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Academic Medicine:
doi: 10.1097/ACM.0b013e31828b0289
Perspectives

There Is No “I” in Teamwork in the Patient-Centered Medical Home: Defining Teamwork Competencies for Academic Practice

Leasure, Emily L. MD; Jones, Ronald R. MD; Meade, Lauren B. MD; Sanger, Marla I. RN, MBA; Thomas, Kris G. MD; Tilden, Virginia P. RN, PhD; Bowen, Judith L. MD; Warm, Eric J. MD

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Author Information

Dr. Leasure is assistant professor of medicine, University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska.

Dr. Jones is associate director of medicine, Summa Health System, and associate professor of medicine, Northeast Ohio Medical University, Colleges of Medicine and Pharmacy, Rootstown, Ohio.

Dr. Meade is assistant professor of medicine and associate program director, Baystate Medical Center, College of Medicine, Springfield, Massachusetts.

Ms. Sanger is system quality program manager, Patient Engagement, Healthcare Improvement Division, PeaceHealth, Vancouver, Washington.

Dr. Thomas is associate professor of medicine and consultant, Division of Primary Care Internal Medicine, Mayo Clinic, College of Medicine, Rochester, Minnesota.

Dr. Tilden is dean and professor emerita, University of Nebraska Medical Center, College of Nursing, Omaha, Nebraska.

Dr. Bowen is professor of medicine, Oregon Health and Science University, Portland, Oregon, and Veterans Health Administration Office of Academic Affiliations, Washington, DC.

Dr. Warm is professor of medicine and program director of internal medicine, University of Cincinnati, College of Medicine, Cincinnati, Ohio.

Correspondence should be addressed to Dr. Leasure, 985185 Nebraska Medical Center, Omaha, NE 68198-5158; telephone: (402) 559-7545; fax: (402) 559-5588; e-mail: emily.leasure@unmc.edu.

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Abstract

Evidence suggests that teamwork is essential for safe, reliable practice. Creating health care teams able to function effectively in patient-centered medical homes (PCMHs), practices that organize care around the patient and demonstrate achievement of defined quality care standards, remains challenging. Preparing trainees for practice in interprofessional teams is particularly challenging in academic health centers where health professions curricula are largely siloed. Here, the authors review a well-delineated set of teamwork competencies that are important for high-functioning teams and suggest how these competencies might be useful for interprofessional team training and achievement of PCMH standards. The five competencies are (1) team leadership, the ability to coordinate team members’ activities, ensure appropriate task distribution, evaluate effectiveness, and inspire high-level performance, (2) mutual performance monitoring, the ability to develop a shared understanding among team members regarding intentions, roles, and responsibilities so as to accurately monitor one another’s performance for collective success, (3) backup behavior, the ability to anticipate the needs of other team members and shift responsibilities during times of variable workload, (4) adaptability, the capability of team members to adjust their strategy for completing tasks on the basis of feedback from the work environment, and (5) team orientation, the tendency to prioritize team goals over individual goals, encourage alternative perspectives, and show respect and regard for each team member. Relating each competency to a vignette from an academic primary care clinic, the authors describe potential strategies for improving teamwork learning and applying the teamwork competences to academic PCMH practices.

Teamwork is essential for reliable, safe, and effective practice. Literature supporting teamwork development and management exists in the military, in aviation, business, and medicine, and in other fields.1–12 Emphasis on teamwork in health care increased after the publication of two reports from the Institute of Medicine (IOM) that illustrated a quality chasm in U.S. health care and called for vastly improved teamwork to help stem the tide of medical errors and preventable conditions.13,14

Although one of these seminal IOM reports, To Err Is Human, focused mainly on inpatient events,13 efforts to improve care have not been limited to hospital settings. The patient-centered medical home (PCMH) movement seeks to improve care in the ambulatory setting by establishing standards of practice that organize care around individual patients (List 1).15 Early PCMH demonstration models suggest that achieving these standards requires an effective interprofessional team and that improved teamwork has a more positive influence on patient outcomes than other quality improvement strategies.16

