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The Q-Wave: The 6 Most Important Mindsets of Urgent Care

John Bielinski, MS PA-C By October 14, 2020June 3rd, 2022No Comments
The Q-Wave: The 6 Most Important Mindsets of Urgent Care

It’s been said that “How we teach is what we teach.” So, what are we at CME4Life really teaching? Are we teaching you Urgent Care medicine, or Emergency Medicine, or how to read an EKG? Yes, but ultimately, we are trying to teach you how to think, how to process content. And knowing the right antibiotic for sinusitis is the easy part. It’s how do we think about sinusitis? How do we think about the distribution and the stewardship of antibiotics? But most importantly, we are teaching you how to stay out of trouble. Urgent Care is risky.

Now, if you’ve ever worked on an ambulance, if you’ve ever been a paramedic or an EMT, you know the golden rule is scene safety. Meaning if you’re a paramedic and you pull up on a car accident, the worst-case scenario is not that the person in the car dies. That’s not the worst-case scenario. The worst-case scenario is you die trying to take care of that patient. That’s the worst-case scenario.

And that same principle applies to our practice of Urgent Care medicine. Do you understand that if you are getting your butt kicked day in and day out by lawsuits and complaints, if you are having bad outcomes, you can’t survive in Urgent Care? Urgent Care is dangerous.

There are six different things that I want you to know about mindset. Six proper mindsets that I believe you should have if you work in Urgent Care medicine. These six things are what I really hope you leave with. Let’s talk about number one.

#1 Stack the deck.

What does stack the deck mean when it comes to taking care of sick people? Stacking the deck means giving yourself an unfair advantage. Do we agree? If you stack the deck with aces and you’re playing poker, you’d get an unfair advantage. So how do we stack the deck? Risk factors. We have to know what risk factors lead to the disease that we’re thinking about. And ladies and gentlemen, to an absolutely huge degree, it’s what are your arterial risk factors and your venous risk factors.

For every single patient with chest, pulmonary, or belly symptoms you deal with, you better think are they risky. Diabetic smokers are very risky. Women on birth control pills are risky. Have the appropriate degree of concern. You may have heard me talk previously about treating a farmer. I didn’t pick up his ischemic heart disease, which ended with a heart transplant. Complaining non-complainers are risky.

Simply put, I’m suggesting do not walk into every single room thinking every patient is the same. They have different risk profiles. A 10-year-old with a cough is not the same as an 80-year-old with a cough. I know you know that, but I just want you to apply at a better level. When you walk into a room, stack the deck, and think of risk factors.

#2 Bias to bad.

What does that mean? I want you to think the patient that you’re seeing is a catastrophe until you prove otherwise. Don’t have a bias towards benign. I’m sure this is nothing. You know what, if you say, “I’m sure this chest pain is nothing,” you’re going to be right 95 out of 100 times, but you’re going to be wrong five times out of 100 too. “Oh, this cough is nothing.” Yeah, you’re right 95, 98% of the time, it’s going to be nothing. However, two times out of 100, it’s going to be a catastrophe, and if you get into the habit of having a bias for benign, you’re going to have a bias towards benign. You’re going to be casual when you need to amp it up.

I teach you to have a bias towards bad. And you know what that means in Urgent Care? It means you’re going to have to work more people up and you’re going to have to transfer more people. And that takes time and discernment. It means you’re going to have to transfer a lot of soft cases, which takes some time, but that’s still what I recommend.

#3 Think of Pete.

All of your documentation will ultimately come down to what does Pete the plumber, the guy on the jury, think about your care, because there are two different standards of care. You have a legal standard of care, but you also have a standard of caring. For the legal standard of care, consider whether a like-minded provider does the same thing in the same situation. What does that really mean? It means whatever your attorney can prove. That’s all it means.

But what about a standard of caring? That truly comes down to does Pete think you cared. How will he know? You tell me, how is Pete going to know your essence and your character? How is Pete going to know if you cared about a patient? Because that is very important to Pete. Are you a cold-hearted son of a b, someone who wants money and doesn’t care about people? Is that who you are because that’s how the plaintiff wants you to appear. Or are you someone that deeply cares about people, and that’s why you got into this field?

How will Pete decide? Two things. Your chart, the things you say on the chart, and how you present in court. Colleagues. It can go a very long way, giving a positive affirming adjective about your patients in the chart. Friendly male, and you may want to just slip in a nice adjective about somebody-cooperative, nice, friendly, something. It can’t hurt you; it can only help you. I want you to document your discharge instructions, so Pete thinks you are a caring person.

