by Pam Belluck
A 2011 national report gave Nantucket high ratings as a place where people are healthy, ranking it first among Massachusetts counties on measures like health outcomes, mortality, and healthy behaviors. But Nantucket ranked near the bottom in two categories: its high number of uninsured adults and its low number of physicians. Lepore told the local paper that winning healthiest county in the state was like “being the tallest midget.”
Indeed, a few months later came another rating, from the American Trauma Society, which listed Nantucket among the country’s “danger” zones because it can take more than an hour to reach a hospital with advanced trauma care.
Hartmann is in a tough spot. She heads what she calls “an improbably sophisticated facility for the size of the year-round population” and faces bean counters who believe the hospital should be stripped down to “basically a first aid center and a helipad.” Other islanders want “the intimacy of a small place, but they want the cutting-edge delivery of care. People choose to be out on Nantucket probably because they don’t trust and don’t like the way it’s done on the mainland.”
Chabner says “the real issue for Nantucket is how much should they try to do out there versus how much should they refer. I think it has to offer very good emergency service, very good family care, routine internal medicine care, and has to have some capability for emergency surgery. That’s why Tim’s so important. It’s very hard to find a person with his kind of background.”
Recruiting and retaining staff of any kind is “a nightmare,” Hartmann says. “Our costs of living are probably 127 percent of anybody else’s. Everyone’s enchanted in the beginning, and it’s all wonderful. But the island, for the person, let alone their family, it’s a whole different kind of commitment. It either clicks or it doesn’t, and more often than not it doesn’t. Some people, they want the mall and the multiplex cinema, and they want the chain store, and they get island fever very quickly.”
Also nurses and doctors these days want to specialize, but Nantucket needs them to do everything. “You get people saying, ‘I only work in the ER, and I can’t do anything else.’ Well, we can’t hire you then,” former nursing director Bonvini says.
Hartmann says Nantucket needs “a particular kind of person that likes to live this remotely, and is comfortable enough with their skills to function without all the layers of subspecialists, somebody who already knows what they don’t know, and is very good at identifying that and knowing who to call.”
All these tensions are playing out in economic ways. In 2011, the hospital cafeteria was shut because of deteriorating plumbing, reopening after a $50,000 repair bill months later, but only in a scaled-down version. Programs like home health nursing have been eliminated or contracted out to off-island organizations.
For Lepore, the cutbacks are “very stressful,” T.J. says. “He recognizes when things are being lost that shouldn’t be lost. At a hospital that size when you start peeling away services, where does that end?” In the past, “he’s always had people over a barrel who demand things because he’s the only show in town. I’m not sure Mass General really understands that. I think in a lot of ways they see it as a normal feeder hospital, and it’s not.”
Hartmann sees both sides, saying, “We’re really just trying to stabilize the hospital and figure out whether we can be sustainable, which I think we can be.” Hartmann hopes that a fundraising campaign will generate enough to build a new facility on hospital grounds.
But for now, with the resources it has, the hospital is renovating some areas, hoping to improve outpatient clinics, and increasing telemedicine, with mainland doctors giving virtual consultations to patients with strokes, skin conditions, and other problems.
Telemedicine concerns Lepore, especially teleradiology because relying on off-island radiologists could limit his ability to offer input and get scan results quickly. “Other people practice very effectively waiting for the X-ray report. I don’t. You could say, ‘Well, Tim, in the grand scheme of things, this isn’t good for the hospital or the country or the world.’ I don’t care about that. My concern is that particular patient.”
Lepore knows his value to the hospital. “I’m a little bit like an amulet. If I croak, there are problems.” Besides his own medical activities, he mentors young staff members, popping in on a new lab technician and saying, “Can you take my blood?” The technician was so nervous she was practically shaking, but when she finished, Lepore told her, “You’re going to do great.”
