A Toolbox for Surfacing Health Equity Harms and Biases in Large Language Models

Large language models (LLMs) hold immense promise to serve complex health information needs but also have the potential to introduce harm and exacerbate health disparities. Reliably evaluating equity-related model failures is a critical step toward developing systems that promote health equity. In this work, we present resources and methodologies for surfacing biases with potential to precipitate equity-related harms in long-form, LLM-generated answers to medical questions and then conduct an empirical case study with Med-PaLM 2, resulting in the largest human evaluation study in this area to date. Our contributions include a multifactorial framework for human assessment of LLM-generated answers for biases, and EquityMedQA, a collection of seven newly-released datasets comprising both manually-curated and LLM-generated questions enriched for adversarial queries. Both our human assessment framework and dataset design process are grounded in an iterative participatory approach and review of possible biases in Med-PaLM 2 answers to adversarial queries. Through our empirical study, we find that the use of a collection of datasets curated through a variety of methodologies, coupled with a thorough evaluation protocol that leverages multiple assessment rubric designs and diverse rater groups, surfaces biases that may be missed via narrower evaluation approaches. Our experience underscores the importance of using diverse assessment methodologies and involving raters of varying backgrounds and expertise. We emphasize that while our framework can identify specific forms of bias, it is not sufficient to holistically assess whether the deployment of an AI system promotes equitable health outcomes. We hope the broader community leverages and builds on these tools and methods towards realizing a shared goal of LLMs that promote accessible and equitable healthcare for all.

Augmentations vs Algorithms: What Works in Self-Supervised Learning

We study the relative effects of data augmentations, pretraining algorithms, and model architectures in Self-Supervised Learning (SSL). While the recent literature in this space leaves the impression that the pretraining algorithm is of critical importance to performance, understanding its effect is complicated by the difficulty in making objective and direct comparisons between methods. We propose a new framework which unifies many seemingly disparate SSL methods into a single shared template. Using this framework, we identify aspects in which methods differ and observe that in addition to changing the pretraining algorithm, many works also use new data augmentations or more powerful model architectures. We compare several popular SSL methods using our framework and find that many algorithmic additions, such as prediction networks or new losses, have a minor impact on downstream task performance (often less than $1\%$), while enhanced augmentation techniques offer more significant performance improvements ($2-4\%$). Our findings challenge the premise that SSL is being driven primarily by algorithmic improvements, and suggest instead a bitter lesson for SSL: that augmentation diversity and data / model scale are more critical contributors to recent advances in self-supervised learning.

Towards Conversational Diagnostic AI

At the heart of medicine lies the physician-patient dialogue, where skillful history-taking paves the way for accurate diagnosis, effective management, and enduring trust. Artificial Intelligence (AI) systems capable of diagnostic dialogue could increase accessibility, consistency, and quality of care. However, approximating clinicians' expertise is an outstanding grand challenge. Here, we introduce AMIE (Articulate Medical Intelligence Explorer), a Large Language Model (LLM) based AI system optimized for diagnostic dialogue. AMIE uses a novel self-play based simulated environment with automated feedback mechanisms for scaling learning across diverse disease conditions, specialties, and contexts. We designed a framework for evaluating clinically-meaningful axes of performance including history-taking, diagnostic accuracy, management reasoning, communication skills, and empathy. We compared AMIE's performance to that of primary care physicians (PCPs) in a randomized, double-blind crossover study of text-based consultations with validated patient actors in the style of an Objective Structured Clinical Examination (OSCE). The study included 149 case scenarios from clinical providers in Canada, the UK, and India, 20 PCPs for comparison with AMIE, and evaluations by specialist physicians and patient actors. AMIE demonstrated greater diagnostic accuracy and superior performance on 28 of 32 axes according to specialist physicians and 24 of 26 axes according to patient actors. Our research has several limitations and should be interpreted with appropriate caution. Clinicians were limited to unfamiliar synchronous text-chat which permits large-scale LLM-patient interactions but is not representative of usual clinical practice. While further research is required before AMIE could be translated to real-world settings, the results represent a milestone towards conversational diagnostic AI.

