Framework for Grounding Healthcare LLMs in a Causal Knowledge Graph: A Cardiovascular Example Pilot

A recent Nature Medicine study reports that general-purpose frontier LLMs outperform specialized retrieval-augmented clinical tools on medical benchmarks, and that retrieval can hurt strong models. We ask the natural follow-up: does structured knowledge-graph (KG) grounding change this, and when does grounding help at all? We contribute two results. First, a reproduction: the study's headline HealthBench score (~88) is the Consensus variant, not full HealthBench, where frontier models and ideal completions both score ~46-47 under a physician-calibrated grader (agreement 82.5%); we reproduce GPT-5.2 Consensus =90.9 and flag a score-deflating grader bug. Second, a knowledge-boundary result. Using a graph+vector engine (samyama-graph) over the public biomedical KG PrimeKG, neither naive triple retrieval nor an agentic natural-language-to-Cypher loop (82% successful queries) improves MedQA across a weak-to-strong model ladder (all |Delta| <= 3.4). On a synthetic counterfactual KG, and on a hybrid benchmark mixing known and novel facts, the identical pipeline lifts out-of-training accuracy from chance to ~100% (+68 to +79) while adding nothing on known facts (a no-LLM arm answers both). Across three regimes (no-knowledge, graph-aided, hybrid), grounding helps only insofar as the decisive fact lies outside the model's training -- public-KG facts are redundant, private and novel data are where it pays -- matching the study's institutional-data caveat.

Causal discovery is a cornerstone of scientific reasoning, yet whether large language models can perform it reliably remains an open question. Recent benchmarks show that even fine-tuned models plateau on simple causal graphs and degrade as complexity grows, but why they fail has not been established. We prove the failure is fundamental: supervised fine-tuning, direct preference optimization, and in-context learning all produce predictors that cannot distinguish between causal graphs generating similar observational data, and any attempt to do so requires the model's internal representations to grow unboundedly, violating the very conditions under which these methods work. We formalize this as a kernel obstruction theorem, establishing that the limitation is intrinsic to the learning paradigm, not any particular model or dataset. We propose Agentic Causal Bayesian Optimization (A-CBO), wherein a frozen language model serves as an interventional oracle answering targeted queries about intervention effects, while an external Bayesian loop concentrates beliefs over candidate graphs in logarithmically many rounds. Because the decision operates outside the space where the obstruction applies, A-CBO provably converges while the underlying model remains unchanged. On Corr2Cause, A-CBO matches fine-tuned baselines without any training. On Extended Corr2Cause, a new benchmark scaling to 24 variables with 18K test samples, A-CBO significantly outperforms both fine-tuning and preference optimization, with the advantage growing

Modern large language models (LLMs) reach 60-70% diagnostic accuracy on complex clinical case benchmarks, but accuracy alone cannot distinguish stable clinically-grounded reasoning from pattern matching. We introduce clinical reasoning graphs, structured graph representations extracted from free-text LLM diagnostic traces using a domain-grounded ontology with 5 node types and 7 edge types. We apply this pipeline to 750 traces from five LLMs across 50 New England Journal of Medicine Clinicopathological Conference cases and three prompt conditions, and test whether diagnostic traces show stable structured reasoning patterns, or diagnostic schemas, for clinically similar cases. We operationalize this as higher graph similarity among clinically similar cases than among clinically dissimilar ones. Across 15 model-condition comparisons, within-cluster and between-cluster composite similarity are nearly equal, and no comparison survives multiple-testing correction; a component-level analysis finds any residual content signal far below schema scale. Graph similarity is also nearly identical for pairs of models that are both correct (0.488) and both incorrect (0.484), suggesting that graph structure captures a dimension not reflected in diagnostic accuracy. Structured reflection prompting increases explicit discriminating-feature analysis within traces (+33%) but does not increase cross-case consistency. These results show diagnostic competence without schema-scale reasoning consistency, and indicate that final-answer accuracy should be complemented by process-level evaluation. We release the ontology, extraction pipeline, validation protocol, and the extracted reasoning graphs and similarity artifacts as resources for structured evaluation of LLM clinical reasoning.