Mise en Place, Teach the Sous Chef, Save the Patient

By Michael A. Gisondi (@MikeGisondi)

Two very different cooks work in my family’s kitchen.

When it’s my evening to prepare dinner, a predictable and reliable set of steps are executed perfectly each time. Empty the dishwasher and put away the clean dishes. Clean the coffee pot and ready the machine for morning. Anything in the sink goes in the dishwasher and the sink is cleaned. Select the ingredients for dinner and arrange them on the counter for maximal efficiency. And importantly, all dirty utensils and pots go in the dishwasher once used. After a relaxing family dinner, there is nothing more irritating than cleaning a kitchen that could have been kept tidy along the way.

As you might infer, a very different chain of events unfolds every other evening.

Mise en Place

In the late 1800s, professional chefs adopted a now revered method of preparation known as mise en place, or ‘set in place’. Mise en place maximizes efficiency and reduces errors. This approach is taught in every culinary school, and the average cooking class, around the world.

There are 5 steps to mise en place:

  1. Know your recipe — necessary ingredients, cookware, and baking times
  2. Prepare your ingredients — clean, chop, mince… whatever is required
  3. Arrange your ingredients — appropriate size bowls, positioned logically
  4. Prepare your workstation — set the oven temperature, clean the utensils
  5. Arrange your tools — similar logic applied to cookware and necessary equipment

Cooking dinner is a high risk procedure. Grill the burgers a little too much and everyone suffers.

Skip a step at your peril.

Teach the Sous Chef, Save the Patient

Recall the first time you opened a packaged kit for a central venous catheterization. None of it made sense. There were dozens of parts and seemingly hundreds of needles (in truth, there are generally only three.) If not closely supervised, you would have automatically selected the needle that isn’t large enough to pass the guidewire. Why that one needle is so enchanting, I’ll never know.

Annually, I teach our interns how to place a femoral Cordis® catheter using a simulation task trainer. I see my intern self in each of them, staring at an unfamiliar set of instruments arranged in a perplexing fashion. Though the kit may be logical to us, it’s a human factors nightmare to them. I’m then deliberate in my word choice:

If the patient is crashing, you don’t need all of this stuff. [Know your recipe]

You only need 7 items: this needle, a chlorhexidine prep, syringe, guidewire, scalpel, catheter, and suture. [Prepare your ingredients]

Position those items on your sterile tray before you begin. [Arrange your ingredients]

Time is of the essence. Quickly drape the patient. [Prepare your workstation]

Everything else in the kit will only confuse you during a resuscitation. Place all that aside, it is there only to vex the intern. [Arrange the tools]

Now, cook.

Set in Place

Recently, I’ve been teaching my daughter how to cook and instilling my kitchen neuroses in her. “Mise en place saves the sous chef,” I tell my daughter.

It can also save the patient.

Skip a step at their peril.

Photo credit: Unsplash

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About the Author: Michael A. Gisondi, MD is an emergency physician, medical educator, and education researcher who lives in Palo Alto, California. Michael is currently associate professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University. Twitter: @MikeGisondi

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