Human-in-the-Loop Multi-Agent Ventilator Decision Support with Contextual Bandit Preference Learning

Ventilator decision support requires sequential decisions that track evolving physiology and disease trajectories while respecting safety boundaries and clinician specific tuning styles. Rule based approaches rarely generalize personalization, and end to end reinforcement learning or single large language model systems remain difficult to control and audit. We propose the Ventilator Decision Support System (VDSS), a human in the loop multi agent framework that coordinates modular decision components through contract driven structured interfaces and produces traceable evidence for review. VDSS performs online preference adaptation with a contextual bandit, updating clinician specific preferences from the final accepted decision at each adjustment cycle and using them to guide subsequent recommendations. Structured rejection feedback triggers targeted replanning to reduce unproductive iterations and improve interaction stability. Retrospective ICU trajectory replay with expert review indicates higher recommendation acceptability and fewer interaction rounds to reach an acceptable plan, supporting clinically deployable human AI collaboration.

Active Evidence-Seeking and Diagnostic Reasoning in Large Language Models for Clinical Decision Support

Large language models perform well on static medical examinations, yet clinical diagnosis often requires iterative evidence gathering under uncertainty. Building on prior interactive evaluation efforts, we introduce an OSCE-inspired standardized patient simulator and a controlled, reproducible benchmark for active diagnostic inquiry. Across 468 cases and 15 models in our protocol, we observe that multi-turn evidence seeking reduces diagnostic accuracy by 12.75% and lowers supporting-evidence quality by 24.36% relative to full-context evaluation; error analyses associate these drops with premature diagnostic closure and inefficient questioning. Together, these results suggest that static full-context benchmarks may overestimate performance in interactive evidence-seeking settings, motivating complementary interactive assessment for safer clinical decision support.

From Answers to Arguments: Toward Trustworthy Clinical Diagnostic Reasoning with Toulmin-Guided Curriculum Goal-Conditioned Learning

The integration of Large Language Models (LLMs) into clinical decision support is critically obstructed by their opaque and often unreliable reasoning. In the high-stakes domain of healthcare, correct answers alone are insufficient; clinical practice demands full transparency to ensure patient safety and enable professional accountability. A pervasive and dangerous weakness of current LLMs is their tendency to produce "correct answers through flawed reasoning." This issue is far more than a minor academic flaw; such process errors signal a fundamental lack of robust understanding, making the model prone to broader hallucinations and unpredictable failures when faced with real-world clinical complexity. In this paper, we establish a framework for trustworthy clinical argumentation by adapting the Toulmin model to the diagnostic process. We propose a novel training pipeline: Curriculum Goal-Conditioned Learning (CGCL), designed to progressively train LLM to generate diagnostic arguments that explicitly follow this Toulmin structure. CGCL's progressive three-stage curriculum systematically builds a solid clinical argument: (1) extracting facts and generating differential diagnoses; (2) justifying a core hypothesis while rebutting alternatives; and (3) synthesizing the analysis into a final, qualified conclusion. We validate CGCL using T-Eval, a quantitative framework measuring the integrity of the diagnosis reasoning. Experiments show that our method achieves diagnostic accuracy and reasoning quality comparable to resource-intensive Reinforcement Learning (RL) methods, while offering a more stable and efficient training pipeline.

PRISM: Festina Lente Proactivity -- Risk-Sensitive, Uncertainty-Aware Deliberation for Proactive Agents

Proactive agents must decide not only what to say but also whether and when to intervene. Many current systems rely on brittle heuristics or indiscriminate long reasoning, which offers little control over the benefit-burden tradeoff. We formulate the problem as cost-sensitive selective intervention and present PRISM, a novel framework that couples a decision-theoretic gate with a dual-process reasoning architecture. At inference time, the agent intervenes only when a calibrated probability of user acceptance exceeds a threshold derived from asymmetric costs of missed help and false alarms. Inspired by festina lente (Latin: "make haste slowly"), we gate by an acceptance-calibrated, cost-derived threshold and invoke a resource-intensive Slow mode with counterfactual checks only near the decision boundary, concentrating computation on ambiguous and high-stakes cases. Training uses gate-aligned, schema-locked distillation: a teacher running the full PRISM pipeline provides dense, executable supervision on unlabeled interaction traces, while the student learns a response policy that is explicitly decoupled from the intervention gate to enable tunable and auditable control. On ProactiveBench, PRISM reduces false alarms by 22.78% and improves F1 by 20.14% over strong baselines. These results show that principled decision-theoretic gating, paired with selective slow reasoning and aligned distillation, yields proactive agents that are precise, computationally efficient, and controllable. To facilitate reproducibility, we release our code, models, and resources at https://prism-festinalente.github.io/; all experiments use the open-source ProactiveBench benchmark.