On the occasion of the tenth edition of the International Day of Women and Girls in Science, we have invited Associate Professor Giovanna Gagliardi, head of the Radiotherapy Physics and Engineering Section at Karolinska University Hospital in Stockholm, Sweden, to contribute to the ESTRO newsletter by sharing her experience as a scientist, a manager, and, last but not least, as a woman. Here we share her insightful and inspiring thoughts with the ESTRO community.

What have been the main causes of satisfaction related to your position?

There are many reasons for satisfaction, which can be summarised as seeing a team growing, able to work in a structured but also creative way, solid in its knowledge and at the same time able to understand the complexity and the dynamic of the field. All of this is promising, as it means that good minds and good work are in place for the future. We have a lot of really positive feedback from our partners in other clinics, academies and industry. We have built all this gradually and now here we are. Many colleagues from outside our department are now interested in understanding how we work, which is another good sign for all of us. Major satisfaction comes from the fact that thanks to joined forces, we have been able to create the conditions for “systematic” R&D work that starts with questions arising in the clinic and that ends with trying to provide answers back to the clinic.

What have been the main challenges you’ve encountered in your role? 

The main challenge is responsibility, per se. It is important to keep this in mind when it comes to leading positions. I have been leading the radiotherapy physics and engineering team for a long time in a large, interesting and complex hospital, and you need to understand the field as much as the players.

Looking back, the work and the challenges connected to the move to the New Karolinska Hospital were very stimulating and very hard. The move had several components: the physical, as the whole hospital moved in a short time to a new, more compact building; and the organisational, as the whole structure and infrastructure of the hospital were modified at a deep level at the same time. For external radiation therapy, the move was “reinforced” by the complete renewal of the hardware/software, which meant also the conduct of tough tendering processes that had to be repeated a few times for mostly sad reasons. The timeline gives the flavour: the final tendering outcome was made public at the end of 2017, the first parts of the True Beams (TBs) were delivered during the summer of 2018, and eight TBs were drifted clinically between January and April 2019, all while we kept the old department running and moved the patients gradually from the old building to the new. The outcome was great in terms of the new clinic, and we as a team came out reinforced and in a pretty good spirit. The main challenge during this long process was to make sure that our competencies and knowledge were taken into account and were taken seriously, which was not easy and something that I could never imagine would happen, but it did and sometimes still does. The lessons learned were many, along the whole chain. We hope that those lessons are well remembered.   

What are some key leadership lessons you've learned while managing a team? 

Well, I have tried to lead a team rather than manage it. It is a conscious choice that I made and keep making, independent of the managerial culture that is spreading through society.

There are several main leadership lessons for me. The key one is that stability and proper infrastructure provide the necessary, even if not sufficient, conditions for individuals and a group to work with enough peace of mind. This is pretty important everywhere, not least in an activity that requires high safety standards, such as radiation therapy. The second lesson is that the political issues that may be connected to strategic choices should not be underestimated, even down to choices of radiotherapy equipment. It is important to try to understand the scenario and to be ready for what it can mean. The third lesson, or rather mantra, is that when you do not know what to choose, ask yourself, your group and your colleagues what the clinic needs. This question often provides a good compass for making reasonable choices, both operative and strategic. Last but not least, in the very interdisciplinary and multi-professional environment that radiation therapy is, to agree on the definition of responsibility, roles and interfaces, in order to allow the whole multidisciplinary group to work safely and to adapt continuously to changes well.

What initiatives or practices have you implemented to promote diversity and inclusion within your team or department? 

This is a question that usually triggers self-complacency. My honest answer is nothing in particular. I work each day to create a culture of psychological security and trust. It works for the most part, but not always of course. A key issue, however, is the recruitment process, in which competence is a very important parameter but not the only one.