List 1
List 1
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Creating effective health care teams in any practice, including PCMHs, however, presents a significant challenge. Although the physicians, nurses, social workers, pharmacists, care managers, and other health care providers who work in a PCMH must coordinate their efforts to care for a patient, most of these professionals have never trained together to do so. This deficit is particularly heightened both in academic health centers where the curricula of health professions students are largely siloed (e.g., physicians-in-training rarely train with nurses- or pharmacists-in-training), and among large numbers of trainees who move in and out of primary care practices.17,18 Despite these challenges, it is imperative that health professions’ training programs focus on interprofessional team development to prepare future providers for their expected roles in PCMH practices. Evidence shows that programs built on the science of team training benefit through improved team member communication skills, improved team behavior and work performance, and a positive change in the practice safety climate11,19; nonetheless, experience is lacking in academic primary care practices (the term we use throughout this Perspective to describe medical-school-associated or academic ambulatory training environments).

As part of an education summit sponsored by the Society of General Internal Medicine in 2011,20 we explored the concept of teamwork in academic primary care practices that follow the PCMH model. Although several teamwork constructs were available, we felt, after review, that the conceptual framework designed by Salas and colleagues21 clearly and effectively characterized all of our experiences with the essential elements of PCMH interprofessional teamwork in diverse educational settings (collectively, we authors represent clinics of various size, patient populations, and geographic region). Salas and colleagues21 analyzed 20 years of teamwork effectiveness research and identified the “core components” of essential teamwork knowledge, skills, and attitudes. They labeled these components, or competencies, the “Big Five,” and these are team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation. In this Perspective, we describe these five teamwork competencies, originally identified for the military21,22 and later applied to health care,23 that together constitute the skill set of high-functioning health care teams, and we suggest how they might be useful in approaching interprofessional team training in academic PCMH practices.

The vignette that follows, which we created for this Perspective, represents a common scenario in many traditional academic primary care practices, though the team members in the vignette are selective and fewer than would be realistic in a typical practice.

A 58-year-old man with hypertension and stage III chronic kidney disease presented to an academic primary care practice for a medication refill. Although no one in the practice had seen this patient for 18 months, he had received telephone refills for his hydrochlorothiazide prescription during that time. The patient had previously been scheduled for follow-up, but he had cancelled and never rescheduled. Further, he had failed to follow up with nephrology as previously referred by his physician. His resident physician left in June and the new resident, an intern, declined to refill the medication without an office visit. The patient was scheduled for a 20-minute visit. During the visit, the intern was running behind and needed to look through past records on the patient, so the patient spent 95 minutes in an exam room, most of the time alone. His blood pressure was 160/96. The intern added lisinopril to the hydrochlorothiazide, re-referred the patient to nephrology, arranged for a nurse visit in two weeks, and ordered blood work to be drawn on the morning of the nurse visit to enable an examination of the patient’s metabolic panel. At the nurse visit two weeks later, the patient’s blood pressure was still elevated. The patient had stopped hydrochlorothiazide and started lisinopril, instead of taking both. Also, the patient had gotten his blood drawn on the day he saw the intern rather than waiting two weeks, so the medication effects could not be assessed. The nurse paged the intern for guidance, but the intern was on a night float rotation and did not respond. The intern’s continuity clinic schedule was booked for the next four months.

The interactions (or lack thereof) among the team members in the vignette emphasize the lack of inherent teamwork in many academic primary care practices. How could the resident physician who left in June, the new intern, the nurse, and other responsible team members not specifically discussed (faculty preceptor, medical assistant, practice manager, pharmacist, resident partners, scheduler, etc.) work differently to create better care?

Herein we answer those questions and discuss ways the team could have applied the five teamwork competencies to improve care and better meet the PCMH standards. Further, in Table 1, we juxtapose teamwork failures in the case vignette with teamwork successes, providing potential examples of how high-functioning teams could respond within the framework of the PCMH standards.

