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ChatGPT scored 72% in clinical decision accuracy, MGB study shows
Photo: Leon Neal /Getty
Putting ChatGPT to the test to see if AI can work through an entire clinical encounter with a patient – recommending a diagnostic workup, deciding a course of action and making a final diagnosis – Mass General Brigham researchers have found the large language model to have "impressive accuracy" despite limitations, including possible hallucinations .
WHY IT MATTERS
Researchers from the Innovation in Operations Research Center at MGB trained ChatGPT, a large-language model (LLM) artificial intelligence chatbot, on all 36 published clinical vignettes from the Merck Sharpe & Dohme clinical manual and compared its accuracy on differential diagnoses, diagnostic testing, final diagnosis and management based on patient age, gender and case acuity.
"No real benchmarks exist, but we estimate this performance to be at the level of someone who has just graduated from medical school, such as an intern or resident," Dr. Marc Succi, associate chair of innovation and commercialization and strategic innovation leader at MGB and executive director of its MESH Incubator's Innovation in Operations Research Group, or MESH IO, said in a statement.
The researchers said that ChatGPT achieved an overall accuracy of 71.7% in clinical decision making across all 36 clinical vignettes. ChatGPT came up with possible diagnoses and made final diagnoses and care management decisions.
They measured the popular LLM's accuracy on differential diagnosis, diagnostic testing, final diagnosis and management in a structured blinded process, awarding points for correct answers to questions posed. Researchers then used linear regression to assess the relationship between ChatGPT's performance and the vignette's demographic information, according to the study published this past week in the Journal of Medical Internet Research .
ChatGPT proved best in making a final diagnosis, where the AI had 77% accuracy in the study, funded in part by the National Institute of General Medical Sciences.
It was lowest-performing in making differential diagnoses, where it was only 60% accurate, and in clinical management decisions, underperforming at 68% accuracy based on the clinical data the LLM was trained on.
This is good news for those who have questioned whether ChatGPT can really outshine doctors' expertise .
"ChatGPT struggled with differential diagnosis, which is the meat and potatoes of medicine when a physician has to figure out what to do," Succi said. "That is important because it tells us where physicians are truly experts and adding the most value – in the early stages of patient care with little presenting information, when a list of possible diagnoses is needed."
Before tools like ChatGPT can be considered for integration into clinical care, more benchmark research and regulatory guidance is needed, according to MGB. Next, MESH IO is looking at whether AI tools can improve patient care and outcomes in hospitals' resource-constrained areas.
THE LARGER TREND
While most ChatGPT tools created in health tech focus on cutting physician burnout by streamlining documentation tasks or searching for data and answering patient questions , one of the biggest considerations the industry faces with AI is trust, according to Dr. Blackford Middleton, an independent consultant and former chief medical information officer at Stanford Health Care.
In order to convince clinicians at healthcare provider organizations to trust an AI system that health systems want to implement, transparency is key. The ability to provide feedback is also essential, "like a post-marketing surveillance of drugs," when AI is involved in decision-making so that developers can fine-tune systems, Middleton said on HIMSSCast in June.
Knowing what the training data and update cycles are behind the LLM is vital because clinical decision-making with AI is a "green" field.
However, he said, "My belief is that we will have – in the healthcare delivery scenario – we will have many systems running concurrently."
ON THE RECORD
"Mass General Brigham sees great promise for LLMs to help improve care delivery and clinician experience," Dr. Adam Landman, chief information officer and senior vice president of digital at MGB and study co-author, said in a statement.
Andrea Fox is senior editor of Healthcare IT News. Email: [email protected] Healthcare IT News is a HIMSS Media publication.
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Sikorsky Product History
Sikorsky s-72 rotor systems research aircraft (rsra).
The Rotor Systems Research Aircraft was a unique vehicle created to test advanced helicopter rotors in flight. The idea was to provide a capability to more fully explore the in-flight performance of new main rotor designs prior to committing them to a prototype or production helicopter program. Prior to the initiation of the RSRA program, new rotor configurations could only be tested in full scale on a stationary whirl stand or in a large scale wind tunnel. Because of these test envelopment limitations, there always was risk associated with new rotor configuration when they were first flow on the helicopters for which they were designed. To reduce this risk, NASA and the Army concluded that a test aircraft dedicated to safely explore the performance, stability boundaries and loads generated by a new rotor throughout its flight envelope would be worth developing. Having such an aircraft would also encourage the design and flight test of unique rotor configurations that would extend rotary wing technologies. These considerations are what launched the RSRA in the early 1970s.
