Health care costs for adolescents and young adults with cancer: a Wisconsin community-based hospital study between 2005 and 2020.

INTRODUCTION: Adolescents and young adults (AYA) with cancer are at risk of high cumulative healthcare system costs potentially associated with poor health and financial outcomes. Although this has been studied at academic centers, little data on AYA costs at community-based practices exist. The goals of this study were to understand direct health care costs for AYA patients, identify factors for high costs, and assess how total health care costs may relate to survival. METHODS: AYA patients (15-39 years) treated at a community hospital in Wisconsin (USA) between 2005 and 2020 were identified. Patient demographics, cancer characteristics, therapies, support services, and all direct health care charges (including up to 1 year prior to diagnosis to capture any diagnostic workup) were collected. Logistic and Cox proportional hazard regression models identified factors associated with high costs and survival, respectively. RESULTS: The 388 AYA patients had a median follow-up of 9 years (97% survival). Most were 30-39 years (62%), female (61%), white (95%), diagnosed early-stage (85%), and underwent surgery (83%). Complete health care costs were available for 233 patients (60%). Median total costs per patient were $123 K (range, $73-$215 K). On adjusted analysis, higher direct health care costs (> $125 K) were associated with greater odds of hospital admissions (odds ratio [OR] = 1.7, 95% CI = 1.35-2.27), chemotherapy (OR = 4.1, 95% CI = 1.44-12.70), and breast cancer diagnosis (OR = 3.8, 95% CI = 1.07-14.70). Living farther from the hospital (OR = 0.1, 95% CI = 0.02-0.50), later year of diagnosis (OR = 0.7, 95% CI = 0.55-0.77), and uninsured/unknown insurance status (OR = 0.1, 95% CI = 0.01-0.57) were associated with decreased odds of having higher health care costs. On adjusted analysis, death was associated with greater odds of higher direct health care costs per $125 K (hazards ratio [HR] = 7.9, 95% CI = 2.22-27.80) and radiation (HR = 31.8, 95% CI = 3.15-321) but lower odds of hormone therapy (HR = 0.1, 95% CI = 0.01-0.72) and later year of diagnosis (HR = 0.3, 95% CI = 0.12-0.60). CONCLUSION: High direct health care costs among AYA patients are associated with hospital admissions, chemotherapy, breast cancer diagnosis, hospital proximity, and earlier year of diagnosis. Death was associated with high direct health care costs, earlier years of diagnosis, and radiation therapy. Total health care costs in community-based hospitals should be considered in the context of AYA patients with cancer.

Working around hierarchy: Resident and medical assistant teaming.

BACKGROUND: In health care, hierarchy can facilitate getting work done efficiently. It can also hinder performance by suppressing valuable contributions from lower-positioned individuals. Team-based care could mitigate negative effects by creating space for all team members to contribute their unique expertise. PURPOSE: This article sought to understand how resident-medical assistant (MA) dyads interacted before and after primary care clinics transitioned to team-based care. We also studied how they negotiated changes in interpersonal dynamics given the challenge these changes presented to hierarchical norms. METHODOLOGY: We conducted two qualitative interview studies, with 37 residents and 30 MAs at primary care clinics transitioning to team-based care. Interviews were transcribed, coded, and analyzed together using a thematic networks approach and focused coding. RESULTS: An intervention that promoted teamwork prompted resident-MA dyads to change their interactions to counter traditional hierarchy. Residents increasingly asked MAs questions about patient care, and MAs initiated interactions and volunteered ideas more frequently. We also found that MAs and residents expressed some discomfort with the hierarchical ambiguity that their new interactions produced and used alternate scripts to buffer this discomfort and to collaborate as teammates despite formal hierarchy. CONCLUSION: Among resident-MA dyads, a team-based care intervention changed interpersonal dynamics by blurring hierarchical lines and shifting traditional boundaries in ways that were uncomfortable for both groups. They were able to work around discomfort by using new scripts that downplayed the threat to hierarchy. PRACTICE IMPLICATIONS: Organizational structures that encourage greater interprofessional collaboration may neutralize barriers that formal hierarchy in medicine can pose for effective teamwork, but this process can also bring social discomfort. Our findings suggest that health care professionals may use microlevel strategies, such as alternative scripts, to overcome formal hierarchies without openly engaging them. Together, new organizational structures and interaction techniques can help professionals work around hierarchy and improve team performance.

