Island Practice

"You all right?" a companion calls. "Yeah, I'm just bushwhacking," Lepore barks, swinging at the forest with his fists. His shoes are untied. His bald head is swamped in sweat. He peers through perspiration-fogged glasses. "Stay right there until I see if there's a trail."

Lepore is on a house call—not your average house call, even for doctors who still make them. But he is determined to find the home of one of his patients, and if this is what it takes, this is what it takes. Finally, Lepore manages to force some branches apart and locate the remnants of an overgrown path. Slivers of water from Stumpy Pond can be seen at the bottom of a ridge, and turtles sunning themselves on rocks pull their heads in at the commotion.

Lepore trudges up a hill, clambers over roots, tears through thickets of scrub oak, and stops.

"Come up," he calls with triumph in his voice. "What do you see?"

At first there is nothing but forest. Then, through the trees, light glints on a dark green plastic tarp. Underneath is what looks like an igloo that has been intricately woven out of tree branches, grapevines, and reeds. It is about eight feet long, barely five feet wide, and a little over six feet tall. There is a door—wood framed with a large pane of one-way mirrored glass—and Lepore has a key.

"Tom," Lepore calls as he cracks open the door. Calling out is hardly necessary—it's a tiny structure—but it represents a touch of conventional good manners in this very unconventional setting.

Lepore may be the only person who has been invited to visit this house and one of the few people aware that its owner, one Thomas Johnson, has not completely fled the island.

Most people here know of Johnson as Underground Tom, and they think he is long gone, chased away after the discovery of another one of his secret lairs—dug deep under land that belonged to a Boy Scout camp. It was revealed only after a deer hunter stumbled on the black tip of a stove pipe sticking out of the ground.

That home, too, was a phenomenon of makeshift engineering, Lilliputian craftsmanship, and camouflage. It was also quite illegal, so Underground Tom was uprooted. After authorities discovered a tree house and a brush-covered log cabin he had built in other trespassed patches of land, he was, as far as most people knew, driven off the island.

But its roughly 10,000 year-round residents experience Nantucket in an altogether different way. They know the allure and liabilities of living in a place that is not always easy to get to or to get away from. Mystery has a way of drifting ashore, like the scrim of fog that can crease Fat Ladies Beach. And longtime residents are the first to say that this boomerang-shaped island—just fourteen miles long and three-anda-half miles wide at its widest point—seems to host more than its per capita share of outliers: eclectic, independent-minded, occasionally slippery or up to no good, often just aiming for a little reinvention.

"If you're going to make it here, you've got to have something that's different. People have to be characters who live here," asserts Peter Swenson, who runs Family and Children's Services of Nantucket. It's a quality many islanders acknowledge with shrugged shoulders and a touch of pride.

"Nantucket attracts the kind of person who has some flaws, who in the real world would become a problem, but here they're welcome," explains Chris Fraker, Lepore's longtime neighbor. "It's safe out here. You're one step removed."

A sign in the Nantucket town clerk's office puts it plainly: "Thank You for Not Discussing the Outside World." "We print it up on fancy, bordered paper," the town clerk, Catharine Flanagan Stover, pointed out to Lepore one day.

Thirty capricious miles of Atlantic Ocean stretch between Nantucket and its closest contact with the continent, the southern base of Cape Cod, Massachusetts. But the metaphorical distance can feel much greater.

Some people here call the mainland "America"—not wistfully, or in any way unpatriotically, but as a place they have happily, if only slightly and inconsequentially, seceded from.

"I spent ten years in America; I paid my dues," says Richard Ray, a native Nantucketer who heads the health department for Nantucket, which, including the tiny islands of Tuckernuck and Muskeget, has the unusual distinction of being both its own town and county.

Lepore himself decamped nearly three decades ago from Rhode Island. An emergency room doctor tired of shots being fired outside his Providence hospital and the nightly parade of urban gore gracing his gurneys, he was tantalized after a summer shift at Nantucket's bite-sized hospital. With its rows of cedar shingles and white-railed widow's walk coordinating neatly with the island's graceful architectural simplicity, the hospital seemed quirky without being chaotic. Nantucket would offer an easier lifestyle and would be a great place to raise kids, he and his wife, Cathy, a nurse and school counselor, reasoned.

Lepore became the island's general surgeon, the head of medicine at the island's hospital, and the island's medical examiner. "So maybe I can cover up my mistakes," he suggests archly. He is the school physician and the high school football team doctor, and he has been reelected to serve on the school committee for more than twenty years straight. He has bootstrapped himself into becoming a nationally recognized expert on tick diseases, a special scourge on Nantucket.

