Accelerating health system innovation: principles and practices from the Duke Institute for Health Innovation.

The Duke Institute for Health Innovation (DIHI) was launched in 2013. Frontline staff members submit proposals for innovation projects that align with strategic priorities set by organizational leadership. Funded projects receive operational and technical support from institute staff members and a transdisciplinary network of collaborators to develop and implement solutions as part of routine clinical care, ranging from machine learning algorithms to mobile applications. DIHI's operations are shaped by four guiding principles: build to show value, build to integrate, build to scale, and build responsibly. Between 2013 and 2021, more than 600 project proposals have been submitted to DIHI. More than 85 innovation projects, both through the application process and other strategic partnerships, have been supported and implemented. DIHI's funding has incubated 12 companies, engaged more than 300 faculty members, staff members, and students, and contributed to more than 50 peer-reviewed publications. DIHI's practices can serve as a model for other health systems to systematically source, develop, implement, and scale innovations.

Training the next generation of physician-executives: an innovative residency pathway in management and leadership.

The rapidly changing field of medicine demands that future physician-leaders excel not only in clinical medicine but also in the management of complex health care enterprises. However, many physicians have become leaders "by accident," and the active cultivation of future leaders is required. Addressing this need will require multiple approaches, targeting trainees at various stages of their careers, such as degree-granting programs, residency and fellowship training, and career and leadership development programs. Here, the authors describe a first-of-its-kind graduate medical education pathway at Duke Medicine, the Management and Leadership Pathway for Residents (MLPR). This program was developed for residents with both a medical degree and management training. Created in 2009, with its first cohort enrolled in the summer of 2010, the MLPR is intended to help catalyze the emergence of a new generation of physician-leaders. The program will provide physicians-in-training with rigorous clinical exposure along with mentorship and rotational opportunities in management to accelerate the development of critical leadership and management skills in all facets of medicine, including care delivery, research, and education. To achieve this, the MLPR includes 15 to 18 months of project-based rotations under the guidance of senior leaders in many disciplines including finance, patient safety, health system operations, strategy, and others. Developing both clinical and management skill sets during graduate medical education holds the promise of engaging future leaders of health care at an early career stage, keeping more MD-MBA graduates within health care, and creating a bench of talented future physician-executives.

Effect of diet, energy balance and milk production on oxidative stress in early-lactating dairy cows grazing pasture.

The aim of this study was to determine the effect of diet, energy balance and milk production on oxidative stress in early-lactating, Holstein-Friesian dairy cows fed to produce either low or high levels of milk. Indicators of energy balance (non-esterified fatty acids, ß-hydroxybutyrate, glucose and insulin-like growth factor-1) and indicators of oxidative stress (reactive oxygen metabolites and biological antioxidants) were measured in the first 5 weeks of lactation. Energy balance indicators showed that high producing animals had a lower degree of negative energy balance. Diet was found to have an indirect effect on the level of oxidative stress. Factors associated with a high level of oxidative stress were severe negative energy balance (mean -71 ± 6.85 27 MJ/cow/day, P < 0.05) and lower levels of milk production (mean 26.4 ± 0.07 28 L/cow/day, P < 0 .05). Further studies will be required to more precisely determine the specific effects of diet, energy balance and milk production on such stress in dairy cows and to establish normal ranges for these biomarkers.

Should an academic radiation oncologist be allowed to "opt out" of medicare?

Federal law permits physicians to "opt out" of Medicare. When a radiation oncologist chooses this option, he or she may neither bill nor collect from Medicare, but may legally attempt to charge and collect what he or she considers the value of services provided to Medicare-eligible patients. Many academic faculty practice plans permit members to opt out. Even if it is permissible for a radiation oncologist to opt out of Medicare, is it appropriate? The question raises significant ethical and economic issues as one attempts to balance the good of the individual faculty member against the good of the clinical faculty as a whole. In this commentary, the authors offer the principal arguments in favor of and against permitting a faculty radiation oncologist to opt out. They conclude by recommending broad faculty oversight over such decisions.