Table 1
Table 1
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Team Leadership

Team leadership denotes the ability to coordinate team members’ activities, ensure that tasks are distributed appropriately, evaluate performance, provide feedback, enhance the team’s ability to perform, and inspire the drive for high-level performance.23,24 These beneficial leadership skills are associated with increased nursing and physician satisfaction, increased well-being and improved motivation among team members, increased staff retention, and improved organizational goal attainment.25–28 Although the impact of leadership on patient outcomes is more difficult to assess, previous researchers have found that positive team leadership practices have been associated with increased patient ability to accomplish daily goals, increased patient satisfaction, improved clinical microsystem performance, and reduced adverse events.29–31 Importantly, team leadership is fluid, and the role of leader varies by PCMH team, task, and problem. The person most appropriate to detect a system breakdown in a given situation and then coordinate improvement efforts should be in a position to do so. For example, a practice scheduler may detect a growing delay in access due to lack of appointment availability and should be empowered to inform the other team members about the problem, elicit intervention suggestions, and provide periodic feedback on the effects of the chosen interventions.

The case vignette exemplifies an absence of team leadership on multiple levels. Team members’ activities seem uncoordinated; no one has stepped forward to optimize the distribution of their tasks to ensure timely and appropriate care. The team’s performance lacks evaluation, and both their individual and collective execution of work seems uninspired. Finally, the lack of “ownership” for this patient and his care is clear. Without ownership, no one takes responsibility for poor outcomes.

An important leadership intervention targeted at improving performance at this academic primary care practice would involve the creation of several distinct care teams, each of which would consistently provide care for a defined patient panel. The most appropriate leader for each of the various care teams would depend on the unique staffing of the clinic; however, nurses may serve the role of team leaders effectively, as nurses could provide continuity for the patient in a setting that inherently has a fluctuating provider and student presence. Further, a nurse team leader may be able to facilitate face-to-face time with the patient at each visit and may be able to coordinate communication about ongoing care issues among parties between visits.

In addition to the nurse (or other health care professional) leader, several resident providers, allied health professionals, students, and one or more medical assistants may share the defined patient panel. Physician faculty as well as clinic staff from pharmacy, social work, and behavioral medicine would serve across each of the care teams.

The team leader—in this case, a nurse—could organize a care team meeting to review the case, elicit input from all team members and the patient, identify barriers to effective care, and engage the team in addressing these barriers. In turn, any team member could bring issues raised from this case (e.g., how to better track referrals and tests, what kind of self-management assessment to perform with patients at each encounter, and how to systematically review and manage blood pressure outcomes across the patient panel) to a weekly practice meeting for further discussion. The clinic director could also use such weekly meetings to review team members’ roles in an effort to ensure that everyone understands one another’s responsibilities, that team members function at their highest level of training and licensure, and that backup processes exist to coordinate care when one team member is unavailable. Not surprisingly, strong team leadership is necessary to actualize any of the six PCMH standards (see Table 1).

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Mutual Performance Monitoring

Mutual performance monitoring denotes the ability to develop a shared understanding among team members regarding one another’s intentions, roles, and responsibilities so that members can accurately monitor one another’s performance for the purpose of collective success.24 This competency shares several characteristics with “mindfulness,” a construct used to increase reliability and safety in other high-risk industries. Mindfulness includes remaining concerned about and guarding against the possibility of failure even in the most simple or heretofore successful of endeavors, deferring to expertise regardless of rank or status, being able to adapt when the unexpected occurs, concentrating on a specific task while having a sense of the bigger picture, and being willing to alter and flatten hierarchy as best fits the situation.32

Mutual performance monitoring is absent in the example case. Team members seem to function with little knowledge of one another’s responsibilities. They seem preoccupied with their individual tasks, which serves to isolate them further rather than accentuate the team’s potential. For example, the people who authorized and filled the telephoned orders for prescription refills apparently did not question the physician’s order. As may be the case in many academic primary care practices, these team members were undoubtedly busy and addressed the problem quickly rather than correctly or effectively.

A first step to improving care for this patient and others at the clinic might be to hold a practice-wide discussion so as to explore the meaning of teamwork and create shared practice goals. From this initial discussion, the team could establish mutually agreeable communication expectations and ground rules to guide situations in which hierarchy or tradition might previously have limited how team members give feedback to one another. For example, the practice could establish the expectation that each resident meet with his or her care team’s nurse and medical assistant weekly for 15 minutes to discuss any provider-specific problems in patient satisfaction, gaps in patients’ understanding, or delays in care. This debriefing could occur at the beginning or end of a half-day clinic session or weekly practice meeting. The ability of trainees to give and receive this type of feedback while working to improve ambulatory care processes is a crucial performance element of systems-based practice, and thus, supervising faculty should observe and assess a debriefing at least quarterly.

