In this essay—and in the essay we have already written (Fish and Bergquist, 2022) as well as other we will soon be writing—our task is to make sense of the multiple ways in which to view the health care elephant and in which to bring people together to help tether the elephant and make it more caring and effective in addressing contemporary health care needs. We will seek to make sense of the differences between puzzles and problems. Our attention will be directed to the nature and dynamics of polarities in health care.

Of greatest importance will be our attempt to unweave the gordian knot that is to be found in what has recently been described as complex, adaptive systems (Miller and Page, 2007). It is this type of system that is predominant in and often dominate of mid-21st Century health care organizations. We believe that the concept of “emergence” helps to explain the nature and dynamics of these systems, and that these systems can only be effectively lead and managed when this leadership and management is being engaged in a team setting.

What Are Complex Adaptive Systems?

We begin to answer this fundamental question by turning to the writing of John Miller and Scott Page who directly address this question in their book appropriately titled Complex Adaptive Systems. (Miller and Page, 2007). In offering their answer, we should first note that they are primarily interested in social (human) systems. We are fine with this focus given that health care systems are decidedly social—there are very few systems more dependent on the social interaction between people than those systems that deliver health care.

The key point to be made by Miller and Page (2007, p. 9) regarding complex adaptive systems is that they are complex–and not just complicated.

“We are surrounded by complicated social worlds. These worlds are composed of multitudes of incommensurate elements, which often make them hard to navigate and, ultimately, difficult to understand. We would, however, like to make a distinction between complicated worlds and complex ones. In a complicated world, the various elements that make up the system maintain a degree of independence from one another. Thus, removing one such element (which reduces the level of complication) does not fundamentally alter the system’s behavior apart from that which directly resulted from the piece that was removed. Complexity arises when the dependencies among the elements become important. In such a system, removing one such element destroys system behavior to an extent that goes well beyond what is embodied by the particular element that is removed.”

Based on this distinction, we can state that a complex adaptive system (at least as found in a social setting) is composed of numerous elements that are tightly interwoven. They are interdependent and operate in close proximity to one another. It should be noted, that this close proximately allows a complex adaptive system to operate without heavy oversight or control. Each part looks to the one next to it for direction, thus eliminating the need for traditionally valued hierarchical control. The system is adaptive precisely because each part of the system can sense the need for change and can help to direct this change—as is the case among flocking birds.