Although he has no psychiatric training, he provides cut-to-the-chase, profanity-perfused psychological counseling. He acts as an occasional Dr. Doolittle, treating a run-over deer, an ailing sea gull, a postpartum sheep.

When crisis has enveloped the island, as with a string of teenage suicides in recent years, he is one of the people called upon to try to hold things together. And he and his wife have repeatedly taken in teenagers who are in trouble and others needing a place to stay, sometimes fraying the fabric of the Lepore family in the process.

Lepore's family practice accepts all comers. He is not just a sawbones to the summer rich. Sure, he'll handle Jet Ski collisions and overboard yachtsmen. Even a little Botox now and then. Once in a while, a vacationer will show up dangling a bluefish from his head or torso, the hook having snagged not only the fish, but the fisherman. But Lepore also sees many working-class people and foreign laborers whose jobs undergird the luxury life: construction workers with sawed-off fingers or ears, lobstermen with chests crushed by winches, the firefighter's son who shattered a finger launching fireworks.

An equal opportunity malady is something Lepore calls "cobblestone rash"—injuries from falling (or stumbling drunk) on Nantucket's picturesquely uneven streets. There are also moped injuries galore, described with delicacy and decorum by the island doctor: "I've told people if they wanted the moped experience they could just let me hit them with a bat and then go over them with a sander." Bedside manner á la Lepore.

Driven by his own irrepressible volition, Lepore works constantly, never drinks on-island so as not to blunt his reaction time, and rarely goes off-island. "Hundreds of people would have died if he wasn't there, if not thousands," claims Richard H. Koehler, a surgeon on the mainland who comes over to cover for Lepore if he steps off Nantucket for even a day. Koehler figures Lepore "must have coronary arteries the size of the Holland Tunnel"—surgeon-speak for a big heart. "Literally, I don't know how he does it."

There are a handful of other year-round doctors, including three family practitioners, an internist, an orthopedist, a radiologist, and an emergency department director. And there are off-island specialists who visit at various times. But islanders, including other physicians, routinely describe Lepore this way: If you are sick or hurt on Nantucket, Lepore is the person most likely to be there to keep you alive. He is everywhere, and one of a kind.

"His is a job that very few people want to do, and nobody's doing it like he's doing it," says Diane Pearl, an internist on the island, who grew up here. "The fact of being limitless like Tim is—I couldn't do that. This is his kingdom."

Still, to the extent that Lepore is a medical monarch of sorts, he can be controversial. He can talk in brash assertions or unfiltered barbs that he sees no point in editing into more anodyne expressions. He can irritate or confound people who expect him to advocate a particular position. He has a passion for guns, hunting, and other conservative and libertarian issues, but will also perform abortions and supply patients with marijuana cookies. He has stirred tension by proclaiming that the only way to solve Nantucket's tick disease problem is to kill more deer. And he is not known for an especially cuddly bedside manner.

The story of Tim Lepore is in part a tale of a most unusual person who is central to the health and life of a community in ways that rarely occur these days. (Even the pronunciation of his last name is unexpected—not for him the more common "LehPOOR." Lepore rhymes his name, appropriately enough, with "peppery.") Against the background of a changing, churning American medical landscape, a physician like Lepore has become an outlier and a maverick.

His patient-focused approach, once much more the norm, now strains to survive in towns and cities across the country as health care costs skyrocket, medicine becomes more corporatized and monetized, and extended face time with doctors is an increasingly vanishing commodity. This is true in Lepore's own community as well. Nantucket's small hospital was recently swallowed by a big hospital company, forcing Lepore to struggle, not always successfully, to continue practicing medicine his way.

Lepore's island practice also provides a glimpse of the inner life of a place famous for its elite reputation but rarely understood in the human, warts-and-all way that Lepore experiences it every day.

There are many such places in America, some literally islands, others isolated by other geographical realities or by demographic transformations. They might be vacation havens like the Outer Banks or Aspen, Stowe or Sun Valley, places with hardy year-round populations that take on a different identity when visitors flood in each year. They might be the hundreds of less notable small towns dotting the Midwest, the Plains, the South, and the Northeast that have seen their populations whittled as industries leave or contract, or have confronted change as immigrants or other newcomers move in. They might even be neighborhoods in tourist cities like New Orleans or San Francisco, places that outsiders surmise to be a certain way but can never really understand as the locals do.

Lepore's Nantucket, with its saltbox houses, windy moors, and sea-stung sands, may be more offbeat than people would expect. Yet it is also more emblematic of America—in all its diversity, social strain, and economic division, but also in its scrappiness, creativity, and gumption.