He regularly contributes his own money to the hospital, sometimes as much as $25,000, and has purchased equipment on his own dime, including an advanced blood sugar monitor. He recruits donations from his wealthy patients for equipment like a laryngoscope. “The hospital may not see it as a need, but I do, and that’s it. If I think it’s important, I put my money where my mouth is.”
But Lepore can be headstrong even with Hartmann. When one of his dogs, Buddy, a Nova Scotia Duck-Tolling Retriever, had a kidney tumor, Lepore wanted to use the hospital’s ultrasound. He was rebuffed. “They got their undies in a bundle,” says Lepore, who took Buddy to Boston. “It cost them money to cover me when I had to go off-island. And I did not appreciate it.”
Hartmann saw it differently. “If Tim wants to bring a dog into the ultrasound suite, and frankly if he’s feeling the need to make an iconoclastic point, then he will swagger in and do it in the middle of day when everybody is there, which sets me up and sets everybody up. My feeling is ‘if you’re going to do this, fine, I’ll help you. Let’s do it at a time when people aren’t around.’ He didn’t need to be so visible. He set it up so that somebody had to come down and say no, which makes the suits look like the suits and Tim look like the good guy who’s on the side of right.”
Hartmann sees Lepore as “basically a libertarian, maybe with a small l. He’s always going to try and take pot shots at those of us who are not, and he enjoys that. If I’m in the mood, I will play. But if not, I will say, ‘Tim, I am fighting for the survival of this hospital. I don’t need that kind of pot shot.’ And he stops.”
In truth, Lepore doesn’t always pick a fight. His goal, usually, is not to break the fine china but to quietly use his own tried-and-true set of plates. When he transfers a patient off-island, he doesn’t necessarily adhere to the administration’s preference that he send them to Mass General or another Partners hospital. “I send them where I want,” based on what he feels a particular hospital excels in and where “I can make one phone call and the patient’s well taken care of.” Some hospitals “can be a bit of a black hole. I deal with quality people who I trust. I know the patients are going to be treated well, and I know I’m going to hear back.” Besides, it’s a small victory in his crusade to maintain independence from the corporate suits. “It gets their noses out of joint, which makes me happy.”
Chabner, who makes sure that when Lepore calls his office for a cancer patient, “I get him in right away,” would like to see more Nantucket patients sent to Mass General. But he understands that other hospitals “have provided very good service for him when he’s needed it in the past. To suddenly drop those people and establish relationships elsewhere is hard.”
Lepore doesn’t complain about everything in the new hospital landscape. “He doesn’t trust any of it, but on the other hand he’s the first one to tell you that in some ways Mass General has brought good things,” Hartmann reports. “Well, he won’t be the first one to tell you, but if you hang in long enough in the conversation, he will tell you that.”
In fact, says Lepore, “some of the people from Mass General are recognizing that there are some things we need. Once, I wanted to get a psychiatrist to see one of the patients. The reimbursement issues were very unclear. The financial guy said, ‘Look, get the psychiatrist. We’ll deal with the reimbursement later.’”
He has also made accommodations to the new culture, in his own way. He doesn’t wear his hunting vest so much anymore or the clothes from his favorite military su
rplus store. But sometimes he dresses to the other extreme, going beyond the casual clothing other doctors wear. “I wanted to drive people crazy by switching. For a while I was wearing a tie and jacket. People were making fun of me, particularly when I had my initials on my pocket. I just thought I’d spiff up a little, just to separate myself.”
Lepore intends to remain separate. “If they pressure me” to sign up with the MGPO, he says, “I just say I’ll take a month off. They can’t do anything to me. I’m fairly bulletproof.”
Cathy thinks some of that is bravado, and she fears that “things are getting narrower for him with this MGPO. I think he feels like a dinosaur.”
But no one on Nantucket wants Lepore to become extinct. Chabner, whose father was a small-town doctor in Illinois, says people like Lepore “have a different relationship with patients. You become an intimate friend of the family; you go through all sorts of trauma with them, medical and psychological.”
