proudly at the collection. “Now we’re ready to start the day.”

For the 72-year-old Lepore, it’s a day that will put him at the center of the 49 lives that stream through his office. He’ll clip out stitches from a dog-bitten hand, remedy an ingrown toenail, inject steroids into a pair of beat-up knees, clip off cancer splotches, and deliver some good news to a man with a collapsed lung. He’ll discuss with a young mother his work to combat her heroin addiction, and he’ll ease the worries of a nervous older man about an upcoming hernia operation. The less urgent moments will come too, like conversations with patients about the delicacies of Filipino cuisine, prized dog breeds, and this year’s high school football team. He’s a small-community doctor in the most important sense: part physician, part advocate, part friend.

“I like to take care of people,” Lepore is fond of saying. “Treating them is my thing.”

Just what form that takes is as varied as the patients who come to him.

Lepore’s path to medicine followed a straight line. His father, John, a trained surgeon, ran a family practice out of a second-floor garage space at the family home in Marlborough, Massachusetts, 30 miles west of Boston. Lepore shared few interests with his father except one: medicine. John Lepore also served as chief of surgery at Marlborough Hospital, and every New Year’s Day he brought his son to work. There, the young Lepore shadowed his dad in the OR and looked over his shoulder as he operated.

Lepore graduated from Harvard in 1966 and Tufts medical school four years later. Following his surgical residency, the newly married doctor relocated to Providence in 1975 to take a job in the emergency room at Roger Williams Medical Center. But city life and the rigid job structures that came with working at a big hospital felt confining. Lepore couldn’t simply bound outdoors to go birding or long-distance running; hospital hierarchy relegated him to just being a surgeon.

Nantucket was a happy accident. In August 1981, Lepore landed a monthlong stint in the island’s ER, which was often understaffed during summer. He and his wife, Cathy, a trained nurse, returned the following year. On the ferry home at the end of that second summer, Lepore looked at Cathy and said, “Why are we going back?”

As it happened, the island’s lone surgeon was retiring. Lepore applied for the job, and on January 1, 1983, he started his new position. “My bosses [in Providence] refused to believe I was leaving until my last day,” says Lepore. “‘You won’t like it,’ they kept saying. ‘You’ll get bored and won’t grow.’” favorite dogs, and there’s a black-andwhite of a shirtless 16-year-old Lepore standing next to his 1955 Chevy. The waiting area has two large glass cases that display human skulls, arrowheads, knives, and a Civil War medical kit.

OPPOSITE : Lepore, left, in his early years on Nantucket (c. mid-1980s), peers at x-rays with the hospital’s radiologist, Dr. Kenneth Seagrave.

LEFT : This bobblehead in Lepore’s image was a gift from one of his patients. “There are only two of these in the world, and she has the other one—I think it’s part of her shrine to me,” Lepore jokes.

BELOW : Lepore chats with patient Kenneth Bidlack during a checkup. The room’s institutional decor isn’t Lepore’s style, but his own office was being renovated at the time.

“It’s like a bad museum,” says Diana Hull, a nurse who’s worked with Lepore for 15 years. “Every time I look, I see something stranger. I think it’s because his wife doesn’t want the stuff hanging around their house.”

Wrapped around the whole scene is Lepore’s love for guns. Framed posters and old advertisements for firearms share wall space with the other pictures. Two of the examining rooms are named “Colt” and “Smith & Wesson.” The staff bath is referred to as the “P-Shooter Room.” In a nurse’s filing cabinet he keeps a pair of antique pistols given to him by a patient; in the cleaning supply cabinet there’s a set of old rifles.

The decor is in part a reflection of Lepore’s renegade streak, a defiant personality carving out some independence in a field that’s predisposed to a love of rules. But the collection serves another purpose: It underscores Lepore’s wish to make those who come to his office feel welcome. This is not a place of cold, blank walls or impersonal doctor visits. His history here stretches across lives and generations. Beyond his patients’ files, he knows their stories, where they’ve come from, what they’re sometimes up against. He’s hunted, fished, and worked out with them. He’s gone to their weddings, celebrated their birthdays, and attended their funerals.

Not far from those running photos and gun posters hang the most telling evidence of Lepore’s connection to the community: pictures of patients he’s lost over the years. The elderly couple whose weekly appointments were often just an excuse to see their good friend. A young woman he’d known since she was a little girl who lost her battle to cancer. A middle-aged man who finally found love just before cancer took his life, too. Those experiences will change a doctor.

“Rough edges get ground down,” Lepore says. “Dealing with patients who are desperately ill, you learn something from them. I’ve learned to be more patient and caring, and that things aren’t always as they seem to be. I listen to people more.”