All team members should assist with identifying recurring problems to address at the weekly practice-wide meetings during which they should together discuss what strategies will best streamline processes and improve performance. The team should consider inviting a patient or small patient panel to become partners in the team improvement efforts by attending all or some of these team meetings. Another way to obtain this vital patient input is via a separate patient advisory council or board that can provide consultation and feedback. Several health care systems, such as PeaceHealth Oregon West Network, have worked with patient advisors to help develop or revise practice documents, policies, and programs.33 Through continual analysis of team performance and its effect on patient outcomes and experiences, the practice can better focus improvement efforts on meaningful measures, in line with the overall PCMH patient-centered mission.

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Backup Behavior

Backup behavior denotes the ability to anticipate the needs of other team members and shift tasks in real time to achieve and maintain balance during times of variable workload or increased pressure. A team member can assist in performing a task, can complete a task separately, or can provide feedback to improve performance.34 Backup behavior is different from simply helping in the essential determination of need; backup behavior occurs only when a team member experiences overload or has a schedule- or logistical-based need.35,36

The vignette illustrates many failures in backup behavior. The senior resident approved hypertension medication refills without assessing the patient’s blood pressure control rather than asking an advanced practitioner, a co-resident, or a nurse for backup to evaluate the patient. The 95-minute hypertension visit tied up an exam room and wasted the patient’s time. The team had no system in place to assist the intern when she ran behind. Finally, a nurse needed orders for blood pressure medication adjustment, but no backup provider was identified for when the intern was not available.

Employing all three types of backup behavior could have improved care. Early in the case, another care team member could have completed the task by examining the patient when the patient requested refills but had not been seen within the past six months. When the intern or another physician examined the patient, a medical assistant, nurse, or pharmacist could have assisted by assessing the patient’s understanding of the medication change in a “teach-back” format, which involves asking the patient to state, in his or her own words, the medication change and providing more tailored instructions if he or she is not able to do so.37 In addition, the nurse could have given feedback to the intern regarding documentation of an anticipatory plan of action (e.g., importance of documenting a blood pressure goal, a plan if the blood pressure remains above goal, and a provider to contact should questions or problems arise at the nurse visit).

For backup behavior to be successful, team members must be familiar with one another’s roles, and they must be cross-trained where appropriate. Successful backup behavior also requires a fundamental shift in the attitude of health professions trainees—from success defined as independence to success defined as interdependence. Sharing physical workspace and clinic time helps to facilitate both this attitude and backup behavior itself by providing more opportunities for interacting, communicating, and detecting team member cues and triggers.38 Starting patient care sessions with a team huddle to discuss the anticipated workload and backup needs reinforces communication and trainees’ understanding of others’ perspectives and capabilities. Effective backup behavior helps the practice augment PCMH accessibility, care management execution, and self-management support (see also Table 1).

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Adaptability

Adaptability denotes the capability of team members to adjust their strategies for completing tasks on the basis of feedback from the work environment.39 This capability requires compensatory behaviors; that is, each team member must be able to redistribute team resources or alter a course of action in response to changing conditions,40 allowing the team to meet mutually defined goals. Skills needed for adaptability include recognizing that a change has occurred (i.e., situational awareness) and identifying the potential negative impact it could present for care quality or outcomes.

In the example case, low team adaptability has contributed to a practice environment in which individuals operate with limited support and team function has been underused. Adaptive behaviors were not initiated because the resident, scheduler, and nurse all failed to identify the provision of open-ended refills on medications without a scheduled follow-up appointment as a deficit in care. When the patient did come in for an exam, the visit was chaotic, raising further questions about previsit preparation and team training. The new intern may have been underprepared or undersupported in addressing the low health literacy of this patient, or she may have run behind because she was unaware of potential team supports. In scheduling the follow-up visit, the scheduler met the limitations of the intern’s ambulatory schedule with a sense of organizational helplessness, a further indication that the team’s failure to adopt effective teamwork practices has negatively affected team resilience and patient care quality.

