Clinical Decision-Making

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17 papers in the last four weeks, up 325% on the four weeks before. 0.2% of all new papers.

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Jul 25, 2026cs.AI

RareLens: Towards End-to-End Rare Disease Care via Aligning Divergent Large Language Model Reasoning

Rare diseases represent one of the most challenging settings for clinical decision-making, where heterogeneous presentations, sparse evidence and limited expertise create persistent uncertainty throughout the care pathway. Although artificial intelligence could help, existing systems largely address isolated tasks, particularly diagnosis, and usually rely on downstream investigations rather than information available at initial presentation. Here we show that clinical AI performance under uncertainty can be improved not by scaling a single model, but by exploiting the diversity of multiple imperfect reasoning systems. Across heterogeneous large language models, we identify divergent reasoning trajectories with complementary error patterns and develop RareLens, which learns to reconcile these perspectives into actionable decisions across four stages of rare disease care: risk screening, diagnosis, treatment planning and prognosis prediction. Built on RarelensBench, a real-world dataset of 157,525 cases spanning all 33 Orphanet categories and more than 7,000 conditions, RareLens outperformed every frontier model tested, including GPT-5, DeepSeek-R1, Claude-3.7-Sonnet and Gemini-2.5-Pro, across all stages. It achieved an area under the curve of 0.917 for screening and top-1 accuracies of 65.5% and 89.8% for diagnosis and treatment. In an external evaluation involving 1,287 cases and 23 physicians, autonomous RareLens and physicians assisted by RareLens both outperformed unaided physicians, while demonstrating that effective human-AI collaboration requires more than simply providing model outputs. These findings establish divergent model reasoning as an exploitable source of information and suggest a general strategy for building AI systems that operate reliably under high clinical uncertainty.

Xi Chen, Hongru Zhou, Shiyu Feng +24

Sports Medicine Center, Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China · Center for Cleft Lip and Palate Treatment, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China · School of Data Science, The Chinese University of Hong Kong, Shenzhen (CUHKSZ), Shenzhen, China +13

Rare Disease DiagnosisHealthcareClinical Decision-MakingLanguage Model EnsemblesClinical Risk Prediction
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Jul 22, 2026cs.LG

Bayesian uncertainty estimation improves clinical decision making in medical AI agents

Machine learning models for medical image analysis typically lack a reliable measure of confidence, limiting their use in ambiguous or atypical cases. Here we show that Monte Carlo dropout, applied to a multi-task chest-radiograph classifier (eight thoracic findings, 137,593 training images), provides an epistemic uncertainty signal that tracks generalisation across training-set scales and flags confident yet error-prone predictions. Adding this signal to the point prediction raised error-detection AUROC from 0.74 to 0.77 (ΔΔAUROC +0.023, 95% CI [+0.014, +0.033]). In a controlled 2x2 factorial experiment, a clinical-decision-support agent exploited this uncertainty only when it was delivered as a binary error-risk flag rather than as raw scores, cutting confident misdiagnoses on unreliable findings from 8.5% to 2.7%. Epistemic uncertainty estimation thus carries decision-relevant information beyond point predictions, but its value for downstream agents depends on how it is communicated.

Frederik Hauke, Patrick Wienholt, Christiane Kuhl +4

Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany. · Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Heidelberg, Germany. · Else Kröner Fresenius Center for Digital Health, TU Dresden, Dresden, Germany. +1

Clinical Decision SupportClinical Decision-MakingEpistemic Uncertainty
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Jul 12, 2026cs.LG

Policy-Driven CT-Agent: Modeling Phase-Aware Diagnostic Control for Clinically Consistent CT Reasoning

Computed Tomography (CT) diagnosis often relies on dynamic selection of imaging phases, such as non-contrast, arterial, or venous phases, based on preliminary findings, clinical suspicion, and diagnostic guidelines. This phase-wise decision process is critical for reducing unnecessary radiation exposure while supporting timely staging and treatment planning. However, phase-selection protocols can vary across hospitals, regions, and guidelines, while most existing CT-based AI methods assume that all phases are available and focus on static tasks under a fixed imaging phase, failing to model whether additional phases are required. This limitation stems from heterogeneous multi-phase representations, the need for knowledge-guided phase control beyond visual cues, and the lack of supervision for phase-sufficiency decisions in existing datasets. To address these challenges, we propose Policy-Driven CT-Agent (PD-CTAgent) for clinically consistent CT phase selection and diagnostic reasoning. PD-CTAgent introduces a Clinical Structure Abstraction Module (CSAM) to harmonize heterogeneous CT phases into a unified, phase-aware evidence representation. Based on this representation, a Knowledge-Guided Diagnostic Control Model (KDCM) evaluates phase sufficiency and iteratively requests additional phases when necessary. The policy-driven agent design further allows PD-CTAgent to flexibly follow different institutional, regional, or guideline-specific diagnostic protocols. Together, PD-CTAgent bridges static CT analysis and real-world clinical workflows. Experiments on two public datasets, LIDC and MCT-LTDiag, and one private dataset demonstrate its effectiveness and clinical consistency. Code will be made public upon acceptance.