Nantucket turned out to be a place that would let Lepore be Lepore. His idiosyncrasies and hobbies are quixotic even by island standards. Anyone for Siberian throat-singing or dog-hair knitting? How about scooping up roadkill or carving prehistoric spear-throwers? His comments, whether uttered in public meetings or patient exam rooms, can be just as colorful: a shot-from-the-hip political incorrectitude here, an arcanely acerbic aphorism there.

"He's peculiar," observes Jim Lentowski, who heads the Nantucket Conservation Foundation, "but we all are peculiar living on this island."

Pam Michelsen, a friend who teaches high school English, particularly Emerson and Thoreau, thinks Lepore could have "walked off the pages of Walden Pond. He is a nonconformist." In fact, both of these nineteenth-century Transcendentalist thinkers gave lectures on the island, which Emerson dubbed the "Nation of Nantucket." Notes Michelsen: "Emerson said, 'What I must do is all that concerns me, not what people think.' Well, that's Tim Lepore."

Part of the island's attraction for personalities of this sort stems from the challenge of living here year-round. Sure, Nantucket has some of the most expensive houses in the country—the median home price in 2011 was $1 million, making Nantucket the only U.S. county with half the homes costing at least seven figures. But those houses belong mostly to summer visitors. For the people who live and work there—teachers, police officers, waitresses, landscapers—those seven-digit numbers serve mostly to make everything, from gasoline to groceries, a lot more expensive.

There are no big-box discount stores, no Wal-Mart or Target. And because rain, wind, or hurricanes can suddenly make it impossible to leave the island, there's no guarantee that provisions from the mainland will always be accessible. Or that someone needing medical care could get off-island to receive it. "There's a certain amount of risk inherent in living on Nantucket, enshrouded in fog sometimes to where even the Coast Guard can't get in," Lentowski explains.

Sean Kehoe, who spent his teenage years on the island, leaving for New York as an adult, feels that "the amount of work that's involved, and sacrifice just to live here, after a while it's just exhausting. You see people move away. You see people just recede into themselves." But "people like Lepore who occupy the character role, who are a little bit eccentric, who are not flamboyant—people are just glad he's here. They trust him because he just wants people alive."

Indeed, much of Nantucket has to trust Lepore at one time or another. "When you're up to your ass in alligators, Tim Lepore is one of the people you want to have with you," says Margot Hartmann, the chief executive officer of Nantucket Cottage Hospital. "He is gutsy. He does not run. That's why he's become the backbone of the island."

And why he can end up stepping into almost any delicate situation, strictly medical or not.

Billy Dexter got to know Lepore in the late 1980s. He began visiting the doctor's office for routine things, but found Lepore good to chat with. And they shared an interest in hunting; Dexter liked black-powder rifles, and he once carved Lepore a squawking duck call. He would drop by Lepore's house with a black Labrador retriever three times the normal size, and when Lepore's children saw him approaching, they would hide in the bushes and yell: "Billy Dexter's here, and he's got a warthog with him."

"Tim was the only person who was kind to him," recalls Michelsen. "Tim thought he was interesting."

But Billy Dexter had a problem—and a predilection. As Lepore described it, Dexter was "a nice guy, but when he drank, he went off the radar."

And, apparently, into someone else's barn. On October 7, 1988, the owner of a Madaket Road stable called the police to say that she had noticed a water pail had been removed from one of her horse stalls and that the horse kept rubbing its hind quarters against the stall, according to a Nantucket police report. The woman believed "that the horse had been sexually assaulted" and "also observed a pair of black Farah pants at the back of the stall. The pants were placed into evidence."

The following day, a second police report was filed: "William Dexter called the station to inquire about some pants that he was missing."

Officers put two legs and four legs together, went to Dexter's Cliff Road house, and arrested him on two counts of sodomy. "Suspect has a history of similar crimes," police records stated, "and is familiar" with the barn owner "and her stables."

The court case caused a stir. Lepore's neighbor Chris Fraker expressed the island's and Lepore's dilemma succinctly: "What do you do with the town weirdo that's doing horses and sheep? Tim's view was 'I don't give a flying Friday what you do; just don't get caught.'" But "people didn't like it anymore, so it went to court."

The assistant district attorney asked Lepore to recommend whether Dexter was criminally liable. Lepore could have taken a hard line. After all, he didn't know the forty-four-year-old Dexter especially well, and no one would say there was an advantage in defending a guy who was into bestiality. But Lepore's judgment was that Dexter did not deserve to be vilified. "At heart he was a very sad, depressed guy. He would drink and have a dalliance with a horse. I knew Billy Dexter, and he was no stallion."