That kind of experience has given him a sense for when to be gentle and when to hold people accountable. At one point, as a patient tries to feign ignorance over how traces of cocaine could have shown up in his blood tests, Lepore waves him off. “Come back next week,” he says. “And don’t give me any more of that crap about the cocaine fairies, OK?”

His history, this approach, is why a number of items in his office—artillery shells, a stuffed pheasant, some of the old handguns—are gifts from his patients. After so many years, the caring has come to work both ways.

“I don’t view payment as an impediment to care,” Lepore explains. “That’s not my interest.” He motions toward a large black-and-white photograph taken in Nepal that hangs at the end of the hall. “This guy came about 20 years ago. Was a high-end photographer and had a hernia. But he couldn’t pay for it. I did it for one of his pictures. Others have brought in lobsters, quahogs, and littlenecks. At one point I wanted to put out a sign that said, ‘If you’re not going to pay, good. Just tell me so I don’t spend $3 sending you a bill.’” He shrugs. “But my business manager thought that was a bad idea.”

In a darkened lab room, Lepore kneels on the floor in front of a big monitor. On the screen is a chest x-ray, taken this morning, that reveals a pair of broken ribs and a collapsed right lung. The patient, a local painter in his early fifties, fell off a ladder earlier in the week, and Lepore, who saw him right after the fall, is concerned that if the man hasn’t healed enough he may have to stick a temporary feeding tube in him. As he’s prone to do when deep in thought, Lepore leans forward and places his left hand on his forehead.

“OK,” he says, pointing to the lung, “it’s not as bad as when he was first in here.”

He jumps to his feet and goes to the hallway outside the waiting area, where his patient, a man with a full head of brown hair and a white beard, greets him, his body leaning heavily to the left.

“How we feeling?” Lepore says with some enthusiasm.

“Feeling good,” the man says. His wife, who is standing nearby, turns to look at him and laughs.

“Feeling good?” she asks.

“Well, I’m wearing one of those Velcro vests,” the man says. “If I take it off, I can take a full breath.”

“That vest keeps your ribs from moving,” Lepore says.

“At least I don’t seem to be searching for air,” he says.

The doctor nods his head. “I’m gonna want another x-ray on Monday to see where you’re at.”

“How did this one look?” the man asks.

“A little better,” says Lepore. “I’m not going to have to stick anything sharp or pointy in you,” he adds with a laugh.

From there, it’s a brisk walk back to the office, where he pounds the phones to find a doctor on the mainland to correct a patient’s failed back surgery. As he does, Diana Hull comes through the door of the waiting room, which is filled with voices.

“It’s like Old Home Day back there,” she says. “Summer’s over and we have the island to ourselves again. Everybody is catching up.”

Lepore soon puts the physician search on hold to tend to another patient, who’s staving off a pair of knee replacements through steroid injec - tions she receives every few months. The woman, who wears a pink blouse and has thick round glasses and long red hair, is already sitting on the examining table when Lepore walks into the room. “You’re keeping my knees alive,” she says with a chuckle. Like many Nantucket residents, Lepore’s patient does a lot of different things to pay the bills. She’s a cleaner and a cabdriver, and she manages the local VFW. She was up at 3 this morning to clean the island’s basket museum.

“What’s that place like?” asks Lepore, gently inserting the Novocain needle into her right knee. “A lot of baskets?” he teases.

The woman clenches her face.

“You need my hand?” asks Hull.

She winces again. “I’m OK. Besides, I might squeeze it too hard.”

Lepore runs three to four times a week, almost always in the wilderness of Nantucket’s moors. He ran a 50-mile course here to celebrate turning 50, but now that he’s 72, he says, “I’ve had to change the rules.”

Lepore looks up. “It’s perfectly OK to hurt the nurses,” he deadpans.

There’s a little more uncertainty with his next patient, a woman in her early fifties who has an infected right index finger and a fever. She had Lyme disease six years ago and is worried that it’s come back. “It’s the worst case of the flu you could imagine,” she says.

Lepore puts his fingers to his mouth and draws in a deep breath. “That’s not what’s making you sick.”

“Well, something is.”

“I know, and we’re going to find it,” he says calmly as he cradles her finger, which has a hard, red bump on its tip. He then asks Hull to look at the results of the blood test he ordered during the woman’s visit to the ER yesterday.

“I had a dog bite about 20 years ago, and I felt something similar,” the woman says. Then, as a quick aside, she mentions that her brother breeds hunting dogs. Lepore, who owns four canines himself, smiles.