#4 Negligence to judgment.

I’m encouraging you to transfer your charts from a negligent chart to a judgment chart. How do we communicate judgment in our thinking? Use the word because. Guys, because means document your medical decision making. Just tell me what you were thinking.

If you have someone with a laceration, you send them home, and a month later, a piece of glass pops out of that wound. Now the wound needs to be explored in the OR. Are you negligent about a foreign body being retained? And the answer is it depends on what you did to work it up. If you just said laceration, I sutured it, have a nice day. If you did that, you were negligent; you didn’t even think about a foreign body. But if you put in your chart mechanism of glass, I transilluminated it, I explored the wound, I do not see a foreign body, and I looked for it. Don’t get me wrong, an x-ray would be the best thing to do. That’s part of wound care, but I’m still saying you want to document your judgment.

So, when it comes to chest pain, shortness of breath, headaches, why are you sending the migraine headache home? Why isn’t that headache a subarachnoid hemorrhage? How are you going to document? Subarachnoid hemorrhage considered, but because this patient has had these frequently, she says it’s the same headache she always has, but the Imitrex didn’t work today, no acute onset. Therefore, subarachnoid hemorrhage is very low on the differential. Not worthy of further workup.

Now hold on, I know I’m being wordy, and you wouldn’t be this wordy in your chart, but I’m telling you every single chart that you see, what are the high-risk features of that. Someone falls and hurts his arm. What’s the high-risk feature of an arm injury? The big one is a scaphoid fracture. Did you miss a navicular fracture?

#5 System 1 vs. System 2 thinking.

So, what does that mean? Colleagues remember you have two systems of thinking. System one is passive, and it’s lazy. System two is incredibly active.

You know system one thinking if you ever jumped in your car and started driving towards work, but it was a Saturday. You weren’t working, but you got off on the exit to go to work accidentally because you just forgot. You got into a habitual system one, oh, you’re going to the mall, not to work today, but you forgot about it. Once you become experienced and get some flow, you can now do a whole day of work and not have it fatigue you because most of the day is in system one.

A really, really, really good clinician has their sensitivity set very, very light, so if something is abnormal, you stop and say, wait, wait, why is this patient tachycardiac, this doesn’t make sense. I better look at it with a vigorous, enthusiastic mindset to find a problem. Honestly, guys, I think that’s been one of my greatest qualities as a clinician. I just didn’t take things for granted. If something didn’t seem right, I investigated it, and I found stuff.

#6 Be likable.

Be likable. Be likable. And we’re going to talk about that on day four, but I do want to share a pneumonic on how to be likable with you. I am a really, really big fan of thinking and how we think. I’m a huge fan of delusions and denials and biases that we have. I am a huge fan of thinking about my own thinking. That’s called metacognition. Metacognition is to think about your own thought process. So, when a medical error happens, okay yeah, you misread an EKG. I want to know why you misread the EKG. Are you just incompetent, or did you look at the EKG, already having a bias, so you didn’t look at it right?

So, part of that is studying influence. How do we influence others? How do we persuade and influence others? There’s a guy named Robert Cialdini who wrote a book called Influence. He’s kind of the godfather of influence. He did a bunch of social science studies. He’s from Arizona. I actually met him, and I went through one of his conferences and lectured on this topic. So, the question then becomes, is there anything that we can do to become more likable. The answer is yes. In Robert Cialdini’s book Influence, he said there are five triggers of influence. These are the tools that make people like us more. As I show you these, I’m going to ask you, starting today, to consider using any of these at a higher level because the fact is when patients like you, every part of your life is better. The fact is when your staff likes you, when the nursing staff likes you, every part of your life is better.

I’ll not forget, I went into an exam room, and there was a teenager, a young teenage daughter, and a mom. And so, I kind of bond with mom and daughter. I make some jokes, I make a nonmedical gesture, I just do the right things. I joked with mom. And what happened, mom liked me. We just hit it off, right? And I remember I ordered a dose of Amoxicillin, and I was going to prescribe a prescription for whatever infection they had. A few minutes later, the nurse comes to me freaking out, Oh my gosh, what? The kid’s allergic to penicillin, and I gave her a dose of Amoxicillin. Ah shit. So, I go into the room and immediately say, listen, we gave your daughter a dose of Amoxicillin. She’s allergic to penicillin. And immediately, I had to deal with the potential anaphylactic reaction, which was nothing. It was no big deal.