Plus Chabner knows Lepore’s knowledge of tick-borne diseases is invaluable to Nantucket. “He’s really an expert at it, something really unique in medicine.”
As a surgeon, Lepore is unusual too, because he’ll perform so many different operations but also turn down surgical opportunities if he thinks patients should go elsewhere.
“You don’t find many surgeons that are willing to open up a big family practice,” T.J. observes. “He is one of the few surgeons I know that would make that choice. It’s going to be hard to find a young person, certainly, who’s going to want to come and do very little surgery and maintain their skill level, but it’s going to be hard to find an older surgeon who wants to work the hours he does. I think that’s one thing that’s going to make it very hard when he retires, if he does retire. He’s practicing a brand of medicine that is hard to do these days, and it’s rare.”
In fact, while Richard H. Koehler, a laparoscopic surgeon, comes to Nantucket to cover when Lepore goes off-island, neither Koehler nor anyone he can think of would fill Lepore’s running shoes. “You will never find a general surgeon who’s going to do primary care. Never. Maybe in the outskirts of rural Montana or Manitoba. I would be stunned. He’s two people. Then, when he acts as an obstetrician, he’s three. He also does endoscopies,” inserting a scope into the body to look inside. Many general surgeons don’t do that either, Koehler says. “He’s four people.”
All of which means, says Pam Michelsen, that if Lepore ever stops doctoring, the island “will be like the rest of the world, and that’s just not Nantucket.”
Lepore, at sixty-seven, shows no sign of retiring, but the hospital is dreading the possibility. “That’s a very serious issue now,” Chabner asserts.
It’s a question other small communities across the country are confronting in their own way: what to do when the kinds of doctors people have always relied on can no longer make a living practicing medicine that way. What to do when medical care becomes less personal, more expensive, farther away, more cookie cutter, less Lepore-like?
“How can you replace a guy like that?” Chabner asks.
Hartmann thinks that, at least for Nantucket, it’s virtually impossible.
“My personal nightmare is succession planning for Tim Lepore,” she says. “There are no Tims out there. There probably really isn’t another Tim Lepore in the whole country.”
One day, a DVD arrives in Lepore’s mailbox. Its title is Trees Inn: The Next Best Trespass. It says it is “a film by Dug Underwood” about “another handmade home by Forest Green.”
Lepore is intrigued. Dug Underwood and Forest Green were two aliases of Underground Tom, who built illegal hovels and hideaways all over Nantucket, but whom Lepore has not seen in a while. The video turns out to be nearly two hours long, a molasses-paced montage with shots of trees and birds. But to Lepore it is invaluable because it gives a fascinating update on his mysterious patient.
“This is Dick Human,” Johnson says, appearing on screen dressed in camouflage pants and cap with netting pulled over his face. “You’re watching the Forest Green show. In this episode, we’re going pioneering.”
What follows is a documentary of Johnson building a new illegal abode, a tree house on stilts somewhere on Cape Cod. Filmed around Christmastime and spiced with country and reggae music, the film shows Johnson under the gun to build his new residence before authorities disconnect utilities in a place he had been squatting.
“Six days ’till they’re shutting the water off,” Johnson grumbles. “Only thirteen more chopping days till Christmas.”
Some days Johnson doesn’t chop because he fears the noise will attract attention. He carefully arranges brush and trees. “As I go along, I camouflage.” One day, he mourns: “Broke my axe. This thing has helped me build so many places.” Still, he presses on, working from before dawn till moonrise: “When you’ve done this as many times as I have, there are few wasted steps or opportunities or wasted materials.”
The first snowstorm of winter arrives, making him fear being discovered if his feet leave “leading tracks back out of here.” Plus, “everything’s frozen solid,” so it is it harder to use his primary tools, a pruning saw and a machete. On Christmas, Johnson sings, “It’s beginning to look a lot like Trespass,” then mutters, “So glad that Christmas is over. All those goddamn songs stuck in my head.”
