Reasoning in Real World Clinical Care: Why Large Language Models Are Not Yet Safe for Autonomous Clinical Decision Support
arXiv:2607.28677v1 Announce Type: new Abstract: LLM now pass medical licensing examinations and, in curated cases, can rival physicians at diagnostic reasoning. These developments have accelerated the use of LLMs for symptom assessment and clinical decision support in diagnostic and treatment guidance, administrative documentation, and rules-based alert enhancement. This Perspective concerns the most consequential of these applications: the autonomous triage of self-presenting, undifferentiated patients, with little or no clinician in the loop. For that task, the evidence of safety does not yet exist. The gap is not in medical knowledge but in the fidelity of clinical evaluation: a model optimized to continue the most probable text is not optimized to act safely when the safe answer is the improbable must-not-miss diagnosis. Safe triage is not the selection of the most likely diagnosis; it is a sequential decision under asymmetric cost, in which the single catastrophic miss outweighs many false alarms, and the decisive signal may be one the patient has not volunteered - and that the model has not been trained to seek. The core deficit is therefore one of information gathering under uncertainty. Under incomplete histories, LLM systems may fail to show the behaviors safe triage requires: broadening the differential; seeking the missing red flag; lowering the threshold for escalation; deferring judgement until sufficient information is obtained; and escalating concern where high-harm diagnoses remain unexcluded. These modes of failure for LLMs can be difficult to detect considering that evaluations to date often use complete, well-curated, confidence-gated simulations. The application of LLMs under these conditions may be amplified by assistant-like behaviors and positive bias, including credulity, agreeableness, and miscalibration - when these are not constrained by clinical triage logic.
-->
[Submitted on 29 Jul 2026]
Title:Reasoning in Real World Clinical Care: Why Large Language Models Are Not Yet Safe for Autonomous Clinical Decision Support
View a PDF of the paper titled Reasoning in Real World Clinical Care: Why Large Language Models Are Not Yet Safe for Autonomous Clinical Decision Support, by Shayndhan Sivanathan and 12 other authors
View PDF HTML (experimental)
Abstract:LLM now pass medical licensing examinations and, in curated cases, can rival physicians at diagnostic reasoning. These developments have accelerated the use of LLMs for symptom assessment and clinical decision support in diagnostic and treatment guidance, administrative documentation, and rules-based alert enhancement. This Perspective concerns the most consequential of these applications: the autonomous triage of self-presenting, undifferentiated patients, with little or no clinician in the loop. For that task, the evidence of safety does not yet exist. The gap is not in medical knowledge but in the fidelity of clinical evaluation: a model optimized to continue the most probable text is not optimized to act safely when the safe answer is the improbable must-not-miss diagnosis. Safe triage is not the selection of the most likely diagnosis; it is a sequential decision under asymmetric cost, in which the single catastrophic miss outweighs many false alarms, and the decisive signal may be one the patient has not volunteered - and that the model has not been trained to seek. The core deficit is therefore one of information gathering under uncertainty. Under incomplete histories, LLM systems may fail to show the behaviors safe triage requires: broadening the differential; seeking the missing red flag; lowering the threshold for escalation; deferring judgement until sufficient information is obtained; and escalating concern where high-harm diagnoses remain unexcluded. These modes of failure for LLMs can be difficult to detect considering that evaluations to date often use complete, well-curated, confidence-gated simulations. The application of LLMs under these conditions may be amplified by assistant-like behaviors and positive bias, including credulity, agreeableness, and miscalibration - when these are not constrained by clinical triage logic.
Comments: 3 figures
Subjects:
Artificial Intelligence (cs.AI)
Cite as: arXiv:2607.28677 [cs.AI]
(or arXiv:2607.28677v1 [cs.AI] for this version)
https://doi.org/10.48550/arXiv.2607.28677
arXiv-issued DOI via DataCite
Submission history
From: Mehdi Zadem [view email] [v1] Wed, 29 Jul 2026 07:12:46 UTC (7,041 KB)
Full-text links:
Access Paper:
View a PDF of the paper titled Reasoning in Real World Clinical Care: Why Large Language Models Are Not Yet Safe for Autonomous Clinical Decision Support, by Shayndhan Sivanathan and 12 other authors
View PDF
HTML (experimental)
TeX Source
view license
Current browse context:
cs.AI
new | recent | 2026-07
Change to browse by:
cs
References & Citations
NASA ADS
Google Scholar
Semantic Scholar
Loading...
Data provided by:
Bibliographic Tools
Bibliographic and Citation Tools
Bibliographic Explorer Toggle
Bibliographic Explorer (What is the Explorer?)
Connected Papers Toggle
Connected Papers (What is Connected Papers?)
Litmaps Toggle
Litmaps (What is Litmaps?)
scite.ai Toggle
scite Smart Citations (What are Smart Citations?)
Code, Data, Media
Code, Data and Media Associated with this Article
alphaXiv Toggle
alphaXiv (What is alphaXiv?)
Links to Code Toggle
CatalyzeX Code Finder for Papers (What is CatalyzeX?)
DagsHub Toggle
DagsHub (What is DagsHub?)
GotitPub Toggle
Gotit.pub (What is GotitPub?)
Huggingface Toggle
Hugging Face (What is Huggingface?)
ScienceCast Toggle
ScienceCast (What is ScienceCast?)
Demos
Demos
Replicate Toggle
Replicate (What is Replicate?)
Spaces Toggle
Hugging Face Spaces (What is Spaces?)
Spaces Toggle
TXYZ.AI (What is TXYZ.AI?)
Related Papers
Recommenders and Search Tools
Link to Influence Flower
Influence Flower (What are Influence Flowers?)
Core recommender toggle
CORE Recommender (What is CORE?)
Author
Venue
Institution
Topic
About arXivLabs
arXivLabs: experimental projects with community collaborators
arXivLabs is a framework that allows collaborators to develop and share new arXiv features directly on our website.
Both individuals and organizations that work with arXivLabs have embraced and accepted our values of openness, community, excellence, and user data privacy. arXiv is committed to these values and only works with partners that adhere to them.
Have an idea for a project that will add value for arXiv's community? Learn more about arXivLabs.
Which authors of this paper are endorsers? | Disable MathJax (What is MathJax?)