Paul Foster, MD
Practice
Thirty years of October pumpkins, alongside thirty years of medicine.
Artist Statement
In October 1996, I finished a 28-day senior resident rotation in the shock-trauma unit at Harborview, the regional referral center for Washington, Alaska, Montana, and Idaho. We ran every resuscitation in transit and worked the medical evaluations from Seattle's skid row. After the last shift, I sat down in front of a pumpkin. What came out was Munch's Scream, carved in relief. I have carved one pumpkin every October since.
What started as emotional processing turned into a thirty-year discipline. The carvings explore the same problems I work on at the bedside — depth and shadow, surface and interior, what can be seen from outside and what only becomes visible when light shines through from within. A setting sun two millimeters thick. A mountain at one centimeter. A doll's house architecture hidden inside the silhouette of a tower. The pumpkins are a sketchpad for thinking about anatomy as geography and a clinical case as a landscape with both topography and hidden depth.
TerrainDx is the digital expression of what these pumpkins have been working on for three decades. Both ask the same question: how do you let a patient and a physician stand in front of the same landscape and see it together? The carvings hold the surface — the silhouette, the visible illness — and the interior, the hidden architecture you only catch a glimpse of when the light comes through. The product does the same, with code instead of a candle.
The Carvings
A chronological selection, 1996 to 2025.
1996 — The beginning
In October 1996, after my last shift on Harborview's shock-trauma rotation, I sat down with a pumpkin and a knife. The face that came out was a version of Munch's Scream — carved in relief by stripping the outer peel back. I never photographed the original; the image here is the Devil, carved in 1998, still working through the same morbid disgust the Scream was trying to name. Both were attempts to put the unspeakable parts of medical residency somewhere outside my body for a few days.
1999 — The Dragon
My first 360-degree carving, made in Arizona in 1999. Until this one, every pumpkin had a front and a back — a face and a hollow shell. The dragon was the first time I carved the whole circumference as a single continuous image. The shift mattered. A patient is also a 360-degree object; we are trained to look at the front, but the explanation often lives in what's wrapping around the side, just out of view.
2000 — The Screaming Knight
Carved Halloween 2000. As clinicians we feel armored by our roles. We face broken bodies bravely; we comfort the sick. We also sometimes feel trapped inside the armor and unable to let the feelings out. The screaming knight was a self-portrait at a moment when the role was holding up but the person inside was not. I think most physicians carve this pumpkin in their head at some point, even if they don't reach for a knife.
2001 — The Skull
The first pumpkin where I carved the inside wall as deliberately as the outside. By thinning some areas of the interior and leaving others thick, the candle inside lit different depths to different intensities — bone-bright in the orbits, dim along the jaw. It was the first time I understood the pumpkin as a layered object with an inside that could be sculpted. Medical illness behaves the same way. The visible surface — the symptoms a patient brings — is only half the carving. The rest is interior, and it lights differently depending on where you cut.
2005 — Sunset on Lake Winnipesaukee
Carved 2005. Water texture in the foreground, a fishing boat coming in to dock, a sun setting behind the silhouette. The sun is carved from behind — a paper-thin pumpkin wall illuminated from inside; the water is carved from the front. Two opposite techniques in the same piece, asking each side to do what it does best. This was the year I stopped thinking of the pumpkin as a single canvas and started thinking of it as a set of layered surfaces, each with its own job.
2007 — Global Warming
Carved 2007. The entire globe with land masses ablaze in orange glow; this photograph shows North America. I often connect the fragility of my patients to the fragility of the world, the anatomy of my patients with the geography of the world. After watching An Inconvenient Truth, I had recurrent dreams of collapsing ice sheets and rising water. The pumpkin was a way to put the dream somewhere I could see it. The line about anatomy and geography is also the line that, two decades later, became TerrainDx's working metaphor — a clinical case rendered as a landscape with terrain you can walk into.
2010 — Archer at Sunset in the Mountains
My most disciplined carving — the same scene shot twice, once lit from the front and once from behind. The setting sun is paper thin. The sky is 2 mm. The foreground is 1 cm. The mountains are 2 cm. The silhouettes are made of pumpkin skin. Depth calibration changes which part of the scene the candle reaches; both versions are the same carving under different light. Carved in 2010, this piece marked a departure from earlier raw emotion toward something more disciplined — the same instinct that, fifteen years later, became the calibrated probability layer in TerrainDx.
2011 — ET Resuscitated
Carved 2011. The resuscitation scene from ET, the Extraterrestrial — a joyful ET with his glowing heart at the moment his alien brothers arrive. There has always been something both alien and magical about medicine. We learn to read bodies the way the scientists in that movie learned to read ET — through cautious observation, instruments, and best guesses, with the patient mostly unable to tell us what they need. Every once in a while the picture lights up from the inside and you remember why you went into this work in the first place.
2012 — Volcano
Carved 2012. A volcano rising from a wider terrain — the mountain visible from a long way off, the magma hidden inside until the candle goes in. The two layers are the entire point: the calm surface, and the molten thing underneath that the surface doesn't yet show. This is the pumpkin I think about most often when I describe TerrainDx. A patient brings the terrain — the visible symptoms, the landscape they can see and name. Hidden inside is the process driving everything: pathophysiology, timing, the risk already moving. A useful map shows both — the surface and the heat below it — so a patient and a physician can navigate together without one having to guess at the other's view.