Yanmeng Dong, Han Li, Yujia Li +7

University of Science and Technology of China · Technical University of Munich

Clinical Decision SupportClinical Decision-MakingComputed TomographyAgentic AI
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Jul 10, 2026cs.AI

LongMedBench: Benchmarking Medical Agents for Long-Horizon Clinical Decision-Making

In this work, we introduce LongMedBench, a real-world EHR-based benchmark for long-horizon clinical decision-making. Prior evaluations of LLM-based medical agents have largely emphasized short-context knowledge QA and tool use. However, real-world medical care is inherently longitudinal, and clinicians must aggregate evidence across repeated visits, tests, and evolving treatments. Therefore, long-horizon interaction is essential for realistic assessment. LongMedBench is constructed via a reproducible pipeline that integrates MIMIC-IV admission records and clinical notes into time-series event streams and long-context memory datasets, enabling long-horizon, multi-session interactions between agents and a clinical environment. It comprises 335 patients, with 19.72 inpatient visits per patient on average and 44.91 medical events per visit. Guided by the long-horizon decision process, we propose an evaluation taxonomy with three suites: fact-based QA, temporal reasoning, and long-horizon decision-making. This taxonomy measures how agents understand and leverage historical patient information over extended horizons. Our experiments show that while recent LLMs can make good use of explicit timestamps, they have challenges in implicit time inference; The RAG and agent memory system can improve the performance of information retrieval tasks, but the performance of decision-making tasks is highly dependent on the model's immediate context.

Zihan Xu, Yanzhen Chen, Xiaocheng Zhang +4

Zhejiang University, Hangzhou, China · Alibaba Group, Hangzhou, China · Transvascular Implantation Devices Research Institute, Hangzhou, China

Long-Horizon Agent EvaluationClinical Decision-MakingLongitudinal EHR ModelingAgent Benchmarks
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Jul 10, 2026cs.LG

A Personalized Computational Framework for Assessing the Sufficiency of Partially Observed Data in Healthcare AI models

Achieving early and timely diagnosis and treatment for disease is a major challenge. Recent applications of machine learning (ML) algorithms trained on patient data have shown promise in many different settings for predicting the patient health state. A challenge often faced when applying these ML algorithms is that at any given time, not all clinical variables (features) needed as input to perform prediction tasks are available. We define the concept of full-feature-capacity (FFC) to refer to prediction performance when such algorithms make use of all features on which they were trained. We then introduce Feature Sufficiency Analysis (FSA) - an analysis for determining whether a subset of all clinical features needed by an AI model is sufficient to achieve FFC. FSA estimates the underlying distributions of missing variables conditioned on features that are available. FSA provides a patient-specific assessment of whether the existing set of measured features achieves FFC. If yes, then there is no need to acquire further inputs and a ML-based prediction. We provide two case studies: prediction of need for postoperative prolonged ventilation in patients recovering from heart surgery; 10-year mortality prediction in an outpatient cohort. We also demonstrate that FSA also provides a clinically interpretable feature-ranking methodology based on prediction sufficiency, identifies intrinsically hard-to-predict patient populations, and has the potential to perform cost-aware optimization for clinical data acquisition. FSA provides a generic computational approach for determining whether incomplete clinical information is sufficient to support trustworthy AI-assisted clinical decision-making, thereby facilitating the prospective deployment of healthcare AI systems across diverse clinical settings.

Qingchu Jin, Felistas Mazhude, Jamie B. Rabb +3

Roux Institute, Northeastern University, ME USA · MaineHealth Institute for Research, ME USA · MaineHealth, ME USA +3

Learning with Missing DataClinical Outcome PredictionClinical Decision-MakingClinical Risk Prediction
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Jul 2, 2026cs.AI

A rubric-based controlled comparison of frontier language models on expert-authored clinical reasoning tasks

Multiple-choice medical benchmarks are increasingly saturated, and recent rubric-based evaluations such as HealthBench have shown that open-ended clinical performance is far from solved - its "Hard" subset top score remains 32%. We present a small, deliberately difficult evaluation dataset of five clinician-authored clinical scenarios spanning four specialties (anaesthesia, internal/family medicine, emergency medicine, and obstetrics), each accompanied by an atomic, weighted, MECE rubric (25-62 criteria per task; 184 criteria total) authored from a clinician-drafted golden answer. We evaluate three frontier models: GPT 5.4, Claude Opus 4.7, and Gemini 3.1 Pro. Mean rubric pass rates were 0.47 (Claude), 0.38 (GPT), and 0.37 (Gemini). The central finding is an inversion of clinical priority: the highest-weighted (weight-5, critical) criteria passed at only 32.4-41.7%, while low-stakes weight-1 criteria passed at 80-90%. 55 of 108 critical (weight-5) criteria (51%) were satisfied by no model. Three LLM autoraters reproduced expert met/not-met labels on 92.8-94.6% of 552 graded criteria. We position this as a methods-and-preliminary-findings contribution: the five tasks demonstrate a scalable, defensible pipeline ready to develop into a large-scale benchmark.

Samiha A. Ismail, Fan X. Chen, Ali Merali

Prime Analytics Consulting Limited · Talbert House; Thomas More University · MAKZ

Clinical Decision-MakingClinical ReasoningRubric-Based EvaluationClinical Language Model Evaluation
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Jun 27, 2026cs.AI

MedEvoEval: Evaluating Continual Evolution of Doctor Agents through Simulated Clinical Episodes

Doctor agents are moving beyond single-turn answer generation toward evolving clinical decision systems. Within an outpatient episode, they acquire evidence, use examination and consultation resources, and decide when to finalize a diagnosis and management plan. Across episodes, their behavior may change through memory, retrieval, reflection, or other update mechanisms. Current evaluations only partially cover this setting. Fixed-input medical QA benchmarks score final answers from complete inputs, whereas many interactive benchmarks still focus on individual encounters or fixed runs, providing limited support for evaluating how episode-level decisions interact with cross-episode experience. We introduce MedEvoEval, an executable longitudinal evaluation framework based on action-gated simulated outpatient episodes. Each source case is converted into role-specific patient, examination, and manager views; evidence is revealed only through valid actions; and each episode records a structured trace that links observations, actions, final outputs, manager scores, and optional experience write-back. We release a runnable E&D artifact with 700 processed episodes, provenance notes, schemas, an episode runner, scoring scripts, configurations, example logs, analysis code, and trajectory- and step-level derivatives. Experiments show that episode traces expose process costs hidden by final-answer scoring, show how MDT-style consultation reallocates resources, and support longitudinal analyses of memory maturation, held-out transfer, update-stage response, and backward retention. Together, these results show that MedEvoEval provides a concrete basis for evaluating whether doctor agents improve through experience, transfer useful behavior, and retain earlier capabilities over time.

