Operational digital twin clinics enable task-based evaluation of embodied AI

Embodied artificial intelligence (AI) must be tested in the clinical environments where it will operate, but building realistic, robot-testable settings is costly and difficult to scale. Here we show that routine clinic images can be transformed into operational digital twins for task-based evaluation of embodied AI. Using 39 ophthalmic clinic scenes, we converted single photographs into editable, simulator-ready environments and assessed reconstruction quality, room-scale geometry, mesh grounding, multi-robot feasibility, perturbation sensitivity and closed-loop policy performance. The reconstructed scenes preserved workspace structure, while local editing enabled controlled device reconfiguration. Device meshes, collision proxies and semantic anchors converted visual reconstructions into contact-aware simulation scenes. Across three robot embodiments, shared task targets showed different patterns of reachability and contact feasibility. Small device translations and rotations produced task-specific changes in contact margins that were not captured by visual similarity alone. Digital-twin trajectories also supported local policy learning and closed-loop evaluation. These findings establish operational validity as a key principle for clinical digital twins and provide an intermediate layer between offline development and physical deployment of embodied AI in healthcare.

ResidencyRL: Reinforcement Learning in Simulated Clinical Environments

In medical education, physicians convert academic knowledge into clinical expertise through residency: years of training across thousands of encounters, with diverse sources of feedback and progressively greater autonomy. Much of clinical reasoning relies on the patient encounter, a dialogue in which a clinician elicits history, refines diagnostic hypotheses, and decides management under uncertainty. While large language models (LLMs) excel on static medical benchmarks, methods to optimize the full sequence of clinical decisions remain underdeveloped. We present ResidencyRL, a reinforcement learning (RL) method for training clinical artificial intelligence (AI) agents through simulated multi-turn clinical encounters (up to 60 dialogue turns and 8 tool calls per trajectory). ResidencyRL pairs the policy agent with LLM simulators capable of complex, adversarial behaviors, training against a structured reward aligned to diagnostic accuracy, management quality, communication, documentation, and safety. On held-out evaluations, the ResidencyRL agent improves diagnostic accuracy by 7.0% under adversarial conditions (88.0% vs. 81.0%) and reduces missed red flag rates by 31%, demonstrating rigorous mitigation of premature closure. Blinded expert clinicians validated these gains, preferring the trained agent in 87.6% of side-by-side comparisons. The procedural competencies transfer to unseen benchmarks: the agent outperforms the base model across all six clinical axes of the AMIE multi-visit benchmark, and shows consistent directional improvements on AgentClinic and CRAFT-MD. Our findings demonstrate that sequential clinical decision-making can be effectively learned through multi-turn RL in simulation, yielding robust, generalizable capabilities, paving the way towards clinical mastery. Prospective validation with real-world workflows remains necessary to establish clinical utility.

A Diffusion-Model Subpopulation Digital Twin for Mobile Health Deployment: A Case Study on the HeartSteps Intervention

Mobile-health interventions increasingly use online learning and decision making algorithms to personalize when to nudge users toward healthier behavior, but a poorly designed algorithm can burden and disengage participants. New algorithm design decisions should therefore be vetted against realistic simulated users before each real-life deployment. We propose a method to develop ``JITAI-Twins'': digital twins of a target subpopulation for comparing candidate online algorithms before a just-in-time adaptive intervention (JITAI) deployment. The method builds on a conditional time-series diffusion model that is temporally consistent (future actions do not affect the generated past), and it supports repeated updating from three sources of information, in three steps: pre-training on a large observational dataset, fine-tuning on small prior intervention deployments in related populations, and inference-time calibration to the next target population from domain-scientist expertise. We validate the twin at each pre-deployment stage of the long-running HeartSteps series (v2 through v4) of physical-activity suggestion intervention deployments, treating each successive deployment as an upcoming study. The proposed method reproduces the target subpopulation's temporal and between-participant structure better than simpler simulators. These results suggest that our twin can be used to simulate a target deployment before it runs, the prerequisite for testing and informing online algorithm design decisions.