In the summer of 1971, NASA and the Army put out an RFP for a “Rotor Test Vehicle Predesign Study”. Sikorsky and Bell responded to this RFP and were awarded nine-month study contracts. A primary requirement was to determine what was practical for such a vehicle and how to minimize development cost and risk.
In July 1972 Sikorsky reported to NASA and the Army on the results of the Predesign study. By now the aircraft were known as “Rotor Systems Research Aircraft”, or RSRA. To keep program costs down as much as possible, the use of existing aircraft or components was encouraged. The size of the test aircraft was defined by a requirement that all rotors to be tested had to be small enough to fit in the NASA Ames 40 x 80 wind tunnel. The aircraft itself had to be mountable in the 40 x 80 tunnel.
Sikorsky’s design included a new fuselage with the dynamic system from a 3700 horsepower “roller” gearbox then under development at Sikorsky under an Army contract. It used General Electric TF-34 turbofan engines for auxiliary propulsion. It had two interchangeable wings, one with a 348 sq. ft. area and a 45.7 ft. span for the 100 to 200 knot speed range, and one with a 184 sq. ft. area and a 33.3 ft. span for speeds up to 300 knots. It included a variable wing incidence; main rotor, tail rotor, wing and auxiliary engine force and moment balance systems; a rotor vibration isolation feature, and a fly-by-wire control system from the pilot’s station. In order to further reduce risk when testing advanced rotors never before flown, a crew escape system, similar to those on fixed-wing aircraft, was included. The desired variable main rotor shaft tilt system was deemed too complex for the value gained, and was eliminated. The aircraft used a fan-in-fin anti-torque system with a series of louvers to cover it up in high speed.
As a result of the Predesign Studies and other analysis done by the parties, NASA and the Army released an RFP for the RSRA program in 1973. On May 15, 1973 Sikorsky submitted its proposal. Although quite similar to the Predesign study aircraft, some practical changes had been made. It had been desired to use the TF-34 engine installation from the Fairchild-Republic A-10, with its side-mounted General Electric turbofan engines. This did not work out contractually, so the top-mounted TF-34 installation from the Lockheed S-3A was substituted, requiring a rather awkward curved mounting structure to be included on the aircraft. The 3700 horsepower roller main gearbox development program had not proceeded as planned, and a production SH-3 2500 horsepower main gearbox was proposed. The Predesign study fan-in-fin anti-torque system, which had been under a then-terminated separate development program, was no longer practical within program costs, and a conventional tail rotor was used. The remainder of the design was virtually the same as shown in the Predesign study.
Sikorsky won the RSRA contract and initiated the design and fabrication of two aircraft.
Initial flight tests were conducted at the Sikorsky factory in Stratford Connecticut. In July 1977, the first aircraft was flown to NASA’s Wallops Island Flight Test Facility on Virginia’s eastern shore. The flight testing was done there since it was a large NASA-controlled facility with fixed-wing runways which would be needed for some compound mode flight testing. It was also convenient to the NASA Langley facility, which had the NASA lead on the project, and to the Army’s Ft. Eustis, the Army’s lead facility on the program. Sikorsky had a team of approximately twenty engineers, technicians, and pilots stationed at Wallops. NASA and the Army also had a staff on sight for the test program.
One of the most interesting facets of the RSRA was the crew escape system. Although it couldn’t be tested in flight, the full system was tested at the Air Force test facility at Holloman Air Force base in New Mexico. In November, 1977 the first flight with the fully qualified escape system took place.
The first flight in the full compound configuration took place on April 10, 1978. After Sikorsky completed the contractor development tests on it, aircraft #2 was delivered to NASA Ames in the fall of 1978. Aircraft #1 continued its test program at Wallops Island, with the rotor vibration isolation system installed.
The Sikorsky flight test phase was concluded on August 17, 1979. The aircraft had flown a total of 60.1 flight hours performing necessary development tests and opening up the envelope to that required by the Government for initial NASA/Army tests. In September RSRA #1 was delivered to NASA Ames to join aircraft #2. At that time, Sikorsky’s contracted RSRA program was concluded, with the exception of final reports and other close-out tasks. NASA did contract with Sikorsky for two years of flight test support at Ames.