Hui Zhang

Beijing Institute of Technology (BIT), China

Continual Learning for LLM AgentsLong-Horizon Agent EvaluationClinical Decision-MakingAI Agent BenchmarksAutomated Evaluation
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Jun 27, 2026cs.AI

An AI agent for treatment reasoning over a biomedical tool universe

Treatment reasoning underpins every therapeutic decision, integrating disease context, comorbidities, medications, contraindications, and evolving biomedical knowledge to select an appropriate therapy. It is inherently iterative: candidates are weighed against many constraints, revised as evidence emerges, and grounded in verifiable sources. Here we introduce ATHENA-R1, an AI agent for treatment reasoning across all FDA approved drugs since 1939, trained by reinforcement learning over a universe of 212 biomedical tools. At each step it identifies missing information, selects and runs relevant tools, and incorporates the evidence. To train it without human-annotated traces, we build a two-level self-learning framework: multi-agent systems construct the tools, tasks, and reasoning trajectories for supervised fine-tuning, then reinforcement learning with scientific feedback rewards reasoning quality (evidence gathering, grounded tool use, logical non-redundancy). Across five benchmarks of 3,168 drug reasoning tasks and 456 patient treatment cases, ATHENA-R1 outperforms language models and tool-use systems, reaching 94.7% accuracy on open-ended drug reasoning and 82.9% on treatment reasoning, 17.8 and 10.7 points above GPT-5. In blinded evaluations by experts from 28 rare disease organizations, it is preferred over reference models on all criteria, and physicians rated it favorably on complex hospitalized cardiovascular and infectious-disease cases. Adverse-event hypotheses it generated, tested in electronic health records from 5.4 million patients, reached adjusted odds ratios of 1.48-1.84, with no elevation among negative controls. Because it requires knowing what evidence to seek before concluding, treatment reasoning has long been hard for AI; we show it can be reframed as a learnable process of iterative evidence gathering that reinforcement learning can train AI to perform.

Shanghua Gao, Ayush Noori, Richard Zhu +13

Department of Biomedical Informatics, Harvard Medical School, Boston, MA · Department of Engineering Science, University of Oxford, Oxford, UK · The Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute, Boston, MA, USA +16

Clinical Decision-MakingLLM Agent TrainingMedical LLMsRL for Tool Use
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Jun 23, 2026cs.LG

Enhancing Clinician Decision-Making via Uncertainty-Aware Multi-Expert Fusion for Stroke Rehabilitation

Tailoring stroke rehabilitation requires assessing how movements are organized, not merely if they succeed. Currently, this assessment is a rate-limiting bottleneck. Instruments like the Action Research Arm Test (ARAT) compress rich behavioral observations into single ordinal endpoints, discarding the movement-quality details that distinguish recovery from compensation. Automated alternatives typically chase accuracy on noisy, single-observer labels to output opaque scores - a technology-centric approach that rarely reaches clinical practice. To address this, we present xAARA: an engine designed to augment rather than replace clinical judgment. From multi-view video, xAARA returns ARAT assessments with calibrated uncertainty and explanations across task, movement-phase, and movement-quality levels. Treating clinical scoring as an ill-posed inference problem, xAARA composes 692 calibrated multimodal models via a Dynamic Bayesian Network with entropy-based gating. It qualifies results against clinical validity rules and defers low-confidence cases. In 105 stroke survivors (788 exercises), xAARA achieved 94.2% task accuracy (Cohen's kappa=0.934) and 81.3% movement-phase accuracy (kappa=0.727), reducing predictive uncertainty by 96.1% compared to single-clinician scoring. For subjective cases, it matched at least one rater 100% of the time and never returned out-of-range scores. Four independent clinicians validated the assessments and indicated willingness to adopt the system. We argue that principled uncertainty quantification and clinician-aligned explainability are the critical bridges moving automated assessment from technical demonstration to a deployable clinical tool.

Tamim Ahmed, Thanassis Rikakis

Bioemdical Engineering, University of Soutehrn California,, Los Angeles, 90007, CA, USA.

Clinical Decision-MakingMultimodal Model InterpretabilityMultimodal FusionUncertainty Calibration
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Jun 20, 2026cs.LG

Cohort-Anchored Foundation Models for Electronic Health Records: From Risk Scores to Auditable Peer Cohorts

Foundation models have achieved remarkable performance across medical question answering, imaging, and electronic health record (EHR) tasks, yet reliable clinical deployment remains challenging due to limited interpretability, vulnerability to distribution shift, and weak alignment with clinician reasoning. We argue that these limitations arise because existing approaches prioritize representation learning while treating patient comparison as an emergent property rather than a primary source of clinical evidence. To address this gap, we propose CAFM, a Cohort-Anchored Foundation Model framework that elevates patient cohorts to a first-class object throughout the learning pipeline. The framework consists of four stages: deviation-aware data curation, cohort-conditioned pretraining, multimodal cohort alignment, and clinician-in-the-loop refinement. Together, these stages improve data quality, organize representations around clinically meaningful cohort structure, preserve modality-specific relationships, and support auditable clinical decision-making. The framework is compositional and can augment existing EHR foundation models without modifying their underlying encoders. We illustrate CAFM through four clinical case studies spanning acute kidney injury prediction, cardiovascular risk stratification from electrocardiograms, optic neuropathy triage from orbital imaging, and electroretinogram-grounded report generation. We further present five empirically testable hypotheses and identify open challenges in data quality, irregular temporality, multimodal learning, distribution shift, and evaluation beyond predictive accuracy. We argue that explicitly anchoring foundation models to patient cohorts provides a principled path toward trustworthy clinical AI.