Proactive Inpatient Bed Requests for Emergency Department Admissions

Emergency department (ED) boarding occurs when admitted patients remain in the ED while awaiting inpatient beds. Boarding is a major driver of ED crowding and has been associated with poor patient outcomes. We propose a framework to help EDs reduce boarding time and length of stay by using information about current patients and bed availability to proactively request inpatient beds before admission decisions are finalized. We formulate the problem as a Markov decision process in which predictions of each patient's admission probability and time to disposition are aggregated to guide early inpatient bed requests. This formulation leads to three data-driven policies based on approximate dynamic programming, reinforcement learning, and a newsvendor-type approach. Using a simulation model based on data from a large ED, we evaluate these policies across a wide range of settings. The simulation study shows that proactive aggregate bed requests can reduce average boarding times for admitted patients by 30-70\% and average length of stay for all ED patients by 6-15\%, while creating only modest idle time for prepared inpatient beds. The newsvendor heuristic provides the most attractive tradeoff between ED performance and inpatient bed idle time, whereas the reinforcement learning heuristic produces smoother bed-request patterns when stability in downstream hospital processes is especially important. Our work shows how EDs can use prediction tools to make proactive bed-request decisions that improve ED operations while helping managers balance reductions in ED delays against inpatient bed idle time. Our findings also illustrate the value of evaluating both simple myopic heuristics and more sophisticated reinforcement learning-based approaches, since each can offer distinct advantages depending on the performance measures and implementation constraints most important to managers.

A Neuroimaging Simulation Framework for Developing and Evaluating Causal AI

Causally linking disease-related factors to image-derived biomarkers provides a powerful pathway to understanding disease mechanisms. Despite growing interest in applying causal artificial intelligence (AI) approaches for this task, these methods still need to be adapted for complex medical images, and especially, neuroimaging. However, the lack of ground-truth data presents a barrier to development. To bridge this gap, we developed and tested a method for generating synthetic neuroimages, which adhere to a user-specified causal structure describing the non-image to image variable relationships, permitting the creation of ground-truth neuroimaging datasets. In the simulated T1-weighted magnetic resonance images, anatomical variability is modeled by sampling from a subspace estimated from real data and deforming a template image to create unique simulated subjects. Causal relationships are encoded via precise volumetric changes of any region-of-interest without unwanted global artifacts. We achieved relative volume errors of 0.3-2.66% for the targeted regions-of-interest and demonstrate their statistically significant causal relationships, while maintaining mean absolute errors for non-target brain regions between 0.034-0.397ml. An initial evaluation of causal discovery methods exposes their limited ability to suppress spurious connections, highlighting the need for image-appropriate methods. Our framework is the first to enable the generation of realistic synthetic 3D neuroimages with explicit causal control that can serve as the missing ground-truth data necessary for the objective benchmarking and development of causal AI methods.

Quantifying the biophysical properties of stomatocytes in health and disease

Hereditary stomatocytosis (HS) comprises red blood cell (RBC) disorders characterized by cup-shaped erythrocytes that respond oppositely to splenectomy: curative in overhydrated HS (OHS) but potentially thrombogenic in dehydrated HS (DHS/xerocytosis). This paradox persists because RBC biomechanics is governed by partly independent parameters--shear modulus, bending rigidity, surface-to-volume ratio (S/V), and cytoplasmic viscosity--that existing assays capture only piecemeal. Here we combine dissipative particle dynamics (DPD) simulations with microfluidic imaging to construct a control discocyte and three stomatocyte models (ST-RBC1-3) at fixed membrane area and decreasing volume (109.7, 101.5, 89.8 fL), spanning the OHS-to-DHS range. Tracing this parameter set through five mechanically orthogonal assays, we find that interendothelial-slit (IES) traversal is geometry-dominated: overhydrated ST-RBC1 requires an order of magnitude higher critical pressure than healthy RBCs, whereas dehydrated ST-RBC3 passes freely. ST-RBC3 nonetheless suppresses membrane tank-treading and raises low-shear whole-blood viscosity by ~29% at physiological haematocrit, comparable to Gaucher-disease hyperviscosity. A funnel-obstacle chip amplifies these differences into a label-free centerline-offset signal predicted to separate all four RBC types (~4.5 standard deviations between extreme phenotypes). These results unite single-cell mechanics, splenic filtration, and hemorheology in one framework, resolve the splenectomy paradox, and point toward microfluidic pre-operative risk stratification in HS.