One note in three: a verified census of three deployed AI scribes, and the instrument that counted it

Ambient AI scribes draft clinical notes under the reassurance that a clinician signs every note. We audited three commercial AI scribes on the same 142 consultations: 565 notes from recorded UK primary-care and US ambulatory encounters plus authored scenarios. Twelve discovery passes proposed 13,678 candidate errors; the 5,898 clearing an importance filter went to an adversarial panel of two models from different families, each told to refute what it could, and 618 survived. One note in three (31.3% [27.0, 35.6]) carries a verified failure, concentrated in allergy and medication information, invented patient identity, and history written up as examination on telephone consultations that can contain none. No product was given a patient record; setting aside the two classes a record would have prefilled, invented identity and dates, the rate is 24.8% [20.8, 29.0]. One failure mode did not fit our scheme, drawn from published scribe-error taxonomies: a treatment the clinician retracts, recorded as delivered care. Two clinicians adjudicated blind, disjoint samples: a physician author upheld 20 of 21 findings (95.2% [77.3, 99.2]) and an independent clinician, not an author, 12 of 12 ([75.8, 100]); both judged every sampled refusal genuine. A failure rate depends on the instrument as much as the scribes. With model, evidence and settings fixed, the review instruction alone moves the share of candidates verified from 9.3% to 79.0%, and the reviewing family moves it too: alone at that instruction the gentler flags 54.8% of notes against 27.8%. Between 28% and 97% of sampled notes carry a failure depending on the standard. Published audits disagree among themselves by a margin instrument differences alone can produce: omission is 54-86% of their errors against our 23.1%. We release all 618 findings with transcript-side evidence, every prompt and model version, and the re-runnable pipeline.

Life Operators: a self-evolving framework for multiscale life modelling

Medical AI is moving beyond recognition towards clinical dialogue and longitudinal prediction. Yet a central question remains: how would a patient's state change under intervention? Statistical models learn future observations, whereas mechanistic models describe selected processes. Neither provides a common framework for representing patient state, coupling scales or revising failed assumptions. We propose Life Operators: task-bounded mappings that define three scientific roles. Perception operators infer task-relevant biological states from multimodal observations, Evolution operators propagate these states under natural or intervention-conditioned dynamics, and Generation operators map them to measurable signals. Each role may be realised by equations, statistical models, neural networks or hybrids. Bridge operators connect components with different variables, scales and time steps. Selected operators and bridges form task-specific Operator Graphs containing the smallest set of states and mechanisms sufficient for a declared claim. This modular structure also makes scientific revision localisable. An AI co-scientist may propose changes to states, operators, bridges or graph structure, while independent evidence determines which variants are retained, restricted or retired. Over time, validated components could accumulate into broader multiscale models of the human body and provide a computational foundation for medical artificial superintelligence.

MedMix: Specialization-Consistent Federated Sparse MoEs under Modality Heterogeneity

Federated multimodal medical AI faces modality heterogeneity at both the client and sample levels: clients may systematically lack access to specific modality types, while individual records within the same client may contain different partial modality subsets. Sparse Mixture-of-Experts (MoE) architectures are a promising remedy for modality-adaptive computation, but their use in federated learning is fragile under cross-client modality heterogeneity, where locally learned routing policies can diverge across clients and drive experts toward incompatible specializations. Different clients may assign the same observed modality configuration to different experts, or train similarly indexed experts on different missing-modality configurations, causing standard aggregation to misalign or overwrite the expert specialization that sparse MoEs are intended to learn. To address this challenge, we propose MedMix, a semantic-alignment framework for federated multimodal sparse MoEs that coordinates cross-client routing and expert specialization using modality context. At the client side, MedMix uses modality-context-aware routing to guide expert selection using each token's modality identity, position, and incompleteness context. Across clients, it uses consensus-guided routing alignment to construct server-side consensus anchors for shared modality patterns and align local routing distributions across clients. Complementing these routing mechanisms, client-adaptive expert aggregation leverages client-specific modality-pattern prototypes to match and aggregate functionally similar experts across clients. Experiments on real-world multimodal medical datasets show that MedMix achieves the best average F1 across diverse modality heterogeneity and modality incompleteness settings, with especially clear gains under severe heterogeneity.