Kaiping Zheng

National University of Singapore

Clinical Decision-MakingMultimodal Model InterpretabilityLongitudinal EHR ModelingClinical Risk Prediction
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Jun 16, 2026cs.CY

Agentic AI Enhances Physician Trust in Clinical Decision Making

Medical AI has shifted from reasoning to agentic AI, a new paradigm that autonomously invokes external tools during reasoning, rendering intermediate reasoning steps and tool outputs transparent to users. Although proven to outperform previous models, physician trust in agentic AI remains largely unexplored. To address this, three physicians evaluated 315 multimodal clinical cases quantifying both process-oriented cognitive trust and outcome-oriented behavioral reliance. Comparing agentic AI against non-agentic baselines, physicians exhibited significantly higher cognitive and behavioral trust for the agentic model (P < 0.001). Specifically, on treatment planning tasks, physicians trusted the agentic reasoning most, preferring it in 89.57% of cases. Furthermore, process-oriented cognitive trust is significantly associated with outcome-oriented behavioral reliance (P < 0.001). However, measurable over-reliance on incorrect agentic outputs still exists, highlighting the inherent limitations of decision-logic transparency alone and underscoring the continuous need for rigorous clinician oversight.

Zhiling Yan, Zhe Fang, David J King +10

Department of Computer Science and Engineering, Lehigh University, Bethlehem, PA, USA · Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA · Department of Medicine, Division of Cardiology, University of Florida, Gainesville, FL, USA +4

Clinical Decision-MakingTrust in AIHuman-AI Decision MakingHuman Oversight of AIAgentic AI
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Jun 15, 2026cs.AI

Medical world models: representing medical states, modelling clinical dynamics and guiding intervention policies

Medical diagnosis and treatment are dynamic processes in which patient states evolve over time and clinical interventions alter future outcomes. Although current medical AI can detect disease, estimate risk and generate reports, many systems still return static labels or scores, offering limited insight into how illness may progress or how alternative interventions may reshape its trajectory. Medical world models adapt the world-model idea from artificial intelligence to healthcare by learning internal simulators of patient-state dynamics. Their long-term goal is to help clinicians anticipate deterioration, compare treatment-conditioned futures and tailor care to individual patients. Yet relevant work remains scattered across foundation models, longitudinal modelling, disease simulation, treatment-effect estimation, reinforcement learning and digital twins. To bridge this gap, this review outlines a roadmap for advancing medical AI from isolated diagnosis and prediction toward medical world models that simulate disease evolution and support intervention decisions. This roadmap is organized around three coupled capabilities: patient-state construction, clinical dynamics modelling and intervention decision support. Across representative systems, the comparison highlights what each capability contributes and how partial components can be integrated into more mature perception--dynamics--planning systems. Finally, we identify the challenges involved in turning plausible rollouts into clinically useful simulators. Related literature is available at https://github.com/1999kevin/awesome_medical_world_models.

Ke Liu, Mengxuan Li, Yanyi Bao +4

College of Computer Science, Zhejiang University, Hangzhou, China. · School of Medicine, Zhejiang University, China. · Department of Biomedical Informatics, Harvard University, USA.

World Model LearningClinical Decision SupportClinical Decision-Making
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Jun 11, 2026cs.LG

Attention-Based Estimation of the Individual Treatment Benefit Probability under Dose Variation

Estimating the probability that a treatment outperforms a control for an individual patient, called the Individual Probability of Treatment Benefit (IPTB), offers a clinically intuitive alternative to population-average metrics. However, existing methods for IPTB estimation are largely confined to binary treatment settings, despite the prevalence of dose-varying interventions in clinical practice. We propose a general framework for IPTB estimation with ordinal outcomes under discrete dose assignments, called Dose-AIPTB (Dose Attention-based IPTB). Our approach recasts the problem as binary classification over the unobserved sign of the individual treatment effect, constructing pseudo-labels from covariate-similar pairwise comparisons and aggregating them via attention mechanisms or Nadaraya-Watson kernel regression. This formulation naturally accommodates multiple discrete dose levels, extending beyond the binary treatment paradigm. Through numerical experiments on real-world and synthetic data under covariate shift, varying sample sizes, and heterogeneous outcomes, we demonstrate that attention-based aggregation consistently outperforms kernel alternatives. The framework provides a foundation for personalized dose selection grounded in individual-level benefit probabilities. Codes implementing the model are publicly available at https://github.com/NTAILab/AIPTBDose.

Lev V. Utkin, Andrei V. Konstantinov, Stanislav K. Kogan +2

Peter the Great St.Petersburg Polytechnic University Higher School of Artificial Intelligence Technologies St.Petersburg, Russia

Causal Effect EstimationClinical Decision-MakingIndividualized Treatment Effect Estimation
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Jun 9, 2026cs.AI

Belief-Space Control for Personalized Cancer Treatment via Active Inference

Cancer treatment is at the core a sequential decision-making problem with partial observability, latent patient heterogeneity, and explicit constraints on the budget for medical measurements. Unlike standard Reinforcement Learning (RL) approaches that control state trajectories, cancer treatments permanently modify patients' transition dynamics, changing how states evolve over time. We model cancer treatment as a belief-space planning problem using active inference, deriving an expected free-energy objective that unifies goal-directed control and information acquisition under measurement budgets without. We implement this framework using real clinical cancer data from the AACR Project GENIE Biopharma Collaborative dataset. Results on clinical data demonstrate a simultaneous patient categorization and high treatment efficacy, under real measurement and treatment constraints.

