July 24, 2012 9:10:00 AM
If you are ever in Nantucket and need medical care, do not be concerned that the doctor you get to has an armadillo comically taxidermied in his waiting room to look as if it is swilling beer. Do not worry if the doctor is a gun nut who names his exam rooms Colt, Winchester, and Smith & Wesson, and don't be surprised if he examines you while wearing a hunting vest instead of a lab coat. Admire his Harvard diploma on the wall, but ignore the framed document that proclaims him "Timothy J. Lepore, Master, Temple of Doom." For all the crazy trappings, he's a good doctor and you are in good hands. In Island Practice: Cobblestone Rash, Underground Tom, and Other Adventures of a Nantucket Doctor (PublicAffairs), Pam Belluck, who writes on health and medical issues for the New York Times, gives an appealing profile of a flinty 67-year-old New Englander doing things his own weird way, and also of the strange island community that he rarely leaves, because it cannot do without him. Funny, startling, and sobering by turns, Island Practice has a few things to say about the American health care system, but the picture of the island and its odd practitioner can't be generalized. It's all too strange, but it works.
One of the first things you should know about Lepore is that you are not pronouncing his name right even as you read it silently. It rhymes, appropriately, with "peppery," and therein starts the cantankerousness. Lepore has an anachronistic approach to his work. He is a general practitioner and general surgeon. He would have little patience with seeing a waiting room full of people who need their blood pressure medicine refilled. He likes action. Trauma is good, but he likes doing anything new. When a nurse working with him wanted her underarm flab removed, she asked Lepore if he could do the job. He had never done the procedure before, but he assured her, "I can do that," read up on it, and did it, to the nurse's satisfaction. She did insist, however, that any flesh removed not be turned into jerky and given to Ajax, Lepore's red-tailed hawk. It is not clear that he really does this with extracted tissue, but Lepore does collect roadkill and keeps it (along with "mice-icles") in the freezer for his feathered hunting partner.
Because of Nantucket's island status, with infrequent ferries and questionable connection to the mainland (which the natives refer to as "America") when the weather is bad, Lepore takes on most challenges himself, and in those cases where transportation off the island is not possible, he does work that ideally ought to go to bigger hospitals with specialized surgeons. He seems unfazed by having such challenges dropped upon him. He calls surgery a simple matter of cut, sew, and tie. He says, "If you can eat in a public place without a bib, you can do surgery," and he calls an emergency Caesarian section "a semimindless procedure you can do if you got opposable thumbs." There are risks in having a general surgeon do C-sections, but there is no one else to call upon in his home turf. He also does abortions. He doesn't like them; he is a conservative or libertarian of Catholic background who listens to Rush Limbaugh, but he also wants to do what is best for the patient who presents to him. Also, he prescribes marijuana cookies for people, and he has a particular baker friend who makes them. (Medical marijuana is illegal in Massachusetts, but as usual, such things don't matter when Lepore wants to do what is best for the patient.) He does not use marijuana himself and thinks it should not be legalized, and while he has no objections to the use of alcohol, he only drinks on those rare times he goes to the mainland, because he cannot tell when someone on the island is going to need his help.
One of the times he goes off-island is to run in the Boston Marathon, which he does every year. His training is erratic, and his times are bad, but he does train and he does finish. The marathon is an annual tradition of longstanding for him. His other oddities can be more ephemeral. He collected dog hair, for instance, for the purpose of knitting sweaters. His family remembers a spell when he restricted their diets to polenta. He harnessed his hobby of flint knapping to make his own scalpels, chipping them out of a block of obsidian. The blades thus made were at least as sharp as steel scalpels, and they worked just fine on hernia repairs and appendectomies. He always got the patient's permission to use the obsidian blades beforehand. The only problem was that they could not be steam-and-pressure sterilized, so he would send the blades he made to Cape Cod Hospital, where ethylene oxide was used to sterilize them. When the C2H4O was found to be carcinogenic, or caused birth defects, or something ("Or it kills wildebeests. I don't know.") it was discontinued as a sterilizer, and the use of obsidian scalpels had to be as well.
Along with his practice, Lepore has made himself the island's expert on Lyme disease, which is common in New England and is hot in Nantucket, because of its deer population. He is not only the island's expert, he is a national expert, and is called upon frequently by doctors that need information on the disease. Lepore likes hunting, and he also likes giving deer carcasses (his and his friends') a frisk to see if he can find ticks that might bear the disease, or the other potential deadly ones, babesiosis and anaplasmosis. His obsessive interest in ticks has been called "obscene," but it is part of his mission. He not only treats those afflicted with diseases borne by ticks, but he wants to decrease the tick population, and the way he wants to do it is to decrease the deer population. Nantucket has not always had deer; the current ones were installed on the island ninety years ago, and they are beloved by residents and visitors as animated lawn ornaments. Lepore's stand on culling deer has made him unpopular with many, not that this makes a lick of difference to him. He himself prints bumper stickers showing a blood-engorged tick and the sarcastic slogan "Save Our Ticks!"
Lepore may be weird, but he is used to seeing weird cases, like the guy who comes in with the complaint, "Doc, I think I have a ballpoint pen up my penis," which gets Lepore's comment, "You're a dumb bastard." The guy takes offense, but for the wrong reason. "Look," Lepore tells him, "you're forty years old and you think you have a ballpoint pen up your penis? That's sort of black and white." There are plenty of sad cases that go with the island beat. Nantucket is closed off, there are extremes of wealth and poverty, the winters are tough, and the summers are dependent on off-island tourists and vacationers. There is lots of drinking. "Half the island goes to AA," he says, "and the other half should." Underage drinking and drug use are particular problems. Lepore has insights that he shares with a lot of patients who come to him for counseling. He also takes in strays, not only animals, but people who need help getting back on their feet. It doesn't always work, but if not, it's not because he didn't go out of his way to give the patient a break. He also is a bane for his accountant and for the hospital that has to bill for his procedures. He makes enough money to get by, of course, but money is clearly not what he is in practice for. If you can't pay, but you can make oatmeal cookies, he will book orders for oatmeal cookies.
Lepore is not always loveable, as his wife and children attest, and his quirky humor can be inexcusably mean at times. Belluck has given an often funny, always thoughtful account of an American original who is doing things his own way and benefitting his community thereby. Everyone who lives on the island knows Dr. Lepore, and many owe their lives to him, although they might not like him very much. He is highly esteemed by his colleagues and the health-care officials on the island, and over the book hangs a serious question for them all: He has spent years doing 24/7 service and everyone agrees no one else can do it, and he will have to quit sometime. He is irreplaceable, but who will take his place?
5. A Stone's Throw: The veil COLUMNS