By the early 1980s both NASA and the Army were directing the majority of their rotary wing research funding to the tilt rotor concept. With the exception of a few minor tests this brought the RSRA program to a halt before it was able to perform its intended tasks.
RSRA was soon reincarnated as the test vehicle for the X-Wing concept. X-Wing used a rigid four bladed rotor which was stopped in flight to become an “X” wing. The critical technology was the rotor starting and stopping sequence. With the RSRA’s fixed wing, which allowed initial start/stop conversions without requiring the rotor/wing to maintain lift, the RSRA was the ideal test vehicle for X-Wing. The X-wing program is described separately in this Sikorsky product history.
The RSRA fuselage was all new, designed for low drag and for the high dynamic pressures required to fly up to the 340 knot maximum structural design speed. It had a two man side-by-side cockpit and a flight test engineer’s station in the cabin. The cabin was approximately six feet long and also accommodated test equipment on racks along the aft bulkhead. Large drag brakes were included on the lower empennage.
The drive system was taken directly from Sikorsky’s SH-3/S-61 series of aircraft. The delivered rotor was also taken from the SH-3/S-61. This rotor was, of course, to be used only for the initial shake-down flight testing. Once the aircraft was delivered and checked out by NASA/Army, new rotors were to be installed
The flight controls were fly-by-wire from the evaluation pilot’s station (left side of the cockpit). Although the sticks and pedals looked conventional, they were not connected mechanically to the aircraft control system. An electronic connection was made to the safety pilot’s controls on the right crew station. Thus the second pilot became the back-up or safety pilot if the electronic controls were not functioning as designed. Digital computers were used to modify and augment the inputs from the evaluation pilot’s controls as desired by the testing being done, before they were inputted into the safety pilot’s mechanical controls. The flight control computers also controlled, with limited authority, numerous other actuators in the mechanical control system.
The concept of two wings, one for medium speed and one for high speed, from the Predesign study was found not to be required. A single large variable incidence wing with high-lift devices was provided to offload the rotor in forward flight or, with negative incidence, to overload the rotor in level flight. The wing was easily removable for testing as a basic helicopter. The TF-34 auxiliary engines provided horizontal propulsion to test rotors when they were not producing the horizontal thrust necessary for level flight. These also had to be easily removed. A variable high-drag device was included in the tail to overload the rotor’s forward thrust requirements
General Arrangement Drawing
The main transmission was mounted on a force/moment measuring system to give accurate data for the rotors being tested. Seven load cells were mounted in orthogonal directions to provide data in aircraft coordinates. Necessary redundancy was included in the attachment of the transmission mounting frame to the fuselage
An alternate transmission mounting system added vibration isolators between the mounting frame and the fuselage. This was a “focused pylon” system with ground adjustable cant angles and variable spring rates for tuning and attenuation, with control of the resulting static displacements being provided by servo controlled hydraulic centering. Four inplane soft isolators and four nominally vertical load cells were used. An alternate design for other types of rotors used seven soft isolators.
The wing was mounted low and included the variable incidence feature, with in-flight variation from 15 degrees nose up to 9 degrees nose down. This mounting system also included accurate load cells to measure wing forces and moments
One of the truly unique features of the RSRA was the inclusion of a crew escape system. This was designed to be similar to those used on fixed wing aircraft, but had to deal with the rotating rotor overhead blocking safe extraction of the flight crew. It had been determined that trying to eject the crew downward would not be acceptable due to human factors issues plus the need for RSRA to operate on many flights close to the ground.
Thus, a blade severance system was developed. This used shaped explosive charges around the blade roots to sever the blade spars and blow the blade away from the aircraft. To assure that no blade was thrown forward where the extracting pilots might hit it, or aft where it might strike the empennage, a two stage blade severance was used. On the five bladed baseline rotor, first three blades were severed, being flung to the sides of the aircraft. After another 72 degrees of rotation the last two blades were also thrown to the sides. The crew extraction system itself was developed by Stanley Aviation, Inc. using small rockets which pulled the crewman up out of the aircraft, rather than the more conventional rocket mounted on the seat itself, as is used in most fixed wing applications
Although this system could not be practically tested in flight, it did undergo numerous ground tests which culminated in a full system test at speed being conducted on the Holloman Air Force Base “Long Track” in New Mexico. The RSRA system became the first and only crew escape system qualified for use on a flight rotary wing vehicle.
