Distant Doctors: A Surgical Theater in Romania

Distant Doctors: A Surgical Theater in Romania

– By Cristina A. Pop –

Someone has a fondness for purple decor, I decide, as I look around the examination room at a gigantic poster of blooming irises, a mauve plastic cover atop the gynecological table, and a vase of artificial lilac cuttings on the windowsill. No need to look further: sitting at a desk covered in patient paperwork, the doctor sports a lavender gown. We have been chatting for twenty minutes in this brightly lit examination room located in the gynecological cancers section of a public oncologic clinic in Romania. The doctor answers my questions, obviously proud of the advances in cervical cancer treatment through intracavitary brachytherapy.

Earlier, the doctor, a gynecologic oncologist, walked me through the stages of a full brachytherapy session, assisted by a medical resident and a technician. After a quick pelvic exam by the doctor, the resident inserted a ring-shaped radioactive device into a patient’s cervix. The patient was then left alone, laying on the bed, in a room whose now carefully sealed doors featured the three-bladed black radiation warning on a yellow background sign. Gathered in an adjacent room, we observed the patient via video camera while the technician started the computer-assisted irradiation session. On the screen, a tridimensional animation showed radioactive waves slowly filling the optimal pear-shaped volume around the patient’s cervix designed to target the malignant tumor, while sparing her bladder and uterus.

After watching the intracervical device flooded with iridium-192 and observing the “dose sculpting” on the tomography, I scribble down field notes during a quick debriefing with the doctor. I ask her about radiation doses, duration, and distance to tumor, and about the efficacy of brachytherapy in various categories of patients. But the doctor, quite emphatically, wants me to remember one thing: “A good oncologist will look directly at a woman’s cervix the same way a beautician looks straight at her face.”

Given that I have just witnessed state of the art cancer treatment technology in action via a computer screen, I am surprised by the doctor’s statement expressing a fundamental trust in the power of the (trained) naked eye. I have always assumed that it was the use (and abuse) of medical screening technologies that produced spikes in the number of diagnosed conditions, including cancers. How could the fallible human gaze, unenhanced by machines, be better at detecting the slow and silent killers located deep inside the body?

“Given that I have just witnessed state of the art cancer treatment technology in action via a computer screen, I am surprised by the doctor’s statement expressing a fundamental trust in the power of the (trained) naked eye.”

The gynecologic oncologist’s assertion confirms, but also expands, my knowledge about the ethnographic value of questioning medical practitioners. After years of fieldwork involving women in a small town in southern Romania, I recently published a book about cervical cancer. Aware of what I haven’t tackled yet, I see this publication as the first in a series of three volumes. The book is about women and their reproductive experiences in a country with intriguingly high cervical cancer incidence and mortality. Yet, women’s stories reflect only one of the many ways to understand the current cervical cancer crisis in Romania. What do doctors who encounter cervical cancer patients in the clinic have to say? How does bureaucracy generate and obscure cervical cancer prevention programs all the way from the Health Ministry and NGOs to rural family physicians’ practices? Attempting to answer these questions and to gain new insight into the management of cervical cancers in Romania is part of the reason I have shifted my research location to the oncology hospital.

The medical encounter is a site of bodily scrutiny, private interactions, negotiations of shared meanings, and intimate conversations. Anthropologists have long documented how clinical practitioners see, hear, and witness what no one else does [1]. And indeed, the gynecologic oncologist describes patients’ anxieties that are unknown to me, despite having spent so much time talking to women just like those in hospitals in Romania and elsewhere. For instance, none of the women I knew ever articulated a fear of chemotherapy rendering one contagiously radioactive. Yet, the doctor, the medical resident, and the brachytherapy technician assure me that they all encounter such reservations daily. Patients instead are often hesitant to start chemotherapy and brachytherapy out of fear that their bodies would become sources of radioactive pollution affecting those around them. Medical practitioners voice frustration with these misconceptions and dismiss the terror of invisible radiation as irrational. Their professional bias distances doctors from their patients and reveals what I already suspected – I needed to retrace my steps and learn more from the women themselves, reinscribing the complicated spiral that interweaves contested and authoritative knowledge.

