1. McDaniel, Reuben R. Jr.

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The commentaries provided by Professors Crabtree and Montgomery are both extremely positive additions to the ideas presented in our paper "Surprise, Surprise, Surprise" and they extend our thinking on the topic of surprise in significant ways. Professor Crabtree calls our attention to the particular issues faced by primary care practices as they attempt to deal with the pressures of dramatically increasing complexity in their daily lives. Professor Montgomery provides an important analysis of barriers that make it difficult for health care systems to see surprise in a positive light. Both of these extensions are consistent with our original ideas about surprise in health care and provide interesting insights that lead to additional suggestions for enhancing a health care organization's capacity for dealing with surprise in a positive manner.


When we are faced with failure in doing things the "old way" it is tempting to simply say, well let's do things in a new way. However, one of the critical barriers to doing things a new way is our basic frame of reference or our fundamental view of the world. Traditional, mechanistic thinking about organizations and, therefore, about the nature of surprise, may well limit our ability to come up with alternative strategies and tactics for dealing with surprise. This can lead to significant frustration in an uncertain world. Our paper attempts to present an alternative view of the world, health care organizations as complex adaptive systems, that might suggest new ways of thinking about some of the problems in managing primary care practices noted by Professor Crabtree and new ways for dealing with the barriers of denial, control and prevention noted by Professor Montgomery. We were pleased that both of the commentators felt that this new perspective had real promise as a strategy for developing alternative approaches to dealing with surprise.


Certainly, primary care practices face special obstacles to viewing surprise as a gift. Among others noted by Professor Crabtree, the small size of most practices and the lack of managerial training may be particularly problematic. Much of the work on complexity science has been done on very large systems or very small systems and thus is difficult to translate to systems on the scale of primary care practices. Such translations will require the kind of intimate knowledge being developed by Professor Crabtree's research team. Also, the managerial practices required for effective and efficient management of complex adaptive systems are, at present, underdeveloped and, therefore, not very accessible. The recommendations suggested by Professor Crabtree are, as he noted, consistent with those we identified but they go beyond our recommendations in a very useful way. Professor Crabtree's recommendations, grounded in relationship building, are particularly suited for organizations of the size of primary care practices and organizations that may lack in depth managerial understanding.


Professor Montgomery's analysis of barriers to reframing surprise is very well done. Unquestionably, the barriers of denial, control and prevention of surprise are high in health care. These barriers will not fall easily. However, they certainly will not fall unless we bring new tools to the task and complexity science can provide some of these tools. The importance of stakeholder partnerships as a tool in managing surprise cannot be overestimated. We might add that physician-physician relationships may also be important for reframing barriers. The central role of trust as a tool for coping with surprise is clearly identified by Professor Montgomery and we certainly agree that trust is key to the relationship building required to see surprise as a gift. If one looks at the recommendations developed by Professor Crabtree and his research team, it is clear that trust is central to their implementation and may be the glue that ties these two commentaries together.


The commentators have enriched our understanding of surprise in health care organizations. They have moved the discussion to new areas and opened new topics for exploration. They have also provided concrete strategies for more effective management of surprise. Both commentators provide, in their bibliographies, rich sources of additional insights into the issues they raise. Both commentaries are complimentary to our efforts and, taken as a package, the main article along with the two commentaries provides readers with a thoughtful and helpful examination of the critical topic of surprise in health care management.