“You know, all hunting dogs derive from falconry,” he says. “I have a redtailed hawk but she hates dogs. You might know Tommy Mahoney in ’Sconset? He’s got a beagle and a red tail.” And off Lepore goes. There’s an easiness to the doctor’s conversation, and it settles in over his patient.

From there he sits down with an elderly Filipino woman who has stage-4 lung cancer. And it goes like this for the remainder of the day. Lepore doesn’t have his own office. He just roams, grabbing a seat when he can on a stool at the nurses’ station, where he fields questions from his staff or sorts through a box of old medical equipment he wouldn’t allow the hospital to throw out. Throughout the workday the only thing he consumes is a mug of black coffee and a small bowl of potato soup.

At a little before 3, he’s informed that his friend Paul Thompson, a cardiologist at Hartford Hospital who’s in town to give a talk tonight, has arrived and needs a lift from the ferry.

“I’ll do it,” says Lepore.

“No, you won’t,” says his 30-year-old business manager, Libby Maynes. “You need to stay here. We’ll figure it out.”

Lepore shrugs. “Let me just run down.”

“You’re already behind on your patients,” she says, taking a seat in an office chair in front of her boss.

“I’m almost done.”

“No,” says Maynes, sharply. “You’re not almost done. You don’t have time for this.” She sticks her right leg out to block him from going to the door.

“I know,” says Lepore in a soft voice. “But he’s my buddy.”

He nudges her shin and looks at her. “Come on,” he says. “I have to do this.”

Maynes shakes her head. “Fine,” she says, pushing herself out of the way.

Lepore bounds out the door.

“Drive really fast,” she shouts after him. “Hurry!”

As the doctor passes by his plastic toys, the frog lets out a deep croak. Lepore laughs.

If he wanted to, Lepore could work any hour of the day. After so many years on Nantucket he has little anonymity. There are no “quick” trips to the hardware store or the market. There’s always a rash to look at, a prescription to call in. It’s why Lepore prefers to go running in the woods rather than in town. Even dinners out with Cathy are hard. At an expensive restaurant last year, the doctor was interrupted in the middle of his meal by the chef, who discreetly asked if Lepore could look at his hemorrhoids.

Lepore smiled. “Let’s take a look.” While Cathy quietly steamed, he examined his patient in the kitchen.

“He literally can’t go anywhere,” says Hull. “We were at a funeral and a patient of his leans over and says, ‘I know this isn’t an appropriate place the same doctor who left Providence all those years ago because he feared doing the same thing every day. He relishes being pushed to learn what he doesn’t know, to find answers to difficult questions.

Five years ago, Lepore saw how the island’s resources were desperately failing the community’s growing issues with drug and alcohol addiction. He eventually became a licensed prescriber of Suboxone, which inhibits the effects of opioid medication, and now focuses his Fridays exclusively on those trying to get sober. But that work can go only so far, and in the past year he’s started a small nonprofit to launch a full-time treatment and therapy center.

“If I allow myself to get cynical, I can look at somebody and let myself think, He’s just a drug user,” Lepore says. “But to ask you about this, but I have a few questions about Lyme disease.’ A funeral! Can you imagine?”

But Lepore isn’t working in just a small community; he’s working on an island, where weather sometimes determines when a patient can receive treatment. Nantucket Cottage Hospital isn’t resource-heavy Massachusetts General, with teams of residents and nurse practitioners. When the ferry or the planes can’t go, neither can patients, no matter the emergency. During a big storm several winters ago, Lepore phoned his cardiologist friend Paul Thompson to be walked through how to implant a pacemaker.

“We can do anything for 12 hours,” says Lepore. “After that, we run out of staff, we run out of everything. But on those dark and stormy nights when the Coast Guard isn’t available and MedFlight isn’t flying, we can do anything.”

You get the sense, however, that the challenges that come with an island practice fuel Lepore. He’s still then you stop and think, and you realize that 15 years ago he was a kid who went to our school. Maybe he played football. He’s got parents, maybe a kid of his own. So that makes me want to do everything I can.”

It’s just past 4:30 and Lepore is gearing up to go. He wants to head home for a stretch with Thompson, grab a bite to eat, then listen to his friend’s talk this evening. As he’s about to leave, though, he notices something.

“Wait, wait, wait—I almost forgot.” He opens the back door and begins hauling in his collection—the flamingos, the penguin, the goose. He stands them on the floor near a desk except for the goose, which he holds up for a few long seconds to admire. He smiles and gives it a look of approval, as if he’s seeing it for the first time. He then places it on the desk by the window.

“I want them looking out, so they can see what’s going on outside,” he says.

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