The doctor’s statement about “look[ing] directly at a woman’s cervix” speaks also about other ways in which the clinical encounter proves insightful, beyond the well-documented dynamics of power, uncertainty, and intimacy between patients and doctors. The oncology clinic I visited is one of the most important in Romania. Located in a major university city, it serves about a third of the country’s population. Patients with advanced cervical cancers arrive with referrals from rural or small-town family doctors, but often with inconclusive exam results from local OB-GYN specialists. The gynecologic oncologist and the brachytherapy technician remember being perplexed, only to realize, over time, why the exam results from referrals were not more categorical. A malignant cervical tumor of 4 centimeters (or 1.5 inches) is easily detectable by the naked eye during a simple pelvic examination with the patient laying in a lithotomy position on the gynecological table. However, depending on its location on the cervix, the same tumor can be invisible during an abdominal ultrasound exam. Interviewing women during the medical anamnesis phase, the oncology specialists realized that most of the patients who had seen an OB-GYN in a local clinic had never received a pelvic examination. The gynecologic oncologist hypothesizes that the increasingly routine abdominal ultrasound may be more convenient for doctors and less embarrassing for women. The seemingly revealing powers of medical imaging are presumably more seductive to patients turned consumers. They are also more lucrative to doctors watching the profitability of their “fee for service” medical practices.

The sheer number of women with advanced cancers who never received a visual pelvic exam leads the oncology specialist to conclude that in Romania we are witnessing a technological and consumerist driven shift in cervical cancer detection. Medical imaging, it turns out, not only reveals, but also obscures tumors. That is why – the doctor obstinately emphasizes – it should not completely replace the “old-fashioned” visual inspection of the cervix. The oncologist’s insight extends from exposing patients’ misapprehensions about irradiation to a broader assessment of changing patterns of medical care.

“The sheer number of women with advanced cancers who never received a visual pelvic exam leads the oncology specialist to conclude that in Romania we are witnessing a technological and consumerist driven shift in cervical cancer detection…

…Women’s cancerous bodies and the semiotics they incapsulate circulate from geographical peripheries to the center, carrying (mis)diagnosis messages between unconnected medical practitioners.”

Speaking with one doctor can provide medical anthropologists with cues about how other unrelated doctors practice medicine. Women’s cancerous bodies and the semiotics they incapsulate circulate from geographical peripheries to the center, carrying (mis)diagnosis messages between unconnected medical practitioners. Inadequate health care investigations and medical errors are quite literally inscribed on women’s bodies and deciphered accordingly in the oncology clinic, where specialists encounter not only cancer patients but also their distant doctors.

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[1] See, for instance, Browner, C. H.   Lost In Translation: Lessons from California on the Implementation of State-Mandated Fetal Diagnosis in the Context of Globalization, Reproduction, Globalization, and the State: New Theoretical and Ethnographic Perspectives, 2011; 204-223.

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Cristina A. Pop, PhD, is an assistant professor of medical anthropology and medical humanities at Creighton University. Her research interests are reproductive health and healthcare, reproductive governance, vaccination hesitancy, post-communism, discourse analysis and ethnographic fiction. She has published in Medical Anthropology Quarterly, Medical Anthropology, Culture, Health and Sexuality and Journal of Religion and Health. Cristina is the author of The Cancer Within: Reproduction, Cultural Transformation and Health Care in Romania, published in 2022 with Rutgers University Press in the series “Medical Anthropology: Health, Inequality, and Social Justice.”

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*Featured title image by: D. Calma, International Atomic Energy Agency, “Combining External Radiation with High-dose Rate Brachytherapy Effective for Cervical Cancer, IAEA Study Confirms”

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