You might not know that doctors’ businesses in the US are going bankrupt. Mine did.  Not me personally, but the business. Medicine is a cog in the economy like everything else. Lots of cogs are blowing out. I have a story, like everyone who goes bankrupt.

When I went to medical school I learned that doctors are pretty well respected. I think that most people live with a level of distrust for doctors…except their own. The other thing I learned was that if I lined up and kept my nose relatively clean (which I have not nearly always done) I would have job security in addition to respect and I could buy a nice house with a manicured yard and super linear shrubbery. I learned that I would work my ass off and I could expect to not make a nickel if I didn’t show up to work. No passive income to speak of.

Some of those lessons have changed. I have touched on the respect part above. Job security is not a given, although it is much better than many fields (but see below and above), and I still believe that there is always room at the top and I make my plan to be the best surgeon I can. I do indeed work hard and passive income is still hard to come by.

So my bankruptcy story has to do with a partner playing Jenga with our practice. He suddenly quit (not a typical partner move), defaulted on financial responsibilities, and those remaining got to watch the rather remarkable tumbling and destruction of a decade of work. I recently went to traffic school for a ticket (I got a warning one early morning from a really nice cop and the next day at the same time, place and channel we did a rerun. We both (kind of) had a laugh about it) and during the 6 hours of “class” we saw many slow-mo traffic-signal traffic-cam videos of car wrecks caused by drivers who were either a)inattentive or b)angry, I learned. Even though they are disturbing there is an irresistible modern dance feel to a car wreck that draws me to it. I catch my breath as the cars, which are usually stubbornly solo, find one another, finally. There is something beautiful in it. Anyway, I kept thinking that I was being reminded of something. Now I know that it is the demise of my business caused by inattention, resentments, assumptions. As I have lived through the process, I will indulge myself in another metaphor: it’s like when the charges go on a building being razed and the center gently drops to its knees and the arms of the building appear to rise in praise or supplication.

Even though I am making (up) something beautiful about this betrayal and embarrassment (I will take the liberty of claiming this blog as my attempt at beauty), I am here writing to get it out of me that I do feel exactly betrayed, pissed, and embarrassed. I am not looking for comfort, to hear its going to be ok (I know for sure it is more than ok, no matter what–for instance we have already been bought by a medium-sized (Ross not Macy’s) box store of a medical-practice-buying group and we didn’t miss a day of work–lots to be grateful for). I am letting myself have the feelings and I since I tell you about things like that, I am telling you about this. My (X)-partner? He knows his motives. I don’t. Don’t want to. I don’t think Karma is too worried about a little medical practice in Central Oregon, but who knows? I do. It’s not. At a minimum I will recommend that he not come here for a reference. His behavior is his problem (or reward depending on if you are me or him, I guess) and I am sure he will have an interesting and rewarding story about all this. My job, today, is to come to terms with rebuilding, remembering who I am instead of looking at what I do, and paying attention to these difficult feelings. Like with my little kiddo, if I pay attention and stay present when he is uncorking, he gets different in a bit. If he goes through uncorking alone or he sees me ignore it, it is actually damaging to him and he saves it as one of those millions of unfelt feelings that we store and eventually have to find an anesthetic for. It’s ironic that anesthesia means to have no feeling and in the world of our emotional selves it is feelings not felt that look for anesthesia, not the ones that we struggle through, feel fully and move on from. Those ones bounce away from us as harmless as the tire thrown bouncing down the road after a wreck.

I have gained weight in the last year. I work with people all day every day on this issue and here I am having gained enough weight that I know that other people notice, wonder, question. Enough that it is getting in the way of relationships, most notably on my side. I feel less of me even though there is more of me. The less of me is what I am noticing the most, ironically. The part of me I have hold of is diminishing. I am falling out of focus.
When I exercise I feel good. I don’t exercise much. When I exercise I lose weight, fortunately. I am not exercising. I am not able to give myself exercise as a gift, a chore or anything else. The reason is that I undervalue me. There is not a mystery at work. I don’t have enough of me to have enough of me. I am writing this to change this and to hold the intention in these words to look for me in the movement of my well made and good enough body. I spend so much time in my head, but I live in this body. I want it back. I can’t really give it to anyone else or be all there while I have so little of so much of me.