Feeling inadequate: Residents' stress and learning at primary care clinics in the United States.

BACKGROUND: Educators hope that residents' experiences in primary care continuity clinics will influence more trainees to enter primary care careers. Unfortunately, evidence shows that outpatient primary care training in the United States is stressful and fails to promote primary care careers. We conducted qualitative interviews with residents to understand the source of stress and to explain this failure. METHODS: In-person individual interviews were conducted with 37 primary care residents training at outpatient clinics in the US. Analysis used the constant comparative method and included open and focused coding, allowing themes to emerge inductively from the data. RESULTS: 73% of residents interviewed reported negative emotions about clinic. Beyond stress, residents reported feeling inadequate as primary care physicians at clinic. Four factors contributed: mental distractions, unfamiliarity with primary care medicine, management of outpatients, and relationships with patients. Residents' comparisons of hospital-based and outpatient experiences favored the former in relation to the four factors. CONCLUSIONS: Residents feel unprepared for primary care and inadequate as primary care physicians, and these feelings discourage them from practicing primary care. This phenomenon must be studied within the entire context of residency, as residents' attitudes about their outpatient experiences were shaped in relation to their inpatient experiences.

Team-based primary care: The medical assistant perspective.

BACKGROUND: Team-based care has the potential to improve primary care quality and efficiency. In this model, medical assistants (MAs) take a more central role in patient care and population health management. MAs' traditionally low status may give them a unique view on changing organizational dynamics and teamwork. However, little empirical work exists on how team-based organizational designs affect the experiences of low-status health care workers like MAs. PURPOSES: The aim of this study was to describe how team-based primary care affects the experiences of MAs. A secondary aim was to explore variation in these experiences. METHODOLOGY/APPROACH: In late 2014, the authors interviewed 30 MAs from nine primary care practices transitioning to team-based care. Interviews addressed job responsibilities, teamwork, implementation, job satisfaction, and learning. Data were analyzed using a thematic networks approach. Interviews also included closed-ended questions about workload and job satisfaction. RESULTS: Most MAs reported both a higher workload (73%) and a greater job satisfaction (86%) under team-based primary care. Interview data surfaced four mechanisms for these results, which suggested more fulfilling work and greater respect for the MA role: (a) relationships with colleagues, (b) involvement with patients, (c) sense of control, and (d) sense of efficacy. Facilitators and barriers to these positive changes also emerged. CONCLUSION: Team-based care can provide low-status health care workers with more fulfilling work and strengthen relationships across status lines. The extent of this positive impact may depend on supporting factors at the organization, team, and individual worker levels. PRACTICE IMPLICATIONS: To maximize the benefits of team-based care, primary care leaders should recognize the larger role that MAs play under this model and support them as increasingly valuable team members. Contingent on organizational conditions, practices may find MAs who are willing to manage the increased workload that often accompanies team-based care.

Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: A mixed methods study.

BACKGROUND: Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. PURPOSE: The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard's Academic Innovations Collaborative. METHODOLOGY: First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs' clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. FINDINGS: Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. PRACTICE IMPLICATIONS: Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to improve aspects of team dynamics may also help resolve critical challenges in workforce planning in primary care.

A faculty development program integrating cross-cultural care into a gastrointestinal pathophysiology tutorial benefits students, tutors, and the course.

A specific faculty development program for tutors to teach cross-cultural care in a preclinical gastrointestinal pathophysiology course with weekly longitudinal followup sessions was designed in 2007 and conducted in the same manner over a 6-yr period. Anonymous student evaluations of how "frequently" the course and the tutor were actively teaching cross-cultural care were performed. The statements "This tutor actively teaches culturally competent care" and "Issues of culture and ethnicity were addressed" were significantly improved over baseline 2004 data. These increases were sustained over the 6-yr period. A tutor's overall rating as a teacher was moderately correlated with his/her "frequently" actively teaching cross-cultural care (r = 0.385, P < 0. 001). Course evaluation scores were excellent and put the course into the group of preclinical courses with the top ratings. Students in the Race in Curriculum Group asked that the program be expanded to other preclinical courses. In conclusion, from 2007 to 2012, a faculty development program for teaching cross-cultural care consistently increased the discussion of cross-cultural care in the tutorial and course over each year beginning with 2007 compared with the baseline year of 2004. Our data suggest that cross-cultural care can be effectively integrated into pathophysiology tutorials and helps improve students' satisfaction and tutors' ratings. Teaching cross-cultural care in a pathophysiology tutorial did not detract from the course's overall evaluations, which remained in the top group over the 6-yr period.