Deniz Sargun, H. Bugra Tulay, C. Emre Koksal

Amazon.com Inc. Palo Alto, CA · HP Inc. Denver, CO · The Ohio State University Columbus, OH

Belief-Space PlanningHealthcareActive InferenceCost-Aware InferenceClinical Decision-MakingOncology
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Jun 5, 2026cs.CL

Beyond English benchmarks: clinical llm evaluation in Brazilian Portuguese

Large Language Models are transforming the support for clinical decision and their application in real scenarios. Yet, most benchmarks are conducted in English, and cross-lingual evaluation is needed to tackle the language gaps in global access. We introduce ClinicalBr, the first bilingual benchmark for clinical decision built from real Brazilian case reports. The corpus contains 2,892 cases drawn from 28 SciELO medical journals, spanning 18 specialties, and is structured as parallel Portuguese-English pairs. Each case supports four evaluation tasks: diagnosis retrieval, differential diagnosis, exam recommendation, and treatment planning. We evaluate four models: MedGemma-27B, Sabiá-4, DeepSeek-R1, and o3-mini, across both languages. The central finding is that the Portuguese-English performance gap is task-dependent, not general. In diagnosis retrieval, English yields a consistent advantage across all models, with +7.5-12.1 accuracy points. This advantage disappears in differential diagnosis, exam recommendation, and treatment planning, where confidence intervals cross zero for most models and Portuguese completeness scores are marginally higher. Brazilian-endemic conditions proved easier than the full corpus, not harder, indicating that tropical presentations are adequately represented in current pre-training. Exam recommendation was the hardest task across all models and both languages, with F1 scores below 0.10, well below the differential diagnosis ceiling of 0.20-0.27.

Giordano de Pinho Souza, Glaucia Melo, Josefino Cabral Melo Lima +1

Federal University of Rio de Janeiro · Toronto Metropolitan University Toronto, CA

Multilingual Language Model EvaluationClinical Decision-MakingClinical ReasoningClinical Language Model Evaluation
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Jun 5, 2026cs.CL

LLM-Guided Evolution for Medical Decision Pipelines

Adapting large language models (LLMs) to clinical workflows often requires costly fine-tuning or manual prompt and pipeline engineering. We study LLM-guided MAP-Elites evolution as an inference-time alternative for discovering medical decision strategies and provide an implementation repository at https://github.com/univanxx/llm_guided_evo_medical. We formulate urgency triage, interactive consultation, and medical image classification as evolutionary searches over executable artifacts optimized by task-specific fitness functions. Across all three settings, evolution improves over manually designed baselines under practical constraints. In triage, evolved programs increase Semigran accuracy from 77.3%77.3\% to 87.1%87.1\% and emergency recall from 0.600.60 to 0.970.97, while improving safety-weighted held-out MIMIC-ESI performance. In interactive consultation, evolved policies improve the accuracy--cost frontier across Llama-3, Qwen-3.5, and Gemma-4 and transfer to held-out iCRAFTMD. In PneumoniaMNIST, prompt-only evolution improves frozen MedGemma VLMs while preserving strict JSON outputs. Qualitative analysis shows that the gains come from interpretable program-level mechanisms, calibrated triage boundaries, targeted evidence acquisition, selective commitment, and finding-oriented visual decision rules, rather than superficial prompt rewording alone.

Ivan Sviridov, Artem Oskin, Ivan Panin +4

1Sber AI Lab · 2AIRI

Clinical TriageLarge Language Model-Guided OptimizationClinical Decision-MakingMedical Image ClassificationQuality-Diversity Optimization
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Jun 2, 2026cs.AI

Gender-Dependent Diagnostic Substitution in LLM Medical Triage: Same Symptoms, Unequal Urgency

We investigate whether large language models produce different medical triage recommendations for identical neurological symptoms when only the patient's stated gender and age vary. Using three model families--Gemini 3.5 Flash, Claude Sonnet 4.6, and GPT-5.4-mini--we present a standardized symptom profile (persistent headache, blurred vision, morning nausea, visual disturbances) across seven demographic conditions: three age groups (25, 38, 65) x two genders (male, female), plus a gender-unspecified baseline (n = 30 per condition per model, 630 total trials). We find a stark, systemic gender-dependent triage disparity: young women receive significantly lower emergency room (ER) referral rates than age-matched men (Gemini: 0% vs. 23.3%; Claude: 6.7% vs. 96.7%; GPT: 6.7% vs. 66.7%, all p < 0.001). The disparity disappears at age 65 for all models. The primary mechanism is diagnostic substitution: the models anchor on a gender-associated diagnosis, preferentially classifying young women with Idiopathic Intracranial Hypertension (IIH)--a condition epidemiologically linked to women of childbearing age--while diagnosing men with generic increased intracranial pressure with space-occupying lesions in the differential. This diagnostic closure routes female patients to lower-urgency care (outpatient doctor appointments) despite comparable severity ratings (7-9/10). Our findings demonstrate that clinical LLMs replicate documented human clinical biases by using epidemiological priors to suppress triage urgency, suggesting that AI triage engines must decouple urgency assessment from probabilistic diagnostic priors. We release all code, prompts, and raw results.