Scarcity brings out the fundamentals in a personality. I will use myself as an example, although I could refer to others in my life as well, “ex” people of several varieties, wives and business partners come to mind–these darker sides come out as people are leaving my life, I guess, or I maybe bring it out in them. Even if I do bring it out, I didn’t make them that way. Maybe no one did. A person who I thought I knew is completely different when things get tight. I bring it out in me too. I usually find that I am short on space or time. I contract, retreat. In the past when this went on long enough my depression or frustration would leak out as destruction–self, relationships, whatever. Now I try to ask for time or space to recharge. I do this blog, write or take photos. I fill the scarcity with the better side of me. Then I feel. Better.

I have said many times here that I have trouble with feeling things. I can literally feel nothing at times. Is that possible? Can I be blank? It is not unpleasant, but it is odd. We are emotional beings. I see it in my son. Feelings, like a river, flow through him. Thoughts however, do not. As thoughts come, the feelings have a hard time getting space. I misplace my feelings and I think my thoughts are feelings. I watch you all very carefully and I can tell you what I should be feeling. What should be feelings can be observations. It is hard to have thoughts and feelings at the same time. Since my brain thinks all the time, I have to ask it to quiet itself so I can have a feeling. These crazy conversations in me. How does this happen? Who is having these discussions. The me looking at me thinking of you, feeling for whom, living this life. As my boy finds his brain, which is really beautiful to see, his ability to have the flows of emotions will diminish. I know now that a human who does not feel his feelings will end up with distorted bubbles of emotions stuck inside him, but the brain does not give a shit. It thinks and thinks and it is good at it and it is very interesting too, in a way. I have to talk myself in to having feelings sometimes. If I don’t I miss out on love from my wife and love for my wife, joy with my son, satisfaction with work, with beauty. I rail against this tendency to see the world as a puzzle constantly. I do this because I can’t do anything else. I have to have my heart in order to have yours. My brain can’t be two things, like this crazy blue plastic grass someone planted can’t be real green grass. I look at my son at marvel at his open heart but I know his brain, his mind, is doing push ups, getting strong and waiting for him, with all its power and it downfalls. His work, like mine, is to know himself, head and heart. My job is to teach him generosity and honesty with both.

My patient had literally burned a hole in his tiny, new stomach with a combination of cigarettes and alcohol. I don’t have a moral position on this except that life is probably worth preserving until one can make an informed decision. Destroying it unconsciously feels arrogant, but again, who am I to judge?
Most people can smoke and drink a whole lot without any problems to the stomach, but after having weight loss surgery, a gastric bypass, it is really risky. The little pouch is relatively unprotected and the combination of impaired blood flow (smokes) and caustic liquids, is a set up for problems.
He was out hunting. Actually he was out mostly drinking and smoking and reflecting (dimly, I think) on why his wife wanted to end the marriage. He woke up with a hole in his stomach that felt exactly like that. He tried to drink water and the it ran out of the hole like rain through a drain pipe. He developed peritonitis. He made his way to a local hospital in remote Oregon. The surgeon there saved his life by sewing a patch of fat over the hole, literally.
He then moved to Central Oregon where I have met him. He is a really nice guy. He can’t figure out the drinking. He used to eat, but then after the operation, he drank. He sits bewildered at night wondering why he still does that, even now, after he almost died. As I talk to him I can see him there with his little glass of vodka, one then two. He is sad, misses his wife, knows it has something to do with this operation he had and how he switched to the vodka from the sugar, but it is fuzzy to him. He is relieved when I tell him there is a way to stop drinking that involves, well, stopping drinking. It is as difficult and as easy as that. The missing ingredient for him is other people. He needs their help. I could tell that made sense to him. I told him where those people were.
My patient has experienced addiction transfer, a boring term for what is really simply addiction, which is the process of filling our empty human-ness with anything other than ourselves. When we abandon our emotions, numb them, the anesthetics become the substitute and they feel like home and heaven and hell at the same time. He started with his foods of choice, eliminated those by having surgery but without understanding the emptiness and started refilling the emptiness with the next thing. He came to me from Reno. It could have been the craps table, but it wasn’t. It was this.
It is anything and everything. We are built, I think, with an emptiness. We are forced to connect to someone outside ourselves in order to fill this emptiness or we instinctively, it seems, fill it with some thing. This doesn’t work, and only when the pain of this gets very apparent do we change course.
Here is what I know from what I have lived and what I see in my work (and I don’t know why this is true, but I think it is): we need love and connection (connection also known as spirituality). We get sick alone and we get better in groups. Healing literally lives in the connection.