But now we just gave an antibiotic that a girl’s allergic to. I had to say to the mom; I am deeply sorry this happened, and I take complete responsibility for it. This is my fault. And I don’t think this is a little thing; I’m very bothered by this. I tell the mom that I’m going to write a letter, so my supervising doctor knows that I made this medical error and that this medical error goes in my record. I don’t think this is a little thing, I think it’s a really big thing. And you know what she said to me? She said I don’t want you to do that. I don’t want you to get in trouble just because she liked me. So being likable makes every part of your life better.

What are the five triggers of likability? The mnemonic I teach is CASTA. You want to “cast a” likable shadow.

So, what does the C stand for? The C stands for compliments. Compliment your patients. As often as you can, compliment them. Just compliment them. Have a very low filter just to say good for you. You’ve been taking Motrin, good, that’s fantastic. That’s excellent, you’re taking good care of yourself. Just look for ways to compliment your patients. And just so you know, in the influence literature, flattery works. Meaning that if you give an insincere compliment, it still increases your likeability. I remember that particular daughter and mom when I walked in the room, she might’ve been a teenager, 14 ish or so. I walked into the room. “Hi, my name’s John and I will be taking care of you.” And I said, Oh, it’s clear your sister brought you in today. No, I’m the mom. Well, you just look so young. I thought you were her sister. No. Did she like it? Of course, she liked it. Was it flattery? Yes, it was flattery. So, colleagues, compliment your patients as often as you can. It increases your likeability.

A is attractive. The literature shows that if you are perceived as physically attractive by the other person, you will have more likeability. Okay, that just makes sense, right? If you doubt that’s true, look at the Pfizer drug reps. Next time you see them ask how they got their job. They all look like supermodels. It wasn’t their GPA. I guarantee it.

S. The S stands for similarity. If you have something in common with another person, you’re going to get along better. So, if you can find something you have in common with your patients, you’re going to bond with them more. So how do we figure that out? We ask questions. If you can take a minute or two to have a conversation with that person about something other than medicine, you know what’s going to happen? You may not be able to see a patient or two in your shift; instead of going through 28 patients, you may only go through 26 patients. But you know what else is going to happen. You’re going to make a lot of good relationships. Lawsuits are going to go down. Your compliment letters are going to go up. And in Urgent Care medicine, one of the greatest compliments that you can possibly get is when a patient asks, “Do you take patients outside of Urgent Care, because I’m looking for a doctor and really like you?” If you’re getting that every once in awhile, that’s what’s up. I like you so much, I want you to take care of my whole body, not just my cut, not just my dental pain. There’s something about you I like so much, I want you to take care of me. That’s what I’m talking about.

T is team. We want to get on the patient’s team as often as we can. Too often, patients feel like it’s the patient against the institution. It’s me against this Urgent Care. You guys just want to make money from me. If you come into the room and your mindset is no, no, no, it’s you and I against the institution, I’m on your team. Now, if you think about it, and if you look at data, what are the two biggest complaints that patients have pasted on Press Ganey data? The two biggest complaints are poor quality communication and time delays. That’s the biggest reason why people complain. So how do we deal? How do we work to fix poor quality communication? You’ve got to work at it. It takes some practice. Ask questions, show some interest in the patient as a person, not just as a laceration. Show a little bit of interest, ask some questions.

Guys, I’ve precepted 50 students in my career. I can teach anybody medicine, that’s easy. It’s hard to teach bedside manner. Some of the best students that I’ve ever precepted were waitresses before they got into medicine. They knew how to talk to people. They knew that their communication, their smile, their presence would increase their tips. If they came into work empathetically, gregarious, helpful, their tips went up 20%. Suddenly, they realized, wow, that’s an effective way to get along with people. So, when it comes to poor quality communication, it just takes practice.

Now time delays, how do we fix time delays? We really can’t. We can’t shorten up the visits because we’re dealing with patient expectations. If I asked you what’s a long time to you, well, what do you mean by that? It’s completely subjective. Long time for what? A long time for a shower? 20 minutes is a long time for a shower. For me, five minutes is a long time for a shower. What’s a long time holding your breath? Three minutes is a long time holding your breath. So, what’s a long time waiting in Urgent Care. It’s entirely subjective. Some people want to be seen right now; they think it’s McDonald’s. So just so you know, the only way, the best way to help with time is to overestimate it. You’ve got to overestimate time. You’ve got to change their perception. You got to make their perception of time seem long and then come in shorter than that. That’s the only way you’re going to fix that problem.