50 years of publication in the field of medical education.

BACKGROUND: The advent of new medical education (ME) journals makes evident the growth of the field of ME. However, the nature and context of growth is undefined. AIM: To analyze the evolution of publication in ME. METHODS: MEDLINE retrieval using medical subject headings was used to analyze patterns of ME publications from 1960-2010: changes in number of ME publications; number of journals publishing ME articles; co-topics occurring frequently in ME articles; differences among journals' publication of co-topics. RESULTS: Annual publication of ME articles increased from 279 in 1960 to 3760 in 2010. 81,531 articles were published in 4208 different journals. 104 journals published ME articles in 1960, 855 in 2010. Despite an increase in journals in all fields, ME journals now account for a larger proportion of all journals indexed in MEDLINE than in 1960. One-quarter of all ME articles were indexed as internship/residency; 16% as graduate ME; 15% as undergraduate ME; and 14% as continuing ME. The five journals that published the most ME articles distinguished themselves by publishing some topics with greater or less frequency. CONCLUSIONS: The increase in the number of ME publications and in the number of journals publishing ME articles suggests a supportive environment for a growing field; but variation in journals' foci has implications for readers, editors and authors.

Extensive sinovenous thrombosis and hemorrhagic infarction during therapy for T-cell acute lymphoblastic leukemia.

Sinovenous thrombosis (SVT) is a well-recognized and serious complication in children treated for acute leukemia. This frequently occurs during or immediately upon completion of induction therapy and is commonly attributed to asparaginase therapy.Headache is the first and most common clinical symptom to occur during the early development of SVT. With advancement of the thrombosis, the clinical symptoms can progress to increased sleepiness, focal neurological deficit, seizures, and altered consciousness. We report the case of a 4-year-old girl who presented after several days of headaches and anorexia, which then progressed to seizures, left-sided weakness, and altered consciousness. She was later found to have a widespread and occlusive SVT with right cerebral hemorrhagic infarction. This case is notable for the extensive nature of the cerebral SVT and the child's complete clinical recovery from the neurological event. The report discusses the relation of the thrombosis and leukemia and also emphasizes the importance of early recognition and prompt management, while incorporating a collaborative multidisciplinary approach to prevent long-term consequences.

Integration of racial, cultural, ethnic, and socioeconomic factors into a gastrointestinal pathophysiology course.

BACKGROUND & AIMS: Our study describes a faculty development program to encourage the integration of racial, cultural, ethnic, and socioeconomic factors such as obesity, inability to pay for essential medications, the use of alternative medicine, dietary preferences, and alcoholism in a gastrointestinal pathophysiology course. METHODS: We designed a 1-hour faculty development session with longitudinal reinforcement of concepts. The session focused on showing the relevance of racial, ethnic, cultural, and socioeconomic factors to gastrointestinal diseases, and encouraged tutors to take an active and pivotal role in discussion of these factors. The study outcome was student responses to course evaluation questions concerning the teaching of cultural and ethnic issues in the course as a whole and by individual tutorials in 2004 (pre-faculty development) and in 2006 to 2008 (post-faculty development). RESULTS: Between 2004 and 2008, the proportion of students reporting that "Issues of culture and ethnicity as they affect topics in this course were addressed" increased significantly (P = .000). From 2006 to 2008, compared with 2004, there was a significant increase in the number of tutors who "frequently" taught culturally competent care according to 60% or greater of their tutorial students (P = .003). The tutor's age, gender, prior tutor experience, rank, and specialty did not significantly impact results. CONCLUSIONS: An innovative faculty development session that encourages tutors to discuss racial, cultural, ethnic, and socioeconomic issues relevant to both care of the whole patient and to the pathophysiology of illness is both effective and applicable to other preclinical and clinical courses.