ResidencyRL: Reinforcement Learning in Simulated Clinical Environments

In medical education, physicians convert academic knowledge into clinical expertise through residency: years of training across thousands of encounters, with diverse sources of feedback and progressively greater autonomy. Much of clinical reasoning relies on the patient encounter, a dialogue in which a clinician elicits history, refines diagnostic hypotheses, and decides management under uncertainty. While large language models (LLMs) excel on static medical benchmarks, methods to optimize the full sequence of clinical decisions remain underdeveloped. We present ResidencyRL, a reinforcement learning (RL) method for training clinical artificial intelligence (AI) agents through simulated multi-turn clinical encounters (up to 60 dialogue turns and 8 tool calls per trajectory). ResidencyRL pairs the policy agent with LLM simulators capable of complex, adversarial behaviors, training against a structured reward aligned to diagnostic accuracy, management quality, communication, documentation, and safety. On held-out evaluations, the ResidencyRL agent improves diagnostic accuracy by 7.0% under adversarial conditions (88.0% vs. 81.0%) and reduces missed red flag rates by 31%, demonstrating rigorous mitigation of premature closure. Blinded expert clinicians validated these gains, preferring the trained agent in 87.6% of side-by-side comparisons. The procedural competencies transfer to unseen benchmarks: the agent outperforms the base model across all six clinical axes of the AMIE multi-visit benchmark, and shows consistent directional improvements on AgentClinic and CRAFT-MD. Our findings demonstrate that sequential clinical decision-making can be effectively learned through multi-turn RL in simulation, yielding robust, generalizable capabilities, paving the way towards clinical mastery. Prospective validation with real-world workflows remains necessary to establish clinical utility.

Optimal Liability Design for Medical AI

Artificial intelligence (AI) is increasingly integrated into medical decision-making, yet its liability implications remain complex, particularly when physicians differ in diagnostic skills and their quality is unobservable. This paper develops a principal-agent model in which a social planner designs medical liability to regulate a physician with private quality information who chooses between a standard treatment, a personalized judgment-based treatment, or following an imperfect AI recommendation. Our analysis yields several novel insights. First, we show that the optimal mechanism under asymmetric information is surprisingly simple: a uniform, one-size-fits-all liability level for all physician types who deviate from the standard of care. Despite physician heterogeneity, this simple policy often achieves the full-information first-best outcome, particularly when standard care is reliable or AI is highly accurate. Second, the relationship between AI accuracy and optimal liability is non-monotonic. Contrary to common intuition, better AI does not always imply more relaxed liability. As AI accuracy increases, the optimal liability either decreases monotonically or follows an inverted-U pattern, depending on the uncertainty of the standard treatment. Third, asymmetric information does not universally reduce social welfare. Welfare loss arises only when standard care is unreliable and AI accuracy is too low; even then, its magnitude follows an inverted U-shape, initially increasing as AI complicates the regulatory problem, but declining as more accurate AI helps mitigate it. Finally, we find that information asymmetry is a double-edged sword in the presence of AI, and greater transparency does not benefit all stakeholders equally.

TreeProbe : A Tibetan Medicine Benchmark for Cultural Bias in LLMs

Large language models are increasingly viewed as a potential means of mitigating global health inequities, yet their outputs often reflect dominant high-resource medical traditions and provide limited coverage of traditional medical knowledge systems. Tibetan medicine, one of the world's four major traditional medical systems, has an independent and highly structured theoretical framework. When models lack grounded understanding of Tibetan medicine, they may fall back on dominant epistemic systems and distort the native knowledge structure during reasoning. However, quantitative tools for evaluating cultural bias in Tibetan medicine remain largely absent. To address this gap, we introduce TreeProbe, the first cultural-bias benchmark organized around the native Tree of Medicine framework in Tibetan medicine. It contains 4,719 expert-adjudicated items covering 467 diseases and 10 subtasks along the three roots. Experiments on representative LLMs show that current models remain limited in native Tibetan medical contexts and exhibit systematic external ontology drift. Further analysis reveals that models diverge in whether they drift toward biomedical or TCM reasoning, shaped by pretraining data composition and surface resemblance between TCM and Tibetan medicine. TreeProbe provides a diagnostic benchmark for developing medical AI systems that are both linguistically inclusive and epistemically fair. Code and data are available in an anonymous repository at https://anonymous.4open.science/r/TreeProbe/.

