Beyond Federated Learning: Decentralized Agentic Systems for Self-Evolving Clinical Intelligence

Clinical expertise is inherently distributed: it resides not in any single dataset or institution but in the accumulated reasoning experiences of thousands of clinicians navigating diverse patient populations, resource constraints, and evolving treatment protocols. Yet current approaches to scaling medical AI, from centralized large language models to federated learning, remain anchored to a data-centric paradigm that treats knowledge as static parameters to be aggregated. In this Perspective, we argue for a fundamental shift from data aggregation to experience aggregation. We propose Decentralized Agentic Systems (DAS), a framework in which distributed AI agents operating across healthcare institutions synthesize collective clinical intelligence by sharing abstracted reasoning trajectories rather than raw data or model parameters. Unlike federated learning, which averages numerical gradients across homogeneous model architectures, DAS exchanges structured records of clinical reasoning, specifically the sequence of observations, hypotheses, tool invocations, and outcome feedback that constitute diagnostic experience. We examine the architectural principles, deployment considerations, governance requirements, and critical open challenges of this framework, laying the groundwork for a collaborative medical AI ecosystem where distributed expertise autonomously adapts to the complexities of longitudinal patient care.