Article translated from the original Italian version
The Women in Surgery Italia (WIS) association was founded in 2015, with the work of Dr. Isabella Frigerio and myself. The spark went off after a duodenocephalopancreasectomy surgery, when my colleague and I realised that there was only one man in the operating theatre: the patient. We realised at that moment that something was changing, because years ago it would have been unthinkable that such a major operation could be performed by an all-female team. We therefore thought we could speed up the process of change by setting up an association representing Italian women surgeons. Right from the start, we focused on unity and representation. We have therefore launched a series of actions to bring women surgeons closer together, and in recent years the number of women surgeons has increased. This number will increase even more in the future, if we consider the trend in the ratio of men to women in medical schools. Today, female medical students account for about 60% of those enrolled in degree courses and female residents account for more than half of all young physicians in specialist training. The number of female surgeons is growing, not only in general surgery, but also in those specialist branches that have traditionally been the domain of men, such as neurosurgery, cardiac surgery and orthopaedics.
The association was therefore created to signal this change, to facilitate it, to promote the adaptation of the system so that it will be able, in the near future, to include female surgeons in the best possible way. The surgical system today is not prepared to welcome women; it has always been designed by men for men. It resembles a pyramid system, which is often based on the machismo and egocentrism of its protagonists. WIS wants to try to rewrite this profession to prevent aspiring female surgeons from giving up on their idea of taking this path and from losing their passion for their work.
We strongly believe in mentorship and today we have become a reference point for many female surgeons. We receive dozens and dozens of requests from students, residents and colleagues on a daily basis. It is mainly younger women who need a reference figure. We don't want to be a purely academic reference point, because the situations in which female surgeons work are very different. There are those who work in university hospitals, those in small provincial hospitals, those in advanced facilities, and those with inadequate resources altogether. The association wants to be as inclusive as possible. WIS wants to unite and represent all surgeons.
Thanks to the passion of its members, the association is growing. We have set up scholarships and established partnerships with international associations that share our aims. We were recently welcomed by the President of the Italian Republic, Mr. Mattarella, and the Deputy Minister of Health. With them, we highlighted the importance of giving greater prominence to women in health care, a fundamental resource not only in strategic and complex times like the ones we are experiencing, but above all in evolution, because if it is true that the number of female medical students is increasing, it is equally true that the number of primary and secondary professors is not. We don't think it's just a question of time, we think it's a question of opportunity. In order to have more opportunities, you have to start changing the patterns of thinking.
Historically, the figure of the surgeon has always been male. Similarly, historically, other specialities have always had a female majority. I am thinking, for example, of gynaecology and paediatrics. These are the extremes, and in between are most medical specialities where the presence of men and women has historically been the same. I believe that surgical disciplines and all those that involve a certain amount of manual work, such as interventional cardiology and interventional radiology, have more work ahead because there has been a greater presence of men.
The issue is very broad, it goes beyond the world of medicine and surgery. I believe that until most of us become aware of the gender bias present in many situations, little or nothing will change. You only have to walk into a toy shop to realise that, even today, there are toys for boys and toys for girls. Cars, robots and dinosaurs for boys. Dolls, princesses, pots and pans for girls.
Conditioning grows with us, right from kindergarten, maybe even before. If these aspects are not changed, if all the professionals involved do not begin to be aware of the biases present, implicit and explicit, in their professions, we will never be able to think of real gender integration. The problem manifests itself in every field, reaching its maximum expression when it comes to leadership.
It must be a priority for each of us, it is the responsibility of everyone, of all women, of all men. It is not only women who have to fight for gender mainstreaming. We must aim to work together to make other logics prevail, for example the logic of merit. We have to overcome the mindset that the boy is a fireman and the girl is a nurse. Awareness of this inherent obstacle must be raised. Greater awareness will make it automatic to recognise the leadership role for women who deserve it.
The problem is obviously not only Italian, it also exists in other parts of the world, as we are told by the foreign associations we are in contact with. There are places, such as Japan, where female surgeons find it very hard to be surgeons. The problem is often an expression of the social condition of women, so it is very marked in countries where it is very difficult, first and foremost, to be a woman.
In the United States, where I spent some periods of my life, the problem is there, but many solutions are already in place. Compared to Italy, they have certainly made progress. Probably having had to deal with the racial issue has made the community more receptive to the issue of discrimination against women. They have not solved the problem of racial discrimination just as they have not solved the problem of female discrimination, but there is a lot of attention, a lot more awareness. The battles they are waging are much more advanced than ours.
American associations with aims similar to those of WIS are very well supported, they manage to access many funds, there are many companies that believe in the cause we are highlighting. In Italy this does not happen. The attention of pharmaceutical companies, for example, is not zero as it was a few decades ago, but we are far from a real involvement aimed at realising a concrete project. In the United States, I have experienced a very different everyday life than in Italy. They are very attentive to the question of political correctness. In the operating theatre no one makes you feel discriminated against, no embarrassing situations are created. Very simply because all this is not allowed by the hospital administration, it is not legal.
The Italian operating theatre environment, on the other hand, is extremely “goliardic”. Whether you are the main physician or the latest arrival among the residents, you will still be the target of ironic or sarcastic jokes, for the simple fact that you are a woman. And this is more or less acceptable. In Italy, sexist jokes are culturally accepted, and if you oppose them, most people consider your behaviour ridiculous.