Compound heterozygosity for MSH6 mutations in a pediatric lymphoma patient.

An 8-year-old male with lymphoblastic lymphoma was noted to have multiple café-au-lait macules and possible Lisch nodules. Work-up revealed the child as compound heterozygous for mutations in the DNA mismatch repair gene, MSH6. This case emphasizes many clinical issues regarding individuals with biallelic mismatch repair mutations, a rare and easily missed hereditary predisposition to childhood cancer. The issues include the need for high clinical suspicion based on skin examination findings and family history, the phenotypic similarity to neurofibromatosis type 1 with possibility of misdiagnosis, the high risk for subsequent malignances, and the need for further research of possible treatment resistance.

Intentional or Not: Teamwork Learning at Primary Care Clinics.

BACKGROUND AND OBJECTIVES: Primary care teamwork has been shown to increase satisfaction and decrease stress for physicians but the impact of outpatient teamwork for primary care residents' learning has not been described. This study aimed to understand the role of teamwork in residents' learning during and after the establishment of teams. METHODS: Interviews with 37 primary care residents addressed their experiences at outpatient clinic, including their perceptions about whether team-based care affected their educational experience. Using qualitative thematic analysis, transcripts were coded to identify themes about teamwork and learning, both positive and negative. RESULTS: Residents described learning both about and through teamwork at continuity clinic, despite variation in the speed and extent of initial integration into teams. As residents learned how to work on a team, they realized the importance of face-to-face time together and trusting one another. Team members also taught residents about the clinical system and social aspects of patient care, as well as some procedural skills, which led them to understand how teamwork can improve patient care and efficiency. Finally, residents learned, through both optimal and suboptimal first-hand team experiences, to see team-based care as a model for future primary care practice. CONCLUSIONS: While integrating residents into primary care teams, educators should consider the potential value of teamwork as an intentional learning method. Team members, beyond the preceptor, can offer valuable instruction, and team-based workplace learning prepares residents to use teamwork to optimize care for patients.

A self-instructional model to teach systems-based practice and practice-based learning and improvement.

BACKGROUND: When mandated as resident competencies in 1999, systems-based practice (SBP) and practice-based learning and improvement (PBLI) were new concepts to many. OBJECTIVE: To describe and evaluate a 4-week clinical elective (Achieving Competence Today-ACT) to teach residents SBP and PBLI. DESIGN: ACT consisted of a four-week active learning course and follow-up teaching experience, guided and supported by web-based materials. The curriculum included readings, scheduled activities, work products including an improvement project, and weekly meetings with a non-expert preceptor. The evaluation used a before-after cross-comparison of ACT residents and their peers. PARTICIPANTS: Seventy-eight residents and 42 faculty in 18 US Internal Medicine residency programs participated between 2003 and 2005. RESULTS AND MAIN MEASUREMENTS: All residents and faculty preceptors responded to a knowledge test, survey of attitudes, and self-assessment of competency to do 15 tasks related to SBP/PBLI. All measures were normalized to a 100-point scale. Each program's principal investigator (PI) identified aspects of ACT that were most and least effective in enhancing resident learning. ACT residents' gains in knowledge (4.4 on a 100-point scale) and self-assessed competency (11.3) were greater than controls' (-1.9, -8.0), but changes in attitudes were not significantly different. Faculty preceptors' knowledge scores did not change, but their attitudes became more positive (15.8). PIs found a ready-to-use curriculum effective (rated 8.5 on a 10-point scale). CONCLUSIONS: ACT increased residents' knowledge and self-assessment of their own competency and raised faculty's assessment of the importance of residents' learning SBP/PBLI. Faculty content expertise is not required for residents to learn SBP/PBLI.

Teaching population health as a basic science at Harvard Medical School.

