Island Practice (37 page)

“I, of course, wanted to do a good job and show that I knew what I was talking about, that I wasn’t bothering him or trying to interrupt his life for something that wasn’t worth his time. So I’m launching into my thing with this guy, and I think I’m doing fine.”

“Margot, Margot, Margot,” Lepore interrupted. Hartmann stopped cold.

“What?” she thought. “Have I missed something major?”

“Margot. You cannot polish a meatball.”

“What? Meatball? Why are we talking about meatballs? That is not in the code at all.”

But she realized “what he was actually saying to me was, this man had so many things wrong with him that basically don’t get your hopes up too high about what the therapeutic goal can be. That was my first real insight into the kind of brilliance and outrage of working with Tim Lepore. What he was saying was, ‘I have heard you. I have taken in all the info, and this is my assessment, and we’re not going to get all bent out of shape about it.’”

It was the first of many experiences. “Tim has this pithy phrase which comes out of who knows where, but what he says has a pearl of truth always. If he wasn’t a good enough clinician to be able to back it up, you wouldn’t care that he has a
Readers’ Digest
funny phrase of the month.”

Lepore can usually take a joke at his expense—when the Anglican minister dressed as Lepore for Halloween, or when a pumpkin carving
contest featured a Lepore look-alike skeleton in a lab coat and running socks, holding an X-ray, a tick crawling across its pumpkin head.

“You must admit I’m an easy target,” Lepore shrugs. Hartmann says Lepore fesses up to mistakes, unlike “some clinicians, who handle the weight of the responsibility by making their colleagues wrong. Tim never does that, and that’s a class act.”

Still, she says, “sometimes he’ll play, ‘I’m the surgeon; I’m going to nail everybody with the most esoteric question in public.’ It’s a gladiatorial combat kind of game.”

Hartmann recalls one meeting when she was running the emergency room. “Tim asked a very, very nasty question of me, a kind of show-off question that was designed to set me up: ‘Could you comment on the fact, Dr. Hartmann, that blah, blah, blah? . . .’ I felt so wrong-footed by this, in front of my peers and the people that I oversee.”

The next day, when Hartmann asked, “Tim, what was that about?” he apologized and sent flowers. She later told Cathy Lepore that the flowers were greatly appreciated. “Oh,” Cathy said, “he has their number on speed dial.”

Now, as the hospital’s CEO, Hartmann has inherited a hospital in strained financial straits. At the hospital’s annual meeting in 2011, which was also the hospital’s centennial, the numbers were sobering. The hospital’s loss from operations the previous year was $8.8 million, compared with $6.4 million in 2009. The cost of providing free care to poor and uninsured patients had grown by 60 percent; 18 percent of adults under sixty-five on Nantucket had no health insurance, twice the percentage in the rest of the state.

These problems reflect upheaval in America’s health system, and they are being felt in hospitals and communities across the country, especially in small towns. “Health care changed around us, and we were too small and really didn’t have the resources and probably didn’t want to know it,” Hartmann says. “We did not keep up. We kept up with the medical care, but not with the business of medical care.”

Nantucket’s hospital gets no financial support from local government, unlike some small community hospitals, and relies significantly on private donors, some not as flush as they once were. The number of patients is declining, as some people move off-island and others go off-island for medical care.

“The little procedures that used to help keep the system afloat, those have been whittled and whittled and whittled away,” Hartmann says. Some patients are going elsewhere because “the technology has advanced so much that we can’t keep up,” says Jane Bonvini, director of nursing at the hospital until she was let go in 2010.

The hospital building, erected in 1957, is in the worst shape and is the least efficient to heat, cool, light, and operate of any in the Partners system, Hartmann says. It costs about a million dollars a year just to keep things repaired and maintained, and Hartmann thinks the building may only be usable for another five years. “I’m pretty sure Florence Nightingale used that sink,” noted Monagle one afternoon in the hospital. “That shade of green is from 1958.”

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 surplus 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.”