Consensus, dissensus and synergy between clinicians and specialist foundation models in radiology report generation

Radiology reports are an instrumental part of modern medicine, informing key clinical decisions such as diagnosis and treatment. The worldwide shortage of radiologists, however, restricts access to expert care and imposes heavy workloads, contributing to avoidable errors and delays in report delivery. While recent progress in automated report generation with vision-language models offer clear potential in ameliorating the situation, the path to real-world adoption has been stymied by the challenge of evaluating the clinical quality of AI-generated reports. In this study, we build a state-of-the-art report generation system for chest radiographs, \textit{Flamingo-CXR}, by fine-tuning a well-known vision-language foundation model on radiology data. To evaluate the quality of the AI-generated reports, a group of 16 certified radiologists provide detailed evaluations of AI-generated and human written reports for chest X-rays from an intensive care setting in the United States and an inpatient setting in India. At least one radiologist (out of two per case) preferred the AI report to the ground truth report in over 60$\%$ of cases for both datasets. Amongst the subset of AI-generated reports that contain errors, the most frequently cited reasons were related to the location and finding, whereas for human written reports, most mistakes were related to severity and finding. This disparity suggested potential complementarity between our AI system and human experts, prompting us to develop an assistive scenario in which \textit{Flamingo-CXR} generates a first-draft report, which is subsequently revised by a clinician. This is the first demonstration of clinician-AI collaboration for report writing, and the resultant reports are assessed to be equivalent or preferred by at least one radiologist to reports written by experts alone in 80$\%$ of in-patient cases and 60$\%$ of intensive care cases.

SASSL: Enhancing Self-Supervised Learning via Neural Style Transfer

Self-supervised learning relies heavily on data augmentation to extract meaningful representations from unlabeled images. While existing state-of-the-art augmentation pipelines incorporate a wide range of primitive transformations, these often disregard natural image structure. Thus, augmented samples can exhibit degraded semantic information and low stylistic diversity, affecting downstream performance of self-supervised representations. To overcome this, we propose SASSL: Style Augmentations for Self Supervised Learning, a novel augmentation technique based on Neural Style Transfer. The method decouples semantic and stylistic attributes in images and applies transformations exclusively to the style while preserving content, generating diverse augmented samples that better retain their semantic properties. Experimental results show our technique achieves a top-1 classification performance improvement of more than 2% on ImageNet compared to the well-established MoCo v2. We also measure transfer learning performance across five diverse datasets, observing significant improvements of up to 3.75%. Our experiments indicate that decoupling style from content information and transferring style across datasets to diversify augmentations can significantly improve downstream performance of self-supervised representations.

Disentangling the Effects of Data Augmentation and Format Transform in Self-Supervised Learning of Image Representations

Self-Supervised Learning (SSL) enables training performant models using limited labeled data. One of the pillars underlying vision SSL is the use of data augmentations/perturbations of the input which do not significantly alter its semantic content. For audio and other temporal signals, augmentations are commonly used alongside format transforms such as Fourier transforms or wavelet transforms. Unlike augmentations, format transforms do not change the information contained in the data; rather, they express the same information in different coordinates. In this paper, we study the effects of format transforms and augmentations both separately and together on vision SSL. We define augmentations in frequency space called Fourier Domain Augmentations (FDA) and show that training SSL models on a combination of these and image augmentations can improve the downstream classification accuracy by up to 1.3% on ImageNet-1K. We also show improvements against SSL baselines in few-shot and transfer learning setups using FDA. Surprisingly, we also observe that format transforms can improve the quality of learned representations even without augmentations; however, the combination of the two techniques yields better quality.