General Characteristics and Performance
The mission of the RSRA was to test advanced rotors through the full range of their lift and horizontal thrust envelope.
After delivery to NASA/Army the aircraft were used for some minor rotor tests. The major test program involved the development of the X-wing. This involved a four bladed rotor which was stopped in flight to become a fixed “X” wing. The X wing is the subject of a separate section of this Sikorsky Product History. An interesting part of the X-wing program was flying the RSRA without a rotor. This was to prove that the RSRA could be used for X-wing starting and stopping tests, where rotor lift would be zero. It also demonstrated the first Sikorsky designed fixed wing aircraft since the days of the flying boats.
Additional Information Sources
American Helicopter Society paper Fifty Years of Sikorsky High Speed Concepts, Arthur W. Linden. Presented at the 64th AHS Annual Forum, Montreal, Canada, April 29 – May 1, 2008.
- by Art Linden
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National Longitudinal Study of the High School Class of 1972 is a large, diverse, nationally representative cohort study that began with a random sample of American high school seniors in 1972. Follow-up surveys were conducted between 1973 and 1986. The sixth follow-up survey will begin in 2024, with participants who will then be ~70 years old. Read more .
High School and Beyond launched another nationally representative, longitudinal cohort study that succeeded NLS-72 in 1980 with high school seniors and sophomores. Follow-up surveys were conducted between 1982-1993 and most recently, the 5th follow-up in 2015 and 6th follow-up in 2022 were completed. Read more .
This material is based upon work supported by the Alfred P. Sloan Foundation under grant number 2012-10-27; the National Science Foundation under grants numbers HRD 1348527, HRD1348557, DRL 1420691, DRL 1420572, and DRL 1420330; the Institute of Education Sciences (IES) under grant numbers R305U140001 and R305U180002; the National Institute on Aging under grant number R01AG058719-01A1 and 1R01AG078533-01, the Alzheimer’s Association under grant number SG-20-717567, and the Spencer Foundation under grant numbers 201500075 and 20160116. This project also benefited from support by the Eunice Kennedy Shriver National Institute of Child Health and Human Development under grant numbers 5 R24 HD042849 and P2CHD042849 (University of Texas Population Research Center), 5R24HD041023 (University of Minnesota Population Center), and P2C HD047873 (University of Wisconsin Center for Demography and Ecology) and from the National Institute on Aging under grant number P30AG066614 awarded to the Center on Aging and Population Sciences at The University of Texas at Austin.
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New Research: This Activity Can Reduce the Risk of Metastatic Cancer by 72%
By Tel-Aviv University December 19, 2022
The researchers discovered that high-intensity aerobic exercise increased the consumption of glucose reducing the amount of energy available to the tumor.
Exercise defeats cancer by increasing glucose consumption.
According to recent Tel Aviv University research, aerobic exercise can significantly lower the chance of developing metastatic cancer by 72%. The researchers found that high-intensity aerobic exercise increased internal organs’ consumption of glucose (sugar), decreasing the amount of energy available to the tumor.
Professor Carmit Levy. Credit: Tel Aviv University
Professor Carmit Levy from the Department of Human Genetics and Biochemistry and Dr. Yftach Gepner from the School of Public Health and the Sylvan Adams Sports Institute at TAU’s Sackler Faculty of Medicine conducted the study. Prof. Levy notes that the new research has resulted in a very important discovery by merging scientific know-how from different schools at TAU, which may help avoid metastatic cancer, Israel’s top cause of death. The study was recently published on the cover of the journal of Cancer Research .
Prof. Levy and Dr. Gepner: “Studies have demonstrated that physical exercise reduces the risk for some types of cancer by up to 35%. This positive effect is similar to the impact of exercise on other conditions, such as heart disease and diabetes. In this study we added new insight, showing that high-intensity aerobic exercise, which derives its energy from sugar, can reduce the risk of metastatic cancer by as much as 72%. If so far the general message to the public has been ‘be active, be healthy’, now we can explain how aerobic activity can maximize the prevention of the most aggressive and metastatic types of cancer.”