Qi Han Wong

Gender Bias in Language ModelsClinical TriageMedical DiagnosisClinical Decision-MakingClinical Language Model EvaluationDifferential Diagnosis+1
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Jun 2, 2026cs.CL

AI Rater Discrimination Depends on Scoring Protocol in Complex Clinical Decision-Making

Clinical AI evaluation increasingly delegates scoring to large language models (LLMs) acting as AI raters, yet their scoring behavior across evaluation conditions has not been quantitatively characterized. We address this gap through a factorial study of AI rater behavior in adult type 2 diabetes (T2D) pharmacotherapy at 12-month outpatient follow-up, a clinical task involving complex decision-making operationalized across seven evaluation questions. Four open-source LLMs served simultaneously as clinical decision support system (CDSS) models and AI raters. Each CDSS output was scored under two scoring protocols: a rubric-anchored Gold Rubric (GR) protocol incorporating a patient-specific rubric, and a rubric-free Non Gold Rubric (Non-GR) protocol. Linear mixed effects models crossed the scoring protocol factor with five design factors -- CDSS model, CDSS prompt configuration (document-referenced generation [DRG] vs.\ Baseline), rater model, prompt character, and prompt type -- and estimated main effects together with their protocol interactions. Across all questions, AI raters yielded consistently higher scores within a very narrow range (74--78 points on average) under Non-GR compared to those under GR (7.69 to 49.64 points lower mean scores; 1.68 to 3.67 times wider interquartile ranges). Within each question, GR amplified the AI rater's discrimination between DRG and Baseline CDSS outputs by factors of 1.76 to 5.10, while also revealing substantial behavioral variation across rater models that Non-GR suppressed. These findings support rubric anchoring as the scoring protocol that preserves discriminative power in clinical AI evaluation; rubric-free scoring cannot substitute when questions require patient-specific or jurisdiction-specific criteria that rater models cannot infer from parametric knowledge alone.

Sangwon Baek, Kyu Yeon Hur, Kyunga Kim

Asclep Korea Inc., Changwon, Republic of Korea · Center for Data Science, New York University, New York, USA · Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea +1

LLM-as-a-JudgeClinical Decision SupportClinical Decision-MakingRubric-Based EvaluationClinical Language Model Evaluation
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Jun 2, 2026cs.AI

ClinicalMC: A Benchmark for Multi-Course Clinical Decision-Making with Large Language Models

Large language models (LLMs) have been widely adopted in healthcare, yet they still encounter significant challenges in complex clinical decision-making scenarios. Existing benchmarks primarily assess LLM performance in single-course settings and lack systematic evaluation in multi-course scenarios, where a patient's condition evolves over time. To address this gap, we propose ClinicalMC, a benchmark for multi-course clinical decision-making. It includes 1,275 Chinese and 5,804 English samples across four stages from admission to discharge. These stages cover triage, first-course examination/diagnosis/treatment, subsequent multi-course examination/assessment/treatment, and final diagnosis. In ClinicalMC, patients in the English dataset undergo an average of 5.11 clinical courses, whereas those in the Chinese dataset undergo 3.42. To assess LLM performance, we construct a multi-agent evaluation framework that includes patient, examiner, and doctor agents. Based on the benchmark and framework, we design two experimental settings -- a single-turn static setting and a multi-turn dynamic setting -- and assess three categories of LLMs: 1) closed-source LLMs like GPT5-mini; 2) open-source LLMs like DeepSeek-V3.2; and 3) medical LLMs like HuatuoGPT-o1. Through extensive evaluation, we aim to better understand LLM performance in the medical domain and support its effective deployment in healthcare.

Ruihui Hou, Siyi Zhu, Ziyue Huai +4

East China University of Science and Technology, Shanghai, China · Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China.

Clinical Decision-MakingClinical Language Model EvaluationMedical LLMs
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Jun 1, 2026cs.AI

ClinEnv: An Interactive Multi-Stage Long Horizon EHR Environment for Agents

Clinical practice is not the selection of an answer from enumerated options: a physician gathers heterogeneous information incrementally and commits to sequential, irreversible decisions under uncertainty. Static benchmarks cannot probe and existing interactive medical benchmarks each compromise on at least one of them. We present ClinEnv, an interactive benchmark that evaluates LLMs as attending physicians over real inpatient admissions under a paradigm we term Longitudinal Inpatient Simulation. Each case is automatically constructed into an ordered sequence of decision stages; at every stage the model must actively query four specialized agents before committing to medications, procedures, and diagnoses. ClinEnv scores both what the model decides, through deterministic ontology-grounded matching, and how it gathers information. Across seven models, the strongest reaches only 0.31 decision F1, and outcome quality is sharply decoupled from process quality. Difficulty concentrates in management decisions and later stages, where models recover discharge diagnoses far more reliably than management actions (0.51 vs. 0.17 F1) and continue to issue redundant queries as cases progress. ClinEnv makes this information-acquisition gap, invisible to outcome-only evaluation, directly measurable.

Yuxing Lu, Yushuhong Lin, Wenqi Shi +4

1Georgia Institute of Technology · 2Peking University · University of Texas Southwestern Medical Center +1

Long-Horizon Agent EvaluationClinical Decision-MakingAI Agent BenchmarksActive Information Gathering
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Jun 1, 2026cs.LG

Aligning Data-Driven Predictors with Allocation: A Decision-Focused Approach to Survival Analysis

Machine learning predictors have become essential tools for guiding automated decision making. However, a major misalignment persists: predictive models are typically optimized in terms of standard statistical metrics in isolation from the algorithmic tasks they inform. We highlight this incongruity in the high-stakes domain of organ allocation by demonstrating that any algorithm relying on (even highly accurate) survival predictors optimized for standard metrics -- such as the Concordance index (C-index) -- can yield arbitrarily poor outcomes when used for allocation, failing to guarantee utility better than a uniform random selection. To bridge the gap between survival analysis and policy optimization, we introduce a decision-focused learning approach based on optimizing normalized discounted cumulative gain (NDCG), a mainstay metric in information retrieval. We establish the utility of NDCG in survival analysis by proving that it translates to guarantees on the performance of allocation. Empirically, we propose a bootstrapping approach to optimize the NDCG of existing survival models. Unlike prior work, we also address the challenge of right censorship when evaluating ranking. On historical heart transplant data from the US, our method dramatically boosts the NDCG of baseline models by 50-100%, which translates to tens of thousands of additional life years gained annually when deployed for transplant allocation. We anticipate that our framework will find broader applications in decision making with predictions.

