Making Judgement Calls

Excerpted and edited from an article by Noel Tichy and Warren Bennis in the Harvard Business Review, October, 2007.


Kathleen Gallo was the director of the emergency department at North Shore University Hospital, a part of Long Island Jewish Hospital System, a Level 1 trauma center. She related that with enough experience and preparation, crisis Judgment calls can be handled routinely. She said: “While the arrival of a helicopter with a whole family of car-wreck victims might look like a crisis and might be a crisis for the family, it is not a crisis for the staff of the hospital because they are prepared. It is just another day at work.” The staff develops a habit of using quiet moments to prepare, scouting out free beds and ensuring that IVs and other equipment are ready. They are constantly sensing and framing.

Here is an example of a typical ER day: A triage nurse decided to keep a feverish child and his parents waiting while mobilizing a team to deal with an elderly man in cardiac arrest. That call seemed logical; the fever was not life threatening. But then a trickier call arose: a pregnant teenage girl came in with a gunshot wound, and the nurse, without hesitation, pulled the team off the elderly cardiac arrest patient and assigned it to the pregnant girl. The old man died; the girl and her baby survived. The nurse relied not just on her medical diagnoses of the two patients, but on her values, to make the call about who would get the limited medical resources. Her values led her to value the two young lives over that of an elderly man experiencing a deadly condition that would likely have ended his life even with medical intervention. Right or wrong, her Judgment reflected a clear set of values. Having a storyline helped her frame her choices and make them quickly and with confidence.

“The call to protect life—and not merely life but another’s identity; it is perhaps not too much to say another’s soul—was obvious in its sacredness. Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.”