Individually, each team member should receive training on a shared model of care, emphasizing team rather than individual goals and responsibilities. Role-play simulations can help each of them learn adaptive responses. At a team level, when the members discuss the experience of this patient at the weekly practice meeting, all should feel comfortable identifying system problems or suggesting processes or adaptations to improve outcomes. A focus on failed appointments could lead to discovering correctable causes (e.g., the patient’s incomplete understanding of disease, limited efficacy for self-care, lack of transportation, or lack of reminders from the clinic). A focus on discharge processes could lead to improvements in assessing for low health literacy with referral for focused education. Lastly, a focus on access and continuity could lead to engaging either the previously described care teams (see Team Leadership) or, alternatively, practice pairings in which a second resident or advance practice nurse works closely with the absent resident to ensure team continuity for timely visits.

Adaptability is essential in a high-functioning PCMH practice. Teams that adapt well to change will successfully meet challenging transitions, such as the implementation of an electronic medical record system and/or the move toward electronically tracked patient population outcomes as required by the Centers for Medicaid and Medicare Services meaningful use standards.41

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Team Orientation

Team or collective orientation denotes the tendency to prioritize team goals over individual goals, to encourage different viewpoints and perspectives, and to show respect and regard for each team member by evaluating and integrating his or her input in an interdependent manner.23,24,42 A collectively oriented individual works well with others, seeks others’ input, contributes to the team outcome, and enjoys team membership.43 Several studies provide evidence that teams scoring higher on collective orientation measures demonstrate faster, more accurate problem solving,44 higher productivity,45 improved cooperation,46,47 improved team performance,42,48 and improved supervisor ratings.49 These results are not surprising, considering that in collectively oriented teams, members benefit from the opportunity to pool information, share resources, and check errors in accomplishing a task—all actions that make teamwork effective.42

In the example case, both the intern and the nurse “did their jobs.” Pursuing goals independent of each other, the nurse measured the blood pressure, and the physician made a medication change. Neither, however, worked with the other, with the patient, or with anyone else to determine the patient’s ability to enact the plan and control his blood pressure. Teams with a high degree of collective orientation prioritize these discussions. For example, reviewing practice-wide data at the weekly practice meetings and soliciting input from all team members can help transform individual-oriented goals (measure blood pressure, change medication) into one high-value, team-oriented goal (help a patient control his blood pressure). We believe that fostering team communication and interdependence at these weekly meetings increases each team member’s opinion of and confidence in teamwork, which, in turn, further promotes collective orientation and improves team processes and outcomes.

At the practice meetings, collaboration with social workers, community health workers, and public health team members around topics prompted by a case (in our example, transportation affecting access, costs affecting medication acquisition, and limited health literacy affecting understanding of the illness and treatment plan) would integrate essential population health content into the team’s reflection. Both the IOM and a number of academic publications have recently underscored the importance of integrating population health concepts into the care of individuals (List 1).50–52 Population health management is vital to PCMH success, and we believe that team orientation is likewise instrumental in achieving that success.

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Competency Interdependence and Integration

Salas and colleagues21 describe other supporting teamwork elements, including the development of a shared mental model (i.e., a common understanding of the relationship between the team’s tasks and goals and how team members interact), the achievement of mutual trust, and engagement in closed-loop communication, that all help coordinate the five competencies. The competencies themselves are also highly interconnected. For example, in order to create a system that adapts to high-volume occurrences, the leadership of the practice would have to use a team’s shared mental model to foster backup behaviors among team members (e.g., coverage by a care team partner) and mutual performance monitoring (allowing team members to provide immediate feedback when someone is overwhelmed and underperforming). The team would need to create the time and space, such as at weekly practice meetings, to allow these conversations to occur (collective orientation). Well-facilitated weekly practice meetings can begin to break down the traditional hierarchical and territorial constructs that exist among health care professions, create accountability for mutual team performance, and lead to the prioritizing of effective closed-loop communication.