The house, finished in six weeks for $195.17, has neatly crisscrossed logs, glass-paned windows, a peaked roof. Johnson builds a wood stove from an ash can and empty soup cans. “I’ll never be done with this place, always be doing something. But no one heard or saw me, and I didn’t get hurt, which is saying a lot with these sharp tools and being accident prone.... But I am bone tired. I feel like my whole body has carpal tunnel syndrome.”
Watching, Lepore worries about Johnson, out in the elements, eating and drinking who-knows-what. Even someone used to reclusive wilderness life is at risk for disease and deterioration. Johnson mentions smoking pot several times, and in at least one scene it appears that he is. He’s contracted poison ivy so bad that his eyes are swollen and his face puffed up. “This is why I live in a swamp all alone,” he says, laughing maniacally, as he stares into the camera. “I got a face like an ass. I got the P.I. as bad as you could hope to have it.”
Johnson’s “Trees Inn” location is a mystery, though he refers to a specific highway, suggesting southern Cape Cod. Later, the house gets discovered by state public works employees. “Somebody lives there,” one says. Johnson replies, “Yeah man, that’s me, dude. Any chance of keeping that cool?” The worker is awestruck: “Unbelievable craftsmanship . . . unfreakin’ real.”
Johnson, afraid of being ratted out, tells him, “I’m freaking out right now, man. . . . I’m homeless you know.”
“Well,” the worker says, “obviously you need some camouflage. I’m going to cut cedar branches for you.”
Another worker tells Johnson: “I read about you on that Nantucket. . . . We’re going to cut back on what we’re doing . . . let you be and let it be our secret.”
Johnson shows them around, proudly displaying a decorative carving of a rat, duck, and shore bird that he creates “in all my places.” He asks that they dispel any rumors about him or the house by saying, “Nah, we just met some guy that was in there for a few days.” A worker readily agrees, saying that would be “a damn believable story. It’s almost more believable than what you’re doing.”
After they leave, Johnson can hardly believe his luck. “Well, I got away with it. To my health, stealth, and wealth.”
At one point in the film, Johnson is briefly on Nantucket, visiting a tree house he built in 1998. It is weathered and some of what appear to be corrugated metal panels are peeling away from the tree house frame. But Johnson looks on with pride. “Still standing after ten years, for all the high winds and storms,” he says, as another storm starts brewing. “And there’s the ironic thunder rumbling in my life.”
At the end, before the credits roll (“construction consultant: Frank Load
Right”), Johnson as “Dick Human, hobo semipro” does a mock commercial for the “Trees Inn. . . . They got everything a bum on the run needs.” For a movie by a hermit with barely a nickel to his name, it is a tour-de-force.
The film prompts Lepore to try a cell phone number Johnson had given him once, but it is disconnected. He pays another visit to Johnson’s Nantucket “twigloo,” which he finds to still be outfitted with crammed-in creature comforts, giving the impression that Johnson may return.
“He sort of comes and goes with the wind,” Lepore muses. Then, after returning home, Lepore has a thought. Firing up Google Maps on his computer, he searches to see if the Hidden Forest house is visible on the satellite images. He doesn’t want people intruding on it, destroying it like they did the Nantucket tree house, which, Lepore discovered when he went to check on it , was pulled down to make way for a Frisbee golf course.
Of course, Lepore figures somebody will stumble upon the twigloo one day. In fact, eventually it will not only be discovered, but dismantled, stripped of its accoutrements, hauled out of the forest on bamboo poles, and set up in a schoolyard—an empty shell to be used as a children’s playhouse. Not a very Tom-like denouement.
But for now, this patient’s secret is safe, zealously guarded by the only person with a key to his hidden homestead. Zooming in as far as possible on the satellite maps, Lepore spots a white smudge and wonders if it is the twigloo. The doctor cocks his head, squinting carefully at the screen. It’s as though he is scanning an X-ray, an X-ray of the life of a patient who trusts almost no one else.
ACKNOWLEDGMENTS