Picture this. You walk into a room, and a patient’s red-lighted because they waited too long. Their perception is they waited way too long in this Urgent Care. Now they’re pissed off and fired up. And you guys, I don’t know where you work right now, but some Urgent Cares are fee for service kind of Urgent Cares. So, you don’t want to piss people off because they won’t come back, and then you’re not going to have a job. So, when you walk into the room of a patient who is red-lighted because of time, get on their team. Don’t fight them on time, get on their team and just say, I apologize for your delay. The wait was long, and I apologize for it. I promise you, I was really busy, but I apologize for the wait. I’m here now, and I want to take good care of you. So, it’s you and me. You and me against the facility. It’s not us against you. Get on the patient’s side. So, the enemy is the facility, it’s the nature of what we do. It’s not me because I’m on your side. I’m your advocate.

Do you know who does this all the time? Car salesman, right? They come to you, and they’re like, listen, I think we can do better than this. I’m going to go in on your behalf, and we’re going to get this car at a lower price. We’re going to get you the floor mats for free. I got you. And then we like them better. Get on their team.

And the last A stands for Associations. Associations. Associations. Associations. The bottom line is this, imagine I work at an emergency room, and you’re at an Urgent Care, 10 miles away. So, Courtney is going into work today; she calls me and says, “Hey, John, I’m sending in a patient.” Now, I don’t know who Courtney is at all. I have never met her before. I just know she’s a name on the phone. She calls me, and she gives me this great sign out. She’s responsive, she’s responsible, she gives a great sign out. She sends over the appropriate letters. Everything she said is to the T. She is accurate. Now you know what happens is I’m judging Courtney to some degree because medicine is medicine. I need to know who I can trust. Can I trust Courtney? She sent in a patient. Her trust level is 99%. Excellent. She calls me next week, “Hey John, it’s Courtney from Urgent Care. Listen, I’ve got another patient I have to send over to you.” Yada, yada, yada, yada. She gives me a really good sign out, and the patient comes over and is exactly what she told me they were going to be, and the trust level is 100%. To me, now she has a halo. I like Courtney. That Urgent Care Courtney, I like her. She’s accurate, she’s precise, she’s concise.

Next thing you know, she sends me a patient, she completely misses the bet on. She’s off. She just wasn’t close. And her trust level was 60%. Well, the bottom line is she already has a halo in my eyes, so I judge her way lighter. So, we have associated the halo effect with first impressions often, and that means ladies and gentlemen, at your Urgent Care, wherever you work, politics are important. What the supervising docs and the primary care docs think of you is important because when something goes wrong in a chart, they’re often going to rate you based, to a considerable degree, on the halo effect. Do you have a halo in their eyes? If you don’t have a strong relationship with the peripheral doctors and the healthcare providers, you might want to work on it. You may want to work on those relationships. That’s my advice.

I found that when I was well-liked big problems went away. When I didn’t care about being liked in my career, and I had some high friction relationships, little things became big things very quickly.
Folks, what you just read was an excerpt from one of our Urgent Care conferences. At CME4Life, our slogan is Maximize Your Mind, but we also understand that how we teach is what we teach. When we teach Urgent Care medicine, we’re not just teaching you the right antibiotic for otitis media, we’re teaching how to think. How to think about the antibiotic you select for otitis media, or how you approach a chest pain or shortness of breath. Measurable increases in confidence and competence.

So, if this intrigues you, if you work Urgent Care medicine, and you want to up your confidence and competence, consider investing in our Urgent Care CME program. It will measurably increase your confidence and competence. In any of the programs you buy from CME4Life, if it doesn’t leverage your behavior, return it. Our whole passion is to help you maximize your mind. How we teach is what we teach.

We teach you critical thinking, so you have the right answer, so you know how to keep yourself out of trouble when there’s a patient in front of you. Consider investing in our CME4Life Urgent Care medicine program, and understand we know that the best way for you to learn is on your timeline, the way that best suits you. With this in mind, we offer CME programs with gift cards to buy an iPad or a tablet so you can learn at work. You can learn how and where it’s best for you, on your terms. So, consider investing in your education. God bless.

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