When it comes to some aspects of inclusion and diversity, there is an obvious bias here because I work in Scandinavia. Sweden is a relatively rich country with a long tradition of solid welfare culture and infrastructure. Family life - and family is defined on a very broad spectrum – is protected and encouraged, and there are practical conditions that really allow people to combine work life, with its developments and opportunities, with family life. Sweden helps us with reasonable regulation also when it comes to the clinical employment of colleagues from other countries. One of the effects is that we have a multinational group of physicists and engineers working in the clinical routine: at least 10 different languages are spoken in our group, beyond Swedish and English, and many more countries than that are represented. This does not mean diversity and inclusion per se, but it certainly broadens the perspectives and the shared common experience. Our life stories together embrace a geographically significant part of the globe and many major events. This is a treasure we are aware of and yes, indirectly it affects the way we deal with inclusion and diversity.

Having said that, one has to be extremely vigilant at all times when it comes to these themes.

What do you believe are the most exciting developments in your field, and how do you see the future of medical physics? 

This is a tricky question; even when looking closely at the radiotherapy field, it is better not to make predictions. What I do not see coming, at the moment, is a paradigm shift of the sort that stereotactic body radiation therapy has been – but times have changed in many aspects.

Artificial intelligence (AI could be a red thread through many of the coming developments, from treatment planning to machines to flow structuring, just to give the easy examples). What we all see is an almost infinite quantity of available and potential data, but we need to train ourselves to pose the relevant questions in order to see meaningful patterns. Predictive biomarkers might link together several fields and push the knowledge forward.

The composition of the staff is already changing: quality management, which has become the backbone of our work, will expand. The capacity clinically to implement new technologies and modalities both at a high pace and safely will follow the same path.

Equipment that can be used to deliver treatment very quickly might also play an important role, considering the increasing need for care. This takes my thoughts to the term “sustainability”. On the one hand, sustainability means access to cure/radiotherapy in a broad sense, and solutions have to be found for this. On the other hand, there is the environmental impact - at the moment, for instance, AI has high costs in terms of energy and water use. Sustainability is therefore one of the terms that I am sure will be taken into account even in the near future.

What advice would you offer to women who aspire to follow in your footsteps? 

 A leadership position in medical physics for a woman is obviously straightforward per se. The welfare frame of the country in which you live and work can make a large difference in practical terms.

At first sight, I am not sure I would advise women or men differently. I would make clear to both that gender issues do exist, even in the apparently most favourable conditions, and that, in general, it is easier to deal with obvious ones than with the subtle ones. We all have a major responsibility here.

I would advise everyone not to fall into the traps of micromanagement and multitasking. This does not work, and it costs a lot and distracts from the focus, i.e. leading a group and an activity of such relevance, even more so in a high-risk environment such as radiation safety. Think a lot about your team, the strengths and the weaknesses, and work on them; recruitment here again is crucial. Try to understand how the other groups that you interact with work, and promote a clear definition of roles and responsibilities - this will help. Define infrastructure, as it will allow a good flow. A leader has to be in the position to be able to look a bit into the future and at the sides, to understand what is going to happen and prepare the team and the environment for this. It is not easy for different reasons; technology gives us enormous possibilities and at the same time traps us in a sort of self-nurturing cycle in which continuous updates and upgrades are the easy parts. It’s difficult to understand whether the promised impact of new technologies and equipment will really be realised.

Having a good network of colleagues outside one’s work group helps a lot; it has given me insights and experiences that have turned out to be extremely useful in many situations. Keeping up to date is part of the work, although the time to do so is very limited. This is a most challenging issue without an obvious way forward, as time is really limited - so I do not have any good advice for this. Equally so for the time to think, which is the most precious time of all ‑ it should be protected.

So, at the end what would I say to women? Probably just … don’t step back!

The one missing word in my above reflection is patients. Make sure, all the time, that they are the polar star of what you are doing.

Giovanna Gagliardi, PhD

Associate professor, medical physicist

Head of Radiotherapy Physics and Engineering

Nuclear Medicine and Medical Physics Unit

Karolinska University Hospital

Oncology and Pathology,

Karolinska Institutet

Stockholm, Sweden