I work with people who are changing their relationship to food. Mostly they are obese and don’t want to be. Most have had surgery under my hand to give them a tool to help them relearn two sensations that their bodies have literally forgotten. The two sensations are full and hungry. Because of the disease process of obesity, the body literally experiences hungry/full in a faulty way, much like someone with diabetes experiences sugar in a faulty way. Making the stomach in to a small pouch changes the experience of hungry (reduces hunger dramatically) and full (increases satiety). The effects are dramatic most of the time.

What does not change is the emotional component of the relationship to food. If food has become the person’s experience of love or connection, that does not miraculously change. When I say something like this to a room full of physicians, some of them do what I imagine you are doing (only they literally do it right in front of me); they shake their heads. These physicians believe that the problem of obesity is eating, and they are wrong. The endgame is eating, like the endgame of alcoholism is drinking, but the problem is one of emptiness. My patients are not hungry. They are empty, like we all are empty. They fill up with food the same way an alcoholic slakes his thirst with a drink: not at all.

If a child is abused (over half of morbidly obese people were sexually abused as kids) and finds warmth when it’s cold from food, that message gets deeply imprinted. Relearning hunger then also means understanding that what the body needs and wants from food is not what the heart will ever get from food. Love is not there, in the end. The truth is that love happens within a person, and it is for that person and it is received and given between people (ok, and dogs). When the part of us that needs love and connection gets filled with the right stuff, even small amounts of food are enough. This is what my courageous patients are learning every day. As cool as it is to see a person lose a hundred pounds and watch the diabetes go into remission, the high blood pressure normalize, and to see them walk in a 5K for the first time, it is even better to watch them do this deeper work and find the real gold: themselves.

Do photographs convey the truth? Photojournalism schools have whole courses that make up answers to this question. It is important for journalists who are writing to tell the truth, I think we would agree. It is impossible, “true”, but striving for an objective story allows me as the reader to think that I am making up my own conclusions. Questions arise: what did the writer leave out here? How were the quotes edited? The same questions arise for photography. Photojournalists agonize over retouching, cropping, context.
I do not do this agonizing, at least not in service of the truth. I am making some level of fiction with my photographs. My writing is creative and while I am telling you something about me, and, I am not (usually) (knowingly) lying, I am formulating an openly subjective perspective. The photograph in this post was recorded digitally and the cloud had that shape and that is what led me to stop the car and record the scene. It’s a funny cloud, like a spring, right? After I get the raw image I believe my job is to make art and to lead you to feel something. To that end, I developed the picture. I cropped it mercilessly, increased contrast, darkened the edges of the roadside, added a bicolor filter, increased the structure and sharpness of the mountain. I reduced the digital noise and I eliminated some tiny clouds in the top right and left corners. That was my perspective and every photograph and photographer has a perspective, even the most hard-boiled journalist who holds the camera a foot from his eye and shoots, which is the problem with truth telling and photography. My act of seeing something with a camera changes the truth about what I am recording. I have changed it to reflect my perspective on the truth. Photographers who own that reality have my respect. With respect to photographers trying to be objective I would also assert this:

Photographic truth is inversely proportional to the effort exerted to make a photograph tell the truth.