Itai Zilberstein, Ioannis Anagnostides, Tuomas Sandholm

Department of Computer Science, Carnegie Mellon University, Pittsburgh, PA · Additional affiliations: Strategy Robot, Inc., Strategic Machine, Inc., Optimized Markets, Inc.

Learning to RankSurvival AnalysisDecision-Focused LearningClinical Decision-Making
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May 31, 2026cs.CL

Implicit Geographic Inference in LLM Medical Triage: Language-Driven Disparities in Emergency Recommendations

We investigate whether large language models produce different medical triage recommendations for identical symptoms based solely on the language of the patient prompt. Using Gemini 3.5 Flash, we evaluate a neurological symptom profile (persistent headache, blurred vision, nausea) across six languages (English, Spanish, Chinese, Hindi, Japanese, Arabic) with 30 runs per condition (n=450 total API calls). We find that the model recommends emergency room visits at rates ranging from 0% (Japanese, Hindi) to 30% (English, Arabic), despite assigning nearly identical severity scores (7.7-8.0/10) across all languages. Adding a single sentence specifying the patient's US location increases ER recommendations by up to 76.7 percentage points for non-English prompts, while the reverse anchor (English prompt with a Tokyo location) reduces the ER rate from 30% to 6.7%. A back-translation control (Japanese to English) produces ER rates comparable to the English baseline, confirming that the disparity is not caused by translation quality but by implicit geographic inference from the input language. We release the complete dataset, experiment code, and results.

Qi Han Wong

Multilingual Language Model EvaluationClinical TriageClinical Decision-MakingLanguage Model Bias EvaluationClinical Language Model Evaluation
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May 28, 2026cs.AI

EHRBench: An Automated and Reliable EHR-based Benchmark for Clinical Decision Making with LLMs

Clinical decision-making (CDM) is central to real-world clinical workflows, where clinicians infer diagnoses, select treatments, or anticipate future health outcomes under incomplete evidence. LLMs are increasingly used to support these decisions due to strong language capabilities, broad biomedical knowledge, and efficiency, yet the reliability of LLMs on real-world clinical decision tasks remains insufficiently understood. To evaluate CDM models, especially LLM-based models, an ideal and practical medical decision benchmark should be constructed via an automated yet reliable pipeline to ensure both scale and quality. Moreover, the grounding of a CDM benchmark in real patient EHRs can better support evaluation on practical CDM tasks that require substantive biomedical knowledge and clinical inference. To fill the gaps, we introduce EHRBench, an automated and reliable EHR-grounded benchmark for evaluating LLM-based clinical decision-making at scale. To ensure scalability and reliability, EHRBench is constructed through an EHR-LLM-KB(knowledge-base) interaction pipeline. For efficiency, we use a specialized LLM to automatically convert encounter-level EHR trajectories into structured templates and deterministically instantiate the templates into QA items. In parallel, we apply systematic KB-based verification and enrichment to filter hallucinated or ambiguous relations and to improve reliability. Using this pipeline, we construct nearly 1M (960,067) QA items spanning three core inference-required clinical decision tasks: diagnosis, treatment, and prognosis. We benchmark more than 30 representative LLMs on EHRBench and provide detailed analyses of performance and robustness. The results show consistent capability trends across settings, further validating the reliability of EHRBench and highlighting actionable gaps toward clinically reliable LLM systems.

Yuzhang Xie, Keqi Han, Yunpeng Xiao +7

Emory University Atlanta, GA, USA · Stanford University Stanford, CA, USA

HealthcareClinical Decision-MakingClinical Language Model EvaluationElectronic Health Records
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May 28, 2026stat.ML

Deep Optimal Individualized Treatment Rules for Bivariate Survival Outcomes via Adaptive Prediction-Powered Learning

In randomized trials involving multiple treatments, bivariate survival outcomes present significant analytical challenges for making decisions. This paper addresses the problem of deriving optimal individualized treatment rules to maximize the joint survival probability beyond fixed time points (t1,t2)(t_1, t_2) through deep neural networks, while accounting for right censoring. We propose a novel approach that models treatment rules via stochastic policies, coupling marginal accelerated failure time models via link function to capture bivariate dependence. To enhance robustness and effectiveness of decision making, we introduce an adaptive prediction-powered method that leverages auxiliary predictions from machine learning models.

Kun Ren, Yifan Cui, Wen Su

Department of Biostatistics, City University of Hong Kong · Center for Data Science, Zhejiang University

Survival AnalysisClinical Decision-Making
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May 27, 2026cs.AI

Do Clinical Models Change Treatment Decisions?

Clinical foundation models are evaluated with factual or exam-style medical QA, but treatment decisions must change when patient context changes. We introduce ClinPivot, an auditable treatment-decision benchmark built from biomedical relations and pivoted patient contexts. ClinPivot asks whether models change treatment choices when new clinical constraints shift the action space. We find that strong medical QA performance does not reliably predict decision-making performance: frontier models and task-adapted Qwen variants often fail to change decisions correctly, and model rankings shift across evaluation regimes. Decision-structured supervision improves pivot-sensitive decision-making and medical QA under matched knowledge budgets, while lightweight replay reduces losses in general assistant ability.

