This article first describes the unique place of emergency medicine (EM) within the American healthcare system. Second, it examines the uncertainty that underlies the practice of emergency medicine. It then describes how risk is perceived, negotiated and minimised by emergency physicians in their day-to-day practice. Finally, it explores how the management of medical risk is related to the establishment of trust within the physician–patient interaction and to the construction of the 'competent physician'. In caring for patients, the emergency physician must minimise risk and instil trust within a pressured, time-sensitive environment. Consequently, the management of risk and display of competence to patients are simultaneously accomplished by symbolic representations, the use of medical diagnostic tools in decision-making, and narrative construction within the clinical interaction.