Modeling Clinical Concern Trajectories in Language Model Agents

Large Language Models (LLMs) show great potential as clinical agents, yet existing benchmarks reduce clinical workflows to static predictions or unconstrained Markov Decision Processes (MDPs) with coarse action sets. To address this, we introduce GPAgentBench-2K, the first Constrained MDP (CMDP) LLM-agent benchmark for primary-care clinical decision-making, constructed from expert-validated records of real-world GP encounters. Our environment models a full spectrum of six foundational clinical actions, imposes a topological workflow prior over the action space, and operationalizes safety-informed abstention as a first-class outcome. Evaluating 16 state-of-the-art LLMs reveals a significant performance degradation as the action space scales. Crucially, we uncover a clinical quality-safety gap: even frontier models with the highest diagnosis accuracy violate safety constraints in over half of high-risk cases. Finally, we establish a reference point using Constrained Group Relative Policy Optimization (C-GRPO), and show that while explicitly modeling constraints improves performance over unconstrained RL methods, it remains far from clinically acceptable safety.

Sepsis management in the ICU requires sequential treatment decisions under rapidly evolving patient physiology. Although large language models (LLMs) encode broad clinical knowledge and can reason over guidelines, they are not inherently grounded in action-conditioned patient dynamics. We introduce SepsisAgent, a world model-augmented LLM agent for sepsis treatment recommendation. SepsisAgent uses a learned Clinical World Model to simulate patient responses under candidate fluid--vasopressor interventions, and follows a propose--simulate--refine workflow before committing to a prescription. We first show that world-model access alone yields inconsistent LLM decision performance, motivating agent-specific training. We then train SepsisAgent through a three-stage curriculum: patient-dynamics supervised fine-tuning, propose--simulate--refine behavior cloning, and world-model-based agentic reinforcement learning. On MIMIC-IV sepsis trajectories, SepsisAgent outperforms all traditional RL and LLM-based baselines in off-policy value while achieving the best safety profile under guideline adherence and unsafe-action metrics. Further analysis shows that repeated interaction with the Clinical World Model enables the agent to learn regularities in patient evolution, which remain useful even when simulator access is removed.

As large language model (LLM) agents increasingly invoke external tools and interact with real-world systems, unsafe actions may cause irreversible consequences on external states, user data, and downstream services. Recent runtime guardrails mitigate such risks by checking proposed actions before execution, but many remain reactive: they primarily assess the apparent safety of the current action, lacking an explicit model of how risk evolves across the trajectory. This limitation creates a critical blind spot for long-horizon risks, where individually benign-looking actions can gradually drift the agent toward hazardous states. In response, we propose DreamGuard, a proactive guardrail for LLM agents built around a risk-aware world model. The world model maintains a compact recurrent latent state over the trajectory and predicts future latent states from which DreamGuard derives immediate-hazard and prefix-risk evidence. It then fuses these multi-horizon signals into intervention decisions before execution. Experiments across four benchmarks and an online guardrail evaluation show that DreamGuard outperforms generic, reactive, and proactive guardrail baselines, achieves the best safety-utility trade-off among evaluated guardrails, and maintains an average end-to-end latency of 25 ms per call.