2013 — Minas Morgul
In 2013, life took some weird turns — half my teaching staff departed, my family endured a brush with cancer, my son's high school closed, the office was caught in regulatory site visits. I felt morbid, gloomy, and in need of protection. So I bought the tallest pumpkin I could find and started carving. Ten hours later, Minas Morgul emerged — the tower from Tolkien that guards the dark lands Frodo must cross. Unseen from outside is a full interior architecture: stairwells, walkways, guard chambers. The orange glow in the windows is an army of orcs ready to march. The interior is the carving I cared most about. Most of medicine works the same way.
2014 — Rock Climber at Sunset
Carved 2014. A climber silhouetted against a desert sunset, the figure made of pumpkin skin suspended inside the softer lines of the vista. The front of the carving is blank white until lit from behind; only when the candle goes in does the climber, the sky, and the depth between them appear. This was an experiment in delayed reveal — a carving that doesn't exist until you change the light. Patients often describe the same experience with their own bodies. The symptoms have been there for weeks, but only when something illuminates them differently do they suddenly become visible.
2015 — Wicked Witch of the West
Carved 2015 — more play with the silhouette screen and internal carving, this time to render three layered images: the witch's face, the hourglass, the candle. Children's stories collapse a lot of medicine into a single iconic image. Time running out. Light burning down. A face that is half villain and half warning. Standing in front of a serious diagnosis, more than one patient has told me they felt like they were inside a Wizard of Oz scene without being able to name which character they were.
2017 — Endless Staircase
A 2017 carving of an Escher-style group of monks climbing an endless staircase, with color used to render the third dimension. By the late 2010s, the technologies that were supposed to free physicians and patients to think together had begun doing the opposite. Decision-support alerts, templated notes, ranked-list AI symptom checkers — all of them miraculous in their way, all of them quietly eroding the conversation between two people in a room. The monks keep climbing, certain the next step is the way up; the staircase keeps folding back on itself. I think about this carving often when I look at the current generation of patient-facing AI. The miracle and the dark side, in the same machine.
2018 — Liberty Underwater
Liberty submerged, the interior lit with a glow that doesn't quite resolve into a single source. The pumpkin is about a kind of pressure that institutions undergo — the slow water-line creeping up around something that was supposed to stand above the tide. Hospitals, medical training programs, and the trust between physicians and patients have all been carved by that same kind of slow pressure. Some of it is visible from above; most of it is below the surface. Two-thirds of this carving is interior — you only see it if you change angles.
2020 — Superspreader
In 2020, the carving was a meditation on the pandemic — the scariness of an invisible thing spreading through breath, the grotesqueness of bodies failing in unfamiliar ways, and the strengths a global crisis pulled out of us. The technical adventure was the discovery of 3D Hubs, a marketplace matching unused private 3D printers with customers. I designed five cookie cutters in the free version of Fusion 360 and printed three — a giant pancake cutter, a sandwich trimmer, and a smaller coronavirus virion. Total spend: $25. The pandemic's other gift was the engine that produced vaccines at unprecedented speed — the most consequential demonstration of global biomedical coordination in living memory. The carving sits with all of that at once: dread, grotesqueness, ingenuity, and the planetary scale of what we figured out together.
2022 — Fiddling on the Roof
Carved 2022. The title plays on Fiddler on the Roof — perched precariously, the fiddler keeps playing because the music is what holds the village together. The piece is vibrant — color, layered light, the music almost audible. What I wanted out of it was the reminder that finding relationships and joy in an unstable world is not optional decoration. It is the structural element that lets people carry hard things. In medical practice, this is true twice over. We sit with patients whose worlds have become unstable, and we ourselves carry medical trauma that needs somewhere to land. TerrainDx has a quiet pause inside the product where a patient can rest, reflect, and remember they are more than their illness. The fiddler taught me to design that space.
2023 — Fumes from the Titanic
In August 2023, I made two decisions: undergo limited prostate surgery, and audition for a community production of Titanic. The combination turned out to be unexpectedly meaningful — a peak theatrical experience, every castmate rising to the occasion, audiences packed in. The musical celebrates the hopes and dreams of the passengers in the face of tragedy, greed, and uncontrolled technology. In this pumpkin, the coal dust from the Titanic wraps the world in a glowing embrace — a tragedy with lessons not yet learned. The same year, in a smaller way, I rode the tension between medical technology that can extend a life and medical technology that can quietly damage one.
2025 — A Hug with Tattered Glory
Looking for hope and wisdom in the strong fibers of a tradition — no matter how torn, no matter how trampled. Starting with a few tears of acceptance and armoring for the journey ahead. Medical work is full of grief, including the kind no one warns you about — patients you cared for over decades, colleagues who leave the profession, decisions you would make differently if you could go back. What I keep finding underneath the grief is the surprising fact that we are in it together. Patients and physicians, both inside the same torn cloth, both still holding on. The carving is a hug.