In 2006-2007, Harvard Medical School implemented a new, required course for first-year medical and dental students entitled Clinical Epidemiology and Population Health. Conceived of as a "basic science" course, its primary goal is to allow students to develop an understanding of caring for individuals and promoting the health of populations as a continuum of strategies, all requiring the engagement of physicians. In the course's first iteration, topical content accessible to first-year students was selected to exemplify physicians' roles in addressing current threats to population health. Methodological areas included domains of clinical epidemiology, decision sciences, population-level prevention and health promotion, physicians' roles in the public health system, and population-level surveillance and intervention strategies. Large-group settings were selectively used to frame the relevance of each topic, and conceptual learning of statistical and epidemiologic methods occurred in conference groups of 24 students. Finally, tutorials of eight students and one or two faculty were used for critical reading of published studies, review of problem sets, and group discussion of population health issues. To help students appreciate the structure and function of the public health system and physicians' role in public health emergencies, the course included a role-playing exercise simulating response to an influenza pandemic. The first iteration of the course was well received, and assessment of students suggested mastery of basic skills. Preclinical courses represent a progressive step in developing a workforce of physicians who embrace their responsibility to improve the health of the population as a whole, as well as the health of the patient in front of them.

Inherited ADAMTS13 deficiency: unique presentation and treatment.

A 3-year-old male presented with severe thrombocytopenia and microangiopathic hemolytic anemia in conjunction with severe bilateral otitis media. After laboratory analysis, a diagnosis of inherited ADAMTS13 deficiency was proven. Rather than treating with prophylactic fresh frozen plasma, to date the patient has been successfully treated with single-donor, directed plasma infusions in response to early signs of relapse. It may be reasonable to consider observational and reactive care rather than prophylactic care in some cases of inherited ADAMTS13 deficiency.

Annual Performance Reviews Of, For and By Faculty: A Qualitative Analysis of One Department's Experiences.

PURPOSE: Although annual performance reviews and feedback are recommended for faculty development, best practices and faculty perceptions have not been documented. The authors sought to evaluate the process in one medical school department that established and has sustained an innovative review tradition for 25 years. METHOD: Content analysis of faculty reports and immersion/crystallization to analyze interviews. RESULTS: Faculty reports described satisfaction and dissatisfaction; facilitators and barriers to goals; and requests for feedback, with community, collaboration and mentorship integral to all three. Interviewees emphasized practical challenges, the role of the mentor and the power of the review to establish community norms. CONCLUSION: Respondents generally found reviews constructive and supportive. The process informs departmental expectations and culture.

Establishing Teams: How Does It Change Practice Configuration, Size, and Composition?

Little is known about how practices reorganize when transitioning from traditional practice organization to team-based care. We compared practice-level (1) configuration as well as practice- and team-level (2) size and (3) composition, before and after establishing teams. We employed a pre-/poststudy using personnel lists of 1571 to 1711 staff (eg, job licenses, titles, and team assignment) and practice manager surveys. All personnel (physician and nonphysician) worked within 18 Massachusetts academic primary care practices participating in a 2-year learning collaborative aimed at establishing team-based care. We found that establishing team-based care can involve changing practice configurations and composition without substantially changing practice size.

Creating enduring change: demonstrating the long-term impact of a faculty development program in palliative care.

BACKGROUND: Improved educational and evaluation methods are needed in continuing professional development programs. OBJECTIVE: To evaluate the long-term impact of a faculty development program in palliative care education and practice. DESIGN: Longitudinal self-report surveys administered from April 2000 to April 2005. PARTICIPANTS: Physician and nurse educators from North America and Europe. All program graduates (n = 156) were invited to participate. INTERVENTION: Two-week program offered annually (2000 to 2003) with 2 on-site sessions and 6-month distance-learning period. Learner-centered training addressed teaching methods, clinical skill development, and organizational and professional development. MEASURES: Self-administered survey items assessing behaviors and attitudes related to palliative care teaching, clinical care, and organizational and professional development at pre-, postprogram, and long-term (6, 12, or 18 months) follow-up. RESULTS: Response rates: 96% (n = 149) preprogram, 73% (n = 114) follow-up. Participants reported increases in: time spent in palliative care practice (38% preprogram, 47% follow-up, P < .01); use of learner-centered teaching approaches (sum of 8 approaches used "a lot": preprogram 0.7 +/- 1.1, follow-up 3.1 +/- 2.0, P < .0001); and palliative care topics taught (sum of 11 topics taught "a lot": preprogram 1.6 +/- 2.0, follow-up 4.9 +/- 2.9, P < .0001). Reported clinical practices in psychosocial dimensions of care improved (e.g., assessed psychosocial needs of patient who most recently died: 68% preprogram, 85% follow-up, P = .01). Nearly all (90%) reported launching palliative care initiatives, and attributed their success to program participation. Respondents reported major improvements in confidence, commitment to palliative care, and enthusiasm for teaching. Eighty-two percent reported the experience as "transformative." CONCLUSIONS: This evidence of enduring change provides support for the potential of this educational model to have measurable impact on practices and professional development of physician and nurse educators.