The harder a journalist tries to make just a straight shot without influencing me and the harder she asserts that what she is doing is objective, the more I have questions about what wasn’t photographed, how the contrast manipulated to convey a point of view, what the angle of light is doing to change my mind. The less a photographer makes a play for the truth, the less I doubt them and the more believable the photograph is. Purely fanciful and contrived photographs are completely believable for what they are and they do not hide anything. This photographer may have whimsy but she has no guile. Purely journalistic photos raise my suspicions and are, inherently I think, prone to lies.

Discuss.

What is a truth and a lie?
A photograph is the lie sitting, like a spider in the web of the truth.

What stays and what moves?
A river does both and stops doing both at the same time.

What is valuable and useless?
Love makes no sense and is all there is.
     Poetry, good poetry like in The New Yorker,
     Should not mention love.
     It (good poetry) should dance around the emptiness
     of the lack of it ‚or dance
     around
     the poignant reach of hopeless rubes
     living as if in square comic portrayals of themselves.
     Leave love out, yo. (But yes, valuable and useless and all
     senseless, yes.)

December was super busy. I took my national boards (passed..!), the kiddo had a minor operation (waiting in waiting rooms is exhausting–I’ll remember that), and my patients, for one month, finally had real insurance. Deductibles take 11 months to pay and then people finally can have the hernia repaired or some other elective operation–our insane medical system at work. It may sound crass, but I feel like a farmer at harvest when December rolls around. And it’s done and that is good.

I have more time to be loved by my family which helps me love them back better. I have time to think about what a dog sees on a walk and make the picture. Both the love and the dog make me happy. I feel happy, and I am not going to talk myself out of it.

Ever feel like you are watching over things that don’t matter? Who is it that does that watching? The thin line between personal mayhem, utter apathy or extreme violence is that we don’t know the time of our dying. If we did, of course, we, or I will speak for me since you probably would have loftier ideals–I would light up a cigarette, rob a bank (nonviolently–it’s a personal preference) and give the money back or away or just light in on fire right there in the bank, run until my knees finally did give out as opposed to the not running I do now in fear of the knees and because of laziness. Just that one piece of info keeps us looking over useless chores and keeps us tidying up corners. Even though we all know it’s coming, we do things we would never do if we knew when it’s coming.

Making dinner does its little part to keep body and soul together so I can see doing that. Plus eating feels good which is a good thing to be doing (feeling, good) while we wait around to meet the inevitable deadline, the one we won’t be late for. In the meantime, I, like millions now and before me, am curious about the thin line of (un)knowing that keeps me doing useless things, shackled to someone else’s beliefs (which they would disavow the second they knew the moment of their own demise, by the way), keeps my head down and my neck bowed staring at my fingers working to the bone.

It was an accident and let’s just leave it at that, she said.
My patient was feeling sheepish and guarded. It was Christmas Eve, 9pm. She had shot herself in the chest, but she didn’t mean to. It was maybe a dare or a rash indiscretion. Guns are tricky, as are relationships. Her boyfriend was provoking her, maybe. She wouldn’t say much. It doesn’t matter. After the trigger does its thing, the reasons seem, well, remote. When someone says let’s just leave it at that, we all know that there is more to the story. Also when someone says “just” they mean the opposite. I was just trying to help means that I was also trying to change who you are. I was just leaving means I was staying a little longer. Etc.

She was right handed. There were no powder burns on her left chest so I figured she was wearing clothes when she just pulled the trigger. She was trying to die when she came in. We put a tube in her chest to drain the blood and re-expand the lung. Her diaphragm was injured and that needed repair. She missed her stomach (5mm) spleen (5mm) and colon (10mm). The bullet left her under the left shoulder blade after tearing through her lung like a sponge, literally. Normally the blood travels in the walls of the little cells of the sponge of our lungs, but when the cells get broken, it is predictably messy.

This is not an anatomy lesson. It is not a lesson at all. I am seeing what is in front of me. I am a surgeon, I am seeing little bubbles of air gurgling. The difference between respirating and drowning is the difference between air and paper. The surface area of the little spongey bubbles our lungs is that of a tennis court. Massive, and contained. She was struggling for air, breath. Most people who fail at suicide, even those who start out wanting to do themselves in, are happy with the second chance. My patient was happy to be getting to the next breath, to the next
(happy)
new
year.