If you are lucky, you will arrive at a hospital where your colleagues and your predecessors have created a smoothly running surgical system. Or, you may arrive and find almost nothing. More likely, you will arrive and find a system which is working somehow, and which badly needs improvement. As well as actually treating the sick you may have to try to make the hospital as a whole, and particularly its surgical services more efficient. To do this you will have to improve: (1) The morale and training of its staff. Congratulations are likely to be much more effective than reprimands. (2) Its fittings and equipment. (3) Its administrative arrangements. (4) Your own skills. The various options before you are shown in Fig. 1-6. In doing this you must be prepared to do any task yourself, no matter how humble and how unfamiliar. There is no place for the attitude ''Oh, but it's not my job[...]'' Our jobs, wherever we are, are to create the ''machine' and make it work.
When you arrive inexperienced in a new place, study it carefully and list the things that need changing. Then, cautiously and steadily, try to implement them during the next few months or years. If you don't note them when you first arrive, you will soon take them all for granted, and do nothing. Beware of constant change, because the staff will not accept it. Get to know them and accept their advice before introducing ''improvements'. When you operate, do as best you can on your own to begin with. Then, after two or three months, when you have the feel of the place and its problems, visit the nearest hospital where they do things well, stay a week or two and learn whatever they can teach you in a short time. Then come back and put what you have learnt into practice.
ALL FOR A PIECE OF CHALK There was once a professor of surgery who found to his astonishment that his operating list had been cancelled. When he asked why his houseman replied ''Because there is no chalk with which to list the cases''. The professor was furious and dismissed his houseman on the spot. The DMS pleaded with him, ''[...]such a nice boy[...]'', even the Minister pleaded, but the professor insisted that he could not have such a person as his houseman. So he continued to clerk his own cases. Finally, weeks later his repentant houseman came to him and said ''About that chalk, Sir, I think I made a mistake[...]'' LESSON Failure to improvise, where this is at all possible, is never an adequate reason for not doing something. Fig. 1-7 DOCTOR ''C' TEACHING HIS TEAM. When Doctor C from the previous figure first arrived at this hospital he found its obstetric wards in a desperate state, and its beds so overcrowded that mothers ruptured their uteri in the corridors almost unnoticed. He soon got to work, and here you see him correcting some of the sloppy habits of his nurses. Soon, his obstetric services were so efficient that he had empty beds. It has been suggested that this shows a very sexist and authoritarian manner of teaching, and that a round table discussion would have been better.