WIS receives reports of female surgeons who are not allowed to operate or of female surgeons who perform tasks at a lower level than their competences. Many female surgeons tell us that they arrive at the end of their training having worked much less than their male colleagues. There are no reports of harassment. The fact that they don't come to us doesn't mean they don't happen.
I think there is a lot of fear in dealing with these issues. For much less serious matters, many colleagues only contact us by phone, because they do not want to leave a written record of what they want to talk about. There is a great fear of talking. It is not by chance that many university and hospital institutions have made available professional counselling and defence figures. At the moment I don't know how much these tools are really used.
The first thing I think of is to establish fixed shifts within the weekly schedule. A surgeon must be able to know which days are occupied by activity in the operating room and for how many hours. Emergencies and unscheduled activities are a matter of the profession of course, but they are only part of our daily work routine. Knowing in advance which days of the week you are busy in the operating theatre would allow you to organise the rest of your life. A rational method of distributing shifts in the operating theatre that would allow the organisation of working life would be a huge step forward, not only for women, but also for men. If today I don't know what I'm going to do next Wednesday or the last Friday of the month, how can I manage my family, my friendships, even something as essential as a dentist appointment? Most people who deal with shifts will turn up their noses and think that this is impossible to do. It is possible, if we start to make it a priority.
The second thing that needs to be revolutionised, in order to have a work model that reconciles work and private life, is the idea that only those who work 12 hours a day work well. I come from a family that thinks in this way, I myself am naturally inclined to think in this way. But this way of thinking is wrong, which is why we are working on introducing a different system.
Clinical activities have hours that are quite compatible with a good management of private life. But people in my profession often work on several fronts, which today are stacked into endless working days. The situation could be improved if we introduced the assignment of tasks, the idea that everyone has to complete projects and organise themselves independently. It is not the one who stays in the hospital all day who is better, but the one who achieves results in the assigned tasks. Physicians today are inclined to think that the number of hours spent in hospital is the measure of a colleague's skills, passion and value.
Thinking in this way, it is clear why women will not be able to occupy leadership positions. In a society that culturally entrusts only women with the management of children (an aspect that fortunately is slowly changing), if the unit of measurement we use is time spent in hospital, it is obvious that the surgeon with two small children is at a disadvantage compared to the surgeon with two small children. Things will change if people are assessed on the results of the projects they carry out, not on the extra hours they accumulate (assuming they are hours worked).
Another key element of the new working model we have in mind concerns the use of new technologies. In my work as an university lecturer, for example, I would find it very useful to be able, when necessary, to lecture remotely or to send a recorded video of the lecture. Giving students the opportunity to address doubts or ask for further information by e-mail would not detract from the quality of teaching. New technologies, which we have been forced to learn in the pandemic context, can help us manage time better. When there are situations that make time management difficult, remote participation in meetings or conferences is a great opportunity.
It is clear to us that some changes have to come directly from a political discussion. The issue of equal opportunities between men and women is a generalised one, WIS is just one of many voices that are raising the issue and proposing solutions. WIS is part of “Inclusione Donna”, a national movement in Italy that aims to create a synergistic and inclusive network of all associations and projects that adhere to two common fronts dedicated to women: employment and representation. This alliance brings together about 60 associations representing women engaged in the most diverse activities. “Inclusione Donna” is fighting so that shared demands can be discussed with political decision-makers at different levels. Clearly, the precarious political situation in Italy does not help in the discussion, because the interlocutors often change and when it seems that we have taken a step forward, we need to start once again.
WIS is very keen on changing the law regulating maternity, which is very cautious towards women. In our view, it is far too cautious in some respects, to the point of making it a professional obstacle. If it is true that entering the operating room is not an absolute contraindication for pregnant women requiring surgery, why can't the woman choose whether or not to go to the operating theatre? Why is it not possible to assess on a case-by-case basis, without this constituting a danger to the woman and the foetus? Today women cannot choose, they are prevented from entering the operating room. In other parts of the world surgeons operate up to the 7th/8th month of pregnancy. There is no free choice, which is unacceptable to us.
A socio-cultural revolution would help all new mothers, not just surgeons. For example, making wide-open public nurseries available in Italy would allow women, as well as men, to work peacefully. Today, women surgeons are forced to entrust their children to grandparents, to spend their salaries on baby-sitters, nannies and private nurseries. Others scale down their activities and ambitions by asking for part-time hours. Others even give up. It is crazy that physicians in hospitals have to start work at 8.00 a.m. and schools open at 8.30 a.m. There is a lot of work to be done to create a better working environment for women.
In my opinion, medicine can improve in terms of organisation and quality. Those who have experienced discrimination at first hand will not allow it to be repeated, so they will try to put systems in place that bring out those who really deserve the recognition. Those who today have to invent every day a way of reconciling their professional and private lives within the framework of hostile environments or discouraging work dynamics will probably be able to organise their working environment better. This translates into a better quality of medicine, because it is based on meritocracy and better organisation. I believe that women are ready to make this contribution. The other 50% of human capital should be invested in. A truly different result can only be achieved when women are included in the equation.
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