Cooperative learning: a new application of problem-based learning in mental health training.

Interaction in problem-based learning (PBL) tutorials is not necessarily cooperative, which may account for variation in learning outcomes. Therefore, a cooperative assessment structure was introduced in a PBL course and the difference examined between this method and individual, lecture-based learning in mental health training. Experimental student groups gained more knowledge between pre- and post-test than did control groups, and the experimental students who scored low on the pre-test made the greatest gains. Groups that reported greater cooperation tended to have higher achievement scores. Experimental students felt that cooperation helped them learn but it also took more time and was sometimes chaotic.

Teaching and learning end-of-life care: evaluation of a faculty development program in palliative care.

PURPOSE: To evaluate the effectiveness of the Program in Palliative Care Education and Practice (PCEP), an intensive faculty development program at Harvard Medical School. METHOD: PCEP is a two-week program offered annually with two on-site sessions in Boston, MA, and an interim period distance-learning component. Training integrates palliative care clinical skill development, learning theory and teaching methods, and leadership and organizational change. Longitudinal surveys (preprogram, retrospective preprogram, and postprogram) of participants from 2000-03 assessed self-reported preparation in providing and teaching palliative care; teaching and patient care practices; and satisfaction with program. RESULTS: The response rate was 96% (n=149) for Session I and 72% for both Session I and II (n=113). Questionnaire responses demonstrated statistically significant improvements with large effect sizes (range 0.7-1.8) on nearly all measures. Preparation increased from 3.0+/-1.1 to 4.2+/-0.7 for providing end-of-life care (1=not well prepared, 5=very well prepared), and from 2.6+/-1.0 to 4.3+/-0.7 for teaching this topic. Respondents reported behavioral changes in patient care and teaching; e.g., after the program, 63% noted that, specifically as a result of attending the course, they encouraged learners to reflect on their emotional responses to dying patients, and 57% conducted experiential exercises (e.g., role-play). Eighty-two percent rated the experience as "transformative," and many responses to open-ended items described powerful learning experiences. Participants rated the program highly (4.9+/-0.1, 1=lowest, 5=highest rating). CONCLUSIONS: Integrating clinical content with learning about educational methods is an efficient and effective approach to enhancing clinical faculty's capacity to model and teach clinical care. This program offers an educational model that engages practitioners, stimulates changes in practice, and offers opportunities for reflection and professional revitalization.

Development and validation of the primary care team dynamics survey.

OBJECTIVE: To develop and validate a survey instrument designed to measure team dynamics in primary care. DATA SOURCES/STUDY SETTING: We studied 1,080 physician and nonphysician health care professionals working at 18 primary care practices participating in a learning collaborative aimed at improving team-based care. STUDY DESIGN: We developed a conceptual model and administered a cross-sectional survey addressing team dynamics, and we assessed reliability and discriminant validity of survey factors and the overall survey's goodness-of-fit using structural equation modeling. DATA COLLECTION: We administered the survey between September 2012 and March 2013. PRINCIPAL FINDINGS: Overall response rate was 68 percent (732 respondents). Results support a seven-factor model of team dynamics, suggesting that conditions for team effectiveness, shared understanding, and three supportive processes are associated with acting and feeling like a team and, in turn, perceived team effectiveness. This model demonstrated adequate fit (goodness-of-fit index: 0.91), scale reliability (Cronbach's alphas: 0.71-0.91), and discriminant validity (average factor correlations: 0.49). CONCLUSIONS: It is possible to measure primary care team dynamics reliably using a 29-item survey. This survey may be used in ambulatory settings to study teamwork and explore the effect of efforts to improve team-based care. Future studies should demonstrate the importance of team dynamics for markers of team effectiveness (e.g., work satisfaction, care quality, clinical outcomes).