Throughout the essay, Gawande shifts between using “compliance” and “adherence” for what is lacking in the use of “know-how” to stop epidemic infections. (p.21) 7 Ironically, the version appearing in The Essay Connection, a college writing anthology where I first encountered Gawande and adapted from the version which first appeared in the New England Journal of Medicine in 2004, does not include a section I found most meaningful and hopeful when I read the book. The essay explores persistent system and human impediments to improving practice, at which success requires making a hundred small steps go right. (p.14) ( We doctors and nurses wash our hands one-third to one-half as often as we are supposed to.)

In Better, ten essays are organized to illustrate the core requirements, and the first essay, “On Washing Hands,” explores the incredible difficulty, the diligence demanded, in getting medical practitioners to be meticulous in a basic practice, the one thing that consistently halts the spread of infections. The question is, having accepted the responsibility, how one does such work well. The question is not whether one accepts the responsibility. To complicate matters, we…are also only human ourselves…Yet to live as a doctor is to live so that one’s life is bound up in others’ and in science and in the messy, complicated connection between the two.

The world is chaotic, disorganized and vexing, and medicine (education?) is nowhere spared that reality. Ingenuity – thinking anew is not a matter of superior intelligence but of character and demands a willingness to recognize failure (not paper over the cracks) and to change it arises from deliberate, obsessive reflection on failure and a constant search for new solutions.Doing right – despite working in a fundamentally human enterprise, therefore troubled by human failings, it is difficult to know when “right” is to keep striving and when it is to stop.Diligence – giving sufficient attention to detail to avoid error and prevail against obstacles – central to performance & fiendishly hard.The core requirements for success in medicine or in any endeavor that involves risk and responsibility: In medicine, as in any profession, we must grapple with systems, resources, circumstances, people – and our own shortcomings as well. Our decisions and omissions are therefore moral in nature… It’s not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling. Introduction: From his junior resident experience with a dedicated senior resident, Gawande generates a key question: What does it take to be good at something in which failure is so easy, so effortless? (P.3) Later he suggests complex dimensions of success: Lives are on the line.

A surgeon's notes on performance