The practice in the example case seems to have added individual clinicians, including trainees, without orienting them to teamwork or requiring them to acquire the team knowledge, values, or skills that would enable them to flourish in a PCMH. Practice leaders could require anyone joining the practice to complete a focused interprofessional team-training orientation module that emphasizes the five teamwork competencies and stresses a knowledge of the roles and responsibilities of all team members. Simple role-play simulations that present authentic practice problems would allow new trainees to work with team members to gain experience with these teamwork behaviors. Ongoing half-day practice retreats that allow for continued exposure to the teamwork content and role-play simulations can help all team members further master these behaviors. Guidelines are available to design such context-specific simulations.53

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Call to Action

Widespread health system failures of cost, quality, and access are pushing academic health centers to adopt and test models of interprofessional training with the expectation that trainees will graduate with the teamwork competencies described in this Perspective.54 However, despite calls encouraging interprofessional education,19 the entrenched silos in training curricula have proven hard to overcome. Recently, a coalition of health professions education associations (American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, Association of Schools of Public Health, American Association of Colleges of Pharmacy, American Dental Education Association, and Association of American Medical Colleges) have made advances in training for working in teams. This six-member committee produced and disseminated a report, Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel,18 which addresses many of the same competencies described by Salas and colleagues.

The federal government is also lending pressure to accelerate change toward interprofessional training and team performance. To illustrate, the Health Resources and Services Administration has sponsored a Coordinating Center for Interprofessional Education and Collaborative Practice (housed at the University of Minnesota); the center holds responsibility for advancing the evidence that interprofessional education leads to teamwork, which, in turn, leads to better patient outcomes. Another federal government incentive for improving teamwork comes from the Patient Protection and Affordable Care Act (ACA) of 2010. Noting an earlier finding that nearly half of U.S. adults report that their physicians did not coordinate their care,55 many tenants of the ACA put pressure on health system provider teams to improve care coordination. New payment models seek to reward value over volume of care, such that value is determined by various metrics ranging from how satisfied patients are to how well a care team avoids preventable rehospitalizations.56 Thus, the ACA adds urgency for a more rapid adoption of the teamwork behaviors described in this Perspective.

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Conclusion and Next Steps

In 1974, Wise and colleagues57 wrote: “It is ironic indeed to realize that a football team spends 40 hours each week practicing teamwork for the two hours on Sunday afternoon when their teamwork really counts. Teams in organizations seldom spend two hours per year practicing when their ability to function as team counts 40 hours each week.”57 Regrettably, not much has changed in many academic primary care practices since then. A team orientation must replace individualistic notions within all aspects of health professions training, and curricular content, policies, pedagogy, and assessment must align interdependence—not independence—with success.

Academic primary care practices that follow the PCMH model should adopt the teamwork competencies identified by Salas and colleagues. Team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation should be explicitly taught, reinforced in the workplace, and assessed using instructive methods that include practical experience and reflection. Training directors from varied programs within an institution should work together to revise curricula to implement these changes. New assessment methodologies that reliably evaluate the desired behaviors must be developed. Faculty from all professions in the PCMH must be mindful that they role model for others, and faculty development programs or curricula designed to improve teamwork should be required for all educators who train future PCMH providers. Trainees must be included in all aspects of authentic team development at the point of care. Finally, academic primary practice teams should periodically apply these five teamwork competencies to authentic internal practice vignettes, in the manner depicted in this Perspective, to ensure that all team members perform to the best of their ability and that each person’s behaviors, skills, and roles are optimized to provide high-quality, efficient, comprehensive, patient-centered care as outlined by the PCMH standards.

Changing the culture of academic primary care practice is hard work. Despite the many challenges ahead, health professions’ training programs must prepare future health care team members to work together to share in the emerging future of high-value health care delivery. There is no “I” in team.

Acknowledgments: The authors wish to thank the Josiah Macy Jr. Foundation for financial support of the 2011 Society of General Internal Medicine Education Summit. The authors also thank other financial and in-kind supporters including the United Health Foundation, American College of Physicians, Primary Care Progress, and the Veterans Health Administration Office of Academic Affiliations. Leaders from the American Board of Internal Medicine, American College of Physicians, Association of Program Directors in Internal Medicine, Association of Subspecialty Professors, Clerkship Directors in Internal Medicine, and the Society of General Internal Medicine served as advisors in designing the Education Summit. Although the majority of summit participants were university- and community-based physician educators in internal medicine and family medicine, participants from nursing and pharmacy provided crucial contributions.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

Previous presentations: This content was presented in part at the Symposium for the Society of General Internal Medicine 34rd Annual Meeting, May 2011, in Phoenix, Arizona, and at the Association of Program Directors in Internal Medicine 2011 Fall Conference in Anaheim, California.

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