So Lepore wrote a letter to the district attorney and scheduled an appointment for Dexter with a therapist at Nantucket Counseling Services. According to the Nantucket Inquirer and Mirror, the therapist, Truman Esau, testified that Dexter should be hospitalized, not jailed, because he suffered from chronic alcohol dependence and zoophilia, having "admitted that having sex with animals is his personal preference."

Lepore acknowledges that Dexter's behavior was "a distasteful thing. This wasn't a guy who was going around knocking over mailboxes." But "I didn't think he represented a clear and present danger to the island." Dexter was eventually sentenced to a hospital instead of jail. A year later, though, he was arrested on federal firearms charges for having a sawed-off shotgun. It was a weapon that Lepore believed Dexter used for shark fishing, but this time Lepore didn't get involved. "I don't write many letters for felons," he said. But he doesn't throw patients overboard either. When, a few years later, Dexter suffered fatal heart failure, "I took care of him."

Dexter's brand of deviance may have been unusual, but Lepore has treated any number of Nantucket's odder ducks. "Not every miscreant is mine," he insists. "Just most."

Lepore has been pulled into some of the island's most notorious criminal cases. He's the person who pronounces murder victims dead, fixes people who are stabbed or shot, analyzes alcohol and drug levels in passed-out substance abusers, and helps evaluate whether crime suspects are mentally sound enough to go to jail.

Thomas Shack, chief of operations for the Cape and Islands District Attorney's office, remembers a recent high-profile case in which a woman seriously injured another woman in a bar fight. Shack's job was to undercut Lepore's testimony about the victim's intoxicated state.

"He has this sort of 'aw shucks' manner—you come in contact with that pretty quickly when he's on the witness stand," Shack observed. "Here I am, having to cross-examine him and kind of be tough on him, keeping in mind that this person might end up saving my life one day."

"People don't realize things happen on Nantucket," says Janine Mauldin, an island police officer. "They think it's a nice quiet island."

For one thing, there is the influence of the sea, the surf, and the sand. Collapsed sandbars can alter the channels that sea water moves through, creating sudden strong currents in unanticipated places. That can endanger swimmers and boaters, causing accidents or drownings.

Jet Ski collisions, man-overboards, and other watery mishaps land in Lepore's lap, like the time the singer Jimmy Buffett's seaplane flipped over as Buffett, an experienced pilot, was trying to take off from Madaket Harbor. The plane was badly damaged, but Buffett managed to swim to shore, where Lepore X-rayed him, identified minor injuries, and released him so he could go on to waste away again in many a Margaritaville.

Natural calamities can instigate human mischief, like the disturbing act of the unknown marauder who committed the federal crime of mutilating the tail of a dead humpback whale that beached in the summer of 2011.

And one fall day in 2010, the bones of a human leg, still in a sock and work boot, surfaced on the sand at Great Point. Police called Lepore. "Tim is the guy that I'm going to bring the bones to," notes Steve Tornovish, a detective. "He's the absolute master of the universe down here."

Lepore immediately sized things up: "A left tibia and fibula. No cut marks or bullet holes. It hadn't been gnawed on. The boot had barnacles on it. The bones had been cleaned of flesh. It had been in the water awhile."

More than a year later, verifying suspicions of many Nantucketers, state authorities determined the leg belonged to Jonathan Hemingway, a Nantucket landscaper who had disappeared one night in March 2010, when he was sailing his powerboat from Hyannis to Nantucket with his family and apparently fell overboard while his wife and children slept below.

The severed leg closed the book on one island mystery. But there is always another.

In July 2011, Lepore found a plastic bag on his desk with another human tibia inside. Someone had found it on the beach near Coatue and brought it—where else?—to Lepore. "Semifresh," he said. "Still smelled." It came from an adult over thirty, he deduced, noting that the bone's growth plates had fused, making it too developed to belong to a child. He sent it to Boston. No idea to whom it belonged, but on this island, "there's always folks missing."

What's never missing on the Nantucket that Lepore encounters every day is a spirit of individuality some people take to stubborn extremes. Gene Ratner gained national attention for his drive to save the four-bedroom home he built more than thirty-five years ago perching just above the great sweep of water off Madaket Beach. As wind, water, and time eroded shards of Nantucket's fragile coast, Ratner's house was increasingly in the crosshairs as the steps he took to protect it clashed with island environmental rules. Finally, in September 2010, after a hurricane left the house crumpled but standing, officials condemned it, and Ratner, by then eighty-five, was forced to take it down.