The research combined an animal model in which mice were trained under a strict exercise routine with data from healthy human volunteers who were evaluated before and after running. The human data, obtained from an epidemiological study that monitored 3,000 individuals for about 20 years, indicated 72% less metastatic cancer in participants who reported regular aerobic activity at high intensity, compared to those who did not engage in physical exercise.
The animal model exhibited a similar outcome, also enabling the researchers to identify its underlying mechanism. Sampling the internal organs of the physically fit animals, before and after physical exercise, and also following the injection of cancer, they found that aerobic activity significantly reduced the development of metastatic tumors in the lymph nodes, lungs, and liver. The researchers hypothesized that in both humans and model animals, this favorable outcome is related to the enhanced rate of glucose consumption induced by exercise.
Prof. Levy: “Our study is the first to investigate the impact of exercise on the internal organs in which metastases usually develop, like the lungs, liver, and lymph nodes. Examining the cells of these organs we found a rise in the number of glucose receptors during high-intensity aerobic activity – increasing glucose intake and turning the organs into effective energy-consumption machines, very much like the muscles.”
Dr. Yftach Gepner. Credit: Tel Aviv University
She continues, “We assume that this happens because the organs must compete for sugar resources with the muscles, known to burn large quantities of glucose during physical exercise. Consequently, if cancer develops, the fierce competition over glucose reduces the availability of energy that is critical to metastasis. Moreover, when a person exercises regularly, this condition becomes permanent: the tissues of internal organs change and become similar to muscle tissue. We all know that sports and physical exercise are good for our health. Our study, examining the internal organs, discovered that exercise changes the whole body so that the cancer cannot spread, and the primary tumor also shrinks in size.”
Dr. Gepner adds: “Our results indicate that unlike fat-burning exercise, which is relatively moderate, it is a high-intensity aerobic activity that helps in cancer prevention. If the optimal intensity range for burning fat is 65-70% of the maximum pulse rate, sugar burning requires 80-85% – even if only for brief intervals. For example, a one-minute sprint followed by walking, then another sprint. In the past, such intervals were mostly typical of athletes’ training regimens, but today we also see them in other exercise routines, such as heart and lung rehabilitation. Our results suggest that healthy individuals should also include high-intensity components in their fitness programs.”
He concludes, “We believe that future studies will enable personalized medicine for preventing specific cancers, with physicians reviewing family histories to recommend the right kind of physical activity. It must be emphasized that physical exercise, with its unique metabolic and physiological effects, exhibits a higher level of cancer prevention than any medication or medical intervention to date.”
Reference: “An Exercise-Induced Metabolic Shield in Distant Organs Blocks Cancer Progression and Metastatic Dissemination” by Danna Sheinboim, Shivang Parikh, Paulee Manich, Irit Markus, Sapir Dahan, Roma Parikh, Elisa Stubbs, Gali Cohen, Valentina Zemser-Werner, Rachel E. Bell, Sara Arciniegas Ruiz, Ruth Percik, Ronen Brenner, Stav Leibou, Hananya Vaknine, Gali Arad, Yariv Gerber, Lital Keinan-Boker, Tal Shimony, Lior Bikovski, Nir Goldstein, Keren Constantini, Sapir Labes, Shimonov Mordechai, Hila Doron, Ariel Lonescu, Tamar Ziv, Eran Nizri, Guy Choshen, Hagit Eldar-Finkelman, Yuval Tabach, Aharon Helman, Shamgar Ben-Eliyahu, Neta Erez, Eran Perlson, Tamar Geiger, Danny Ben-Zvi, Mehdi Khaled, Yftach Gepner and Carmit Levy, 15 November 2022, Cancer Research . DOI: 10.1158/0008-5472.CAN-22-0237
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10 comments on "new research: this activity can reduce the risk of metastatic cancer by 72%".
Interesting study, it seems to go along with High intensity training would be to lower if not completely get rid of any added sugar in our diet. I believe KETO diet will help tremendously in this area.
Most profoundly encouraging research findings ever put in print and again confirming simplicity as the impetus of longevity
I wonder if the article mixed up aerobic with anaerobic. Description of HITT like exercises would be anaerobic…. The difference between aerobic and anaerobic exercise: Slower-paced exercises like jogging or endurance cycling are examples of aerobic exercise. Fast-paced workouts like sprinting, high-intensity interval training (HIIT), jumping rope, and interval training take the more intense approach of anaerobic exercise.