Agentic AI in medicine: architectures, applications, evaluation, and challenges for clinical translation

Large language models and multimodal foundation models are enabling medical artificial intelligence (AI) systems to move beyond isolated prediction and undertake multistep clinical tasks that require planning, tool use, memory, iterative correction, and coordination among specialized agents. However, the scope of agentic AI in medicine remains unsettled, and current evaluation practices are not yet aligned with the requirements of clinical use. We conducted a scoping review with systematic evidence mapping across five electronic sources, screened 1,649 exportable records, and provisionally included 557 unique studies that met predefined criteria for goal-directed task execution, tool use, interaction with external resources, feedback-based refinement, or multi-agent collaboration. The included studies describe single agents that use external tools, workflows supported by retrieval and external knowledge, multimodal agents, and multi-agent systems applied to medical question answering, image interpretation, electronic health record analysis, drug safety, and clinical trial prediction. The evidence base remains dominated by public benchmarks, simulated settings, retrospective datasets, and small-scale expert evaluation. Process reliability, evidence traceability, uncertainty, safety, workflow impact, and external validity are evaluated less consistently. Clinical translation will depend on clearer definitions, reproducible evaluation, auditable oversight, interoperable system design, and prospective validation in real-world clinical workflows.

Evaluating medical AI under missing information: same-provider judges and human raters change apparent safety

Readiness stress-testing of medical AI has focused on closed-ended and multimodal benchmarks. We extend it to open-ended clinical conversation under missing information, where safe behavior means recognizing absent information and qualifying, clarifying, or not over-committing - and where the evaluator becomes part of the measurement. We stress-test four models - three flagships (Claude Opus 4.8, GPT-5.5, Grok 4.3) and one mid-tier model (Gemini 3.5 Flash) - by deleting the latter half of the final user turn in HealthBench conversations, grading responses with a four-provider LLM-judge panel and a blinded clinician-anchored reference. Two evaluator-facing results are robust. First, judge choice materially changes apparent safety: inter-judge agreement is only moderate (Fleiss' kappa = 0.65), and after adjusting for each judge's general leniency (vote-level logistic regression), a positive same-provider association remains (exact permutation p = 0.04; GPT-5.5 ~ +0.10 on the probability scale) - large enough to change which model appears to over-commit least once its own-provider judge is excluded. Second, LLM judges are more permissive than clinicians on a blinded 50-item subsample: all four are significantly more lenient than the stricter independent clinician (crediting appropriate uncertainty on 66-84% of items vs 52%), and three of four than the author-influenced consensus (Grok directional only; judge-vs-consensus kappa = 0.20-0.43). On the author-audited clinical-underdetermined subset the permissiveness gap widened and the point-estimate model ordering held. A closed-ended MedQA anchor confirms accuracy is high and option-order effects are within a +/-5-point equivalence region for three of four models, so the safety gap is about calibration, not knowledge. We release the harness, prompts, per-item outputs, judge panel, perturbation audit, and human-annotation protocol.

MedFailBench: A Clinician-Built Open-Source Benchmark for Medical AI Safety Boundary Inspection

Most medical AI benchmarks measure whether a model knows the correct answer. MedFailBench asks a different question: which safety boundary failed? We present a clinician-built synthetic benchmark and failure atlas that labels medical AI errors by severity (1--5) and safety gate type (missed urgent escalation, unsafe remote dosing, unsafe discharge reassurance, evidence fabrication, unsafe protocol execution, source support gap). The current public release (v0.2.1) contains 44 clinician-reviewed synthetic cases with severity annotations, a live HuggingFace leaderboard preview, a safety gate taxonomy, a clinical severity rubric, and an automated pipeline for archiving model-response screening runs. No patient data, clinical validation claims, or model rankings are included. MedFailBench is released under Apache-2.0 and CC-BY-4.0 and carries the Zenodo DOI 10.5281/zenodo.21205535.

