Health care organizations and how they function have always been surrounded with an air of mystery. For the last hundred years much effort has been expended on rationalizing the behavior of managers and clinicians, starting with Ernest Codman and the American College of Surgeons in the early years of the 20th century, extending over decades of Joint Commission standards and federal and state regulations, and culminating in practice guidelines today. Some years ago the idea of a cascade effect gained prominence because it shed light on the seemingly uncontrollable consequences of initial interventions. Since then complexity theory has received attention as a conceptual lens through which we might get a better understanding of our health care organizations and what happens inside them.

Reuben McDaniel and his collaborators have been leaders in this area. They not only advanced complexity theory as a viable conceptual lens for health care organizations but have applied it in numerous empirical studies. This work has shed light on the fluid nature of health care and the tensions between assumptions of rationality and predictability and the actual nature of health care providers' work and behavior.

In the paper presented here, Dr. McDaniel, Michelle Jordan, and Brigitte Fleeman offer a view of the unexpected as a valuable opportunity rather than an upsetting event. They outline the nature of complex adaptive systems and the inevitability of "surprises" inherent in such systems and conclude that such surprises should be seen as a "gift from an uncertain world" that opens the doors to creativity and learning. We marvel at this positive view of the world and would like to think that it offers insight to researchers who explore our health care system and hope to beleaguered health care managers.

Benjamin Crabtree and Kathleen Montgomery in their commentaries focus specifically on the uncertainties of medical practice. Dr. Crabtree explores sources of uncertainty in the health care system, including the change in providers patients undergo as a result of changes in their insurance coverage. Dr. Montgomery in turn discusses the barriers that prevent us from seeing surprise as a positive element.

We thank the authors and commentators for their work and offer this FORUM to our readers in the hope that it will stimulate the thoughts of both researchers and practicing managers.