Dongkyu Cho, Miao Zhang, Rumi Chunara

New York University

HealthcareClinical Decision-MakingClinical Language Model Evaluation
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May 26, 2026cs.CY

Implementation of Big Data Analytics for Diabetes Management: Needs Assessment in the Rwanda Healthcare System

Diabetes is a chronic metabolic disease that can lead to serious health problems if not diagnosed and managed early. Big Data Analytics (BDA) and machine learning offer practical tools for analyzing large health datasets and supporting early detection and better treatment decisions. However, their use in routine clinical practice is still limited. This study examines the readiness of Rwanda's healthcare system to adopt big data analytics for diabetes management. As the country continues to expand its use of electronic medical records and health information systems, new opportunities arise for improving prediction, monitoring, and clinical decision-making. A five-day workshop involving 25 key stakeholders, including clinicians, data managers, policymakers, medical researchers, nutritionists, and technology providers, was conducted to assess preparedness and identify existing gaps. The findings highlight both the potential and the main challenges of BDA implementation. Based on these results, the paper proposes a practical BDA framework to support diabetes management strategies using explainable machine learning models.

Silas Majyambere, Tony Lindgren, Workneh Y. Ayele +1

Department of Computer and Systems Sciences Stockholm University Stockholm, Sweden · Center for Biomedical Engineering and E-Health (CEBE) University of Rwanda Kigali, Rwanda

Clinical Decision-Making
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May 21, 2026cs.MA

A Generalized Nash Equilibrium-Seeking Scheme for Trauma Resuscitation

Trauma resuscitation is a clinical process for treating life-threatening physiological disorders in safety-critical environments, driven by the experience of healthcare workers (HCWs). Designing and optimizing quantifiable metrics that accurately capture HCW decisions may augment current resuscitation procedures with the potential to improve patient outcomes. This motivates our socio-technical formulation of trauma resuscitation as a distributed generalized Nash equilibrium (GNE)-seeking game with coupled inequality constraints. This method is optimized over a time-varying communication graph. We introduce novel insights from clinical experience to model HCWs behavior. This work facilitates the best possible resuscitation outcome given HCWs workloads, schedules, competencies, and limited resources.

Promise Ekpo, Angelique Taylor, Lekan Molu

Cornell University, NY. · Bala Cynwyd, PA.

Nash EquilibriumMulti-Agent CoordinationHealthcareDistributed OptimizationClinical Decision-Making
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May 20, 2026cs.HC

Understanding Perspectives of Patients, Caregivers and Clinicians towards Emerging Collaborative-decision Making Technologies

In pediatrics, patients, caregivers, and clinicians share responsibility for health decisions, but limited collaboration can undermine outcomes. We conducted a qualitative study examining decision-makers perceptions toward collaborative decision-making technologies, including interactive dashboards, VR simulators, and AI voice assistants. Findings reveal differences in user opinions across groups and indicate technology acceptance is linked to users trust of these technologies. Technology developers and researchers need to explore design and implementation strategies that build and facilitate trust or appropriate distrust between users and these novel technologies before these tools can effectively support collaborative decision-making.

Ray-Yuan Chung, Athena Ortega, Zixuan Xu +7

University of Washington, Seattle, WA · Johns Hopkins University, Baltimore, MD

Clinical Decision SupportClinical Decision-MakingTrust in AI
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May 19, 2026cs.LG

Set-Valued Policy Learning

Conventional treatment policies map patient covariates to a single recommended intervention in order to maximize expected clinical outcomes. However, when multiple treatments yield statistically indistinguishable outcomes or when treatment has no effect, recommending a single intervention may result in somewhat arbitrary interventions, undermining clinical adoption and trust. To address this, we propose a set-valued policy learning paradigm. By outputting sets of valuable treatments whose cardinality reflects the recommendation's ambiguity, our approach better supports clinical decision-making. Evaluating a set-valued policy proves subtle due to the range of possible downstream decisions. To do so, we define the set-policy value using a choice function to model clinical decision-making, and we develop doubly robust estimators thereof. Despite its practical importance, set-valued policy learning for categorical treatments remains largely unexplored. In this context, we introduce two complementary approaches: the Greatest Lower Bound method, which extends the learning-to-defer framework to multiple treatments, and conformal set-valued policy learning, which bridges the gap between unobserved ground-truth optimal treatments and estimated optimal treatment rules. Through experiments on synthetic data and real-world applications to trauma care and in-vitro fertilization (IVF), we demonstrate that our methods produce robust and actionable policies that naturally incorporate clinical considerations while effectively balancing performance and reliability.

Laura Fuentes-Vicente, Mathieu Even, Gaëlle Dormion +3

Inria PreMeDICaL, Inserm, Montpellier, France · Elixir Health, Paris, France · Université Paris Cité, CNRS, MAP5, F-75006 Paris, France +1

HealthcareLearning to DeferClinical Decision-Making
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May 18, 2026cs.AI

What Does the AI Doctor Value? Auditing Pluralism in the Clinical Ethics of Language Models

Medicine is inherently pluralistic. Principles such as autonomy, beneficence, nonmaleficence, and justice routinely conflict, and such ethical dilemmas often sharply divide reasonable physicians. Good clinical practice navigates these tensions in concert with each patient's values rather than imposing a single ethical stance. The ethical values that large language models bring to medical advice, however, have not been systematically examined. We present a framework for auditing value pluralism in medical AI, comprising a benchmark of clinician-verified dilemmas and an attribution method that recovers value priorities directly from decisions. The ecosystem of frontier models spans physician-level value heterogeneity, and models discuss competing values in their reasoning (Overton pluralism) before committing to a decision. However, individual model decisions are near-deterministic across repeated sampling and semantic variations, failing to reproduce the distributional pluralism of the physician panel. Across benchmark cases, these consistent decisions reflect committed, systematic value preferences. While most model priorities fall within the natural range of inter-physician variation, some significantly underweight patient autonomy. A single LLM deployed without regard for its value priorities could amplify those priorities at scale to every patient it serves. Without explicit efforts to balance ethical perspectives with one or multiple models, these tools risk replacing clinical pluralism with a deployment monoculture.

Payal Chandak, Victoria Alkin, David Wu +11

Moral Reasoning in Language ModelsHealthcareLLM AuditingClinical Decision-MakingClinical Language Model Evaluation
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