Scientific Explanations in Health Sciences: Causality, Trust, and Epistemic Adequacy

Medical Artificial Intelligence (AI) is widely expected to transform clinical practice, yet the decision-making processes of many Machine Learning (ML) models remain opaque. Explainability has been advanced as a partial remedy to clarify why AI generates predictions, particularly in high-stakes contexts. Despite ongoing efforts, debates on what constitutes an adequate medical explanation remain unsettled. Yet, explanation has long been a central topic of inquiry in the philosophy of science and medicine. The insights developed in these fields, however, have been largely overlooked in contemporary explainable AI (XAI) research, leaving its foundational assumptions insufficiently examined. To address this gap, this paper develops a critical review at the intersection of philosophy of science and XAI. It examines prevailing accounts of what counts as an explanation in the health sciences and assesses their adequacy for informing XAI in medicine, arguing that they provide necessary conditions for a philosophically grounded approach to explainability in this domain. Building on this foundational philosophical literature, the discussion identifies three central axes of analysis: the role of causality in medical reasoning, the epistemic and relational dimensions of medical trust, and the criteria of explanatory adequacy as shaped by the pragmatic needs of diverse stakeholders. By integrating philosophical analysis with current developments in medical AI, the paper outlines principles for designing XAI systems that offer explanations that are not only epistemically robust but also aligned with the epistemic and practical requirements of clinical decision-making, shaping ongoing debates in medical XAI toward underexplored conceptual foundations.

MedCTA: A Benchmark for Clinical Tool Agents

To make clinically grounded decisions, medical AI agents are expected to go beyond simple recognition and be capable of tool retrieval, evidence acquisition, and integration. Existing benchmarks largely evaluate isolated perception or single-turn question answering, and therefore provide limited visibility into failures of planning, tool recruitment, and rollout reliability. We introduce MedCTA, a benchmark for evaluating medical tool agents on clinician-validated, step-implicit tasks grounded in realistic multimodal clinical inputs, including radiology images, pathology slides, and reports. MedCTA comprises 107 real-world clinical tasks with clinician-verified executable trajectories over 5 deployed tools, and supports process-aware evaluation of tool selection, argument validity, execution stability, trajectory fidelity, and outcome quality. We benchmark 18 open- and closed-source multimodal models and find that even frontier systems remain brittle in multi-step clinical tool use: autonomous rollouts are dominated by protocol failures, premature stopping, and incorrect tool recruitment, while gold-standard tool routing yields large but still incomplete gains. These results show that strong backbone perception does not translate into reliable agentic behavior in clinical settings. MedCTA provides a rigorous testbed for auditing, diagnosing, and advancing trustworthy medical AI agents. The dataset and evaluation suite are available at https://ivul-kaust.github.io/MedCTA/

HealthBench Professional: Evaluating Large Language Models on Real Clinician Chats

Millions of clinicians use ChatGPT to support clinical care, but evaluations of the most common use cases in model-clinician conversations are limited. We introduce HealthBench Professional, an open benchmark for evaluating large language models on real tasks that clinicians bring to ChatGPT in the course of their work. The benchmark is organized around three common use cases central to clinical practice: care consult, writing and documentation, and medical research. Each example includes a physician-authored conversation with ChatGPT for Clinicians and is scored via rubrics written and iteratively adjudicated by three or more physicians across three phases. HealthBench Professional examples were carefully selected for quality, representativeness, and difficulty for OpenAI's current frontier models, to enable continued measurement of progress. Difficult examples for recent OpenAI models were enriched by roughly 3.5 times relative to the candidate pool of 15,079 examples. Additionally, about one-third of examples involve physicians conducting deliberate adversarial testing of models. As a strong baseline, we also collected human physician responses for all tasks (unbounded time, specialist-matched, web access). The best scoring system, GPT-5.4 in ChatGPT for Clinicians, outperforms base GPT-5.4, all other models, and human physicians. We hope HealthBench Professional provides the healthcare AI community a measure to track frontier model progress in real-world clinical tasks and build systems that clinicians can trust to improve care.