It would be interesting if the researchers compared the incidence of metastatic cancer against people with type 1 and type 2 diabetes.
Or don’t eat sugar…this article isn’t going to make women go to the gym. Why don’t you say cancer cells feed off of glucose?
Yes it confirms the link between more challenging life style choices and healthy living. When and if available
This is wonderful information. And I daresay men and women will make adjustments to their workout regime knowing interval and high paced aerobics have this sort of impact on cancer!
It is pretty clear that mall walking is not enough. Also gentle yoga or chair exercises. Getting to 80% of your heart beat capacity is probably unreachable for many but perhaps the way to start is to do short burst of faster paces.
To people who say just don’t eat sugar, our bodies are going to convert food into glucose, and fat as energy will still feed cancer. Carbohydrates, even complex ones, break down into glucose. I have recently had surgery for a malignant tumor that was the worst kind. Since the surgery was very successful and appears to have removed the entire tumor, I am just being monitored for metastasis. This article is one of the first I’ve read that gives me something concrete I can do to help prevent metastasis, beyond “eat healthy and exercise.”
Is the state of ketosis produced by an Atkins-style diet also anti-metastatic?
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How to Design a Qualitative Health Research Study. Part 1: Design and Purposeful Sampling Considerations
- 1 RN, MScN, PhD, School of Nursing, Dept. of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy. Email: [email protected].
- 2 RN MScN PhD student, School of Nursing, McMaster University, Hamilton, Ontario, Canada.
- 3 RN, PhD student, School of Nursing, McMaster University, Hamilton, Ontario, Canada.
- 4 RN, MScN PhD, School of Nursing, Dept. of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.
- 5 RN, PhD, School of Nursing, McMaster University, Hamilton, Ontario, Canada.
- PMID: 31550432
Abstract in English, Italian
In this first part of the article, we aim to provide health researchers with an understanding of how to design a qualitative health research study, including: topic identification, design selection, and engagement in reflexivity. We offer practical guidance for writing an overarching question using a novel framework that helps develop a clearly articulated question that includes the following elements: emphasis, purposeful sampling, phenomenon of interest, and context. We then expand on specific methodological issues: study designs, contexts, sampling, and recruitment. Finally, we provide examples of qualitative health research studies that illustrate the application of different research designs. In part two of this article, we will discuss how to prepare for going into the field, how to generate, manage and analyse data, and plan for the dissemination of qualitative health research.
Attraverso le nostre esperienze di insegnamento della ricerca qualitativa agli studenti in varie discipline sanitarie, abbiamo concluso che molti ricercatori alle prime armi richiedono un supporto chiaro, pratico e focalizzato per sviluppare protocolli di ricerca. In questa prima parte di articolo, miriamo a fornire ai ricercatori sanitari una comprensione di come proget- tare uno studio qualitativo sulla ricerca sanitaria, tra cui: identificazione dell’argomento, sele- zione del disegno e del coinvolgimento nella riflessività. Offriamo una guida pratica per scri- vere una domanda utilizzando una nuova framework che aiuta a sviluppare una domanda chiaramente articolata che include i seguenti elementi: enfasi, campionamento propositivo, fenomeno di interesse e contesto. Quindi, esponiamo questioni metodologiche specifiche: disegno di studio, contesti, campionamento e reclutamento. Infine, forniamo esempi di studi qualitativi di ricerca sanitaria tratti dalla letteratura. Nella seconda parte dell’articolo, discu- teremo come prepararsi per andare sul campo, come generare, gestire e analizzare i dati e pianificare la diffusione della ricerca qualitativa sanitaria.
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The capstone enables students to demonstrate mastery of disciplinary knowledge in their field in the context of resolving a substantial industry or workplace issue. Students reflect critically on theory and professional practice to identify an issue, develop a research question, source and critically analyse literature and data, formulate findings, and produce a series of meaningful recommendations. The completed project demonstrates students’ ability to apply knowledge and skills with a high level of personal autonomy and accountability, and articulate original ideas and thought processes to make a practical contribution to the existing body of knowledge relevant to their profession. In preparing a written report, and making a presentation of their process and outcomes, students demonstrate professional-level competence.
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