Towards Accurate Differential Diagnosis with Large Language Models

An accurate differential diagnosis (DDx) is a cornerstone of medical care, often reached through an iterative process of interpretation that combines clinical history, physical examination, investigations and procedures. Interactive interfaces powered by Large Language Models (LLMs) present new opportunities to both assist and automate aspects of this process. In this study, we introduce an LLM optimized for diagnostic reasoning, and evaluate its ability to generate a DDx alone or as an aid to clinicians. 20 clinicians evaluated 302 challenging, real-world medical cases sourced from the New England Journal of Medicine (NEJM) case reports. Each case report was read by two clinicians, who were randomized to one of two assistive conditions: either assistance from search engines and standard medical resources, or LLM assistance in addition to these tools. All clinicians provided a baseline, unassisted DDx prior to using the respective assistive tools. Our LLM for DDx exhibited standalone performance that exceeded that of unassisted clinicians (top-10 accuracy 59.1% vs 33.6%, [p = 0.04]). Comparing the two assisted study arms, the DDx quality score was higher for clinicians assisted by our LLM (top-10 accuracy 51.7%) compared to clinicians without its assistance (36.1%) (McNemar's Test: 45.7, p < 0.01) and clinicians with search (44.4%) (4.75, p = 0.03). Further, clinicians assisted by our LLM arrived at more comprehensive differential lists than those without its assistance. Our study suggests that our LLM for DDx has potential to improve clinicians' diagnostic reasoning and accuracy in challenging cases, meriting further real-world evaluation for its ability to empower physicians and widen patients' access to specialist-level expertise.

Random Field Augmentations for Self-Supervised Representation Learning

Self-supervised representation learning is heavily dependent on data augmentations to specify the invariances encoded in representations. Previous work has shown that applying diverse data augmentations is crucial to downstream performance, but augmentation techniques remain under-explored. In this work, we propose a new family of local transformations based on Gaussian random fields to generate image augmentations for self-supervised representation learning. These transformations generalize the well-established affine and color transformations (translation, rotation, color jitter, etc.) and greatly increase the space of augmentations by allowing transformation parameter values to vary from pixel to pixel. The parameters are treated as continuous functions of spatial coordinates, and modeled as independent Gaussian random fields. Empirical results show the effectiveness of the new transformations for self-supervised representation learning. Specifically, we achieve a 1.7% top-1 accuracy improvement over baseline on ImageNet downstream classification, and a 3.6% improvement on out-of-distribution iNaturalist downstream classification. However, due to the flexibility of the new transformations, learned representations are sensitive to hyperparameters. While mild transformations improve representations, we observe that strong transformations can degrade the structure of an image, indicating that balancing the diversity and strength of augmentations is important for improving generalization of learned representations.

Towards Federated Learning Under Resource Constraints via Layer-wise Training and Depth Dropout

Large machine learning models trained on diverse data have recently seen unprecedented success. Federated learning enables training on private data that may otherwise be inaccessible, such as domain-specific datasets decentralized across many clients. However, federated learning can be difficult to scale to large models when clients have limited resources. This challenge often results in a trade-off between model size and access to diverse data. To mitigate this issue and facilitate training of large models on edge devices, we introduce a simple yet effective strategy, Federated Layer-wise Learning, to simultaneously reduce per-client memory, computation, and communication costs. Clients train just a single layer each round, reducing resource costs considerably with minimal performance degradation. We also introduce Federated Depth Dropout, a complementary technique that randomly drops frozen layers during training, to further reduce resource usage. Coupling these two techniques enables us to effectively train significantly larger models on edge devices. Specifically, we reduce training memory usage by 5x or more in federated self-supervised representation learning and demonstrate that performance in downstream tasks is comparable to conventional federated self-supervised learning.

Towards Generalist Biomedical AI

Medicine is inherently multimodal, with rich data modalities spanning text, imaging, genomics, and more. Generalist biomedical artificial intelligence (AI) systems that flexibly encode, integrate, and interpret this data at scale can potentially enable impactful applications ranging from scientific discovery to care delivery. To enable the development of these models, we first curate MultiMedBench, a new multimodal biomedical benchmark. MultiMedBench encompasses 14 diverse tasks such as medical question answering, mammography and dermatology image interpretation, radiology report generation and summarization, and genomic variant calling. We then introduce Med-PaLM Multimodal (Med-PaLM M), our proof of concept for a generalist biomedical AI system. Med-PaLM M is a large multimodal generative model that flexibly encodes and interprets biomedical data including clinical language, imaging, and genomics with the same set of model weights. Med-PaLM M reaches performance competitive with or exceeding the state of the art on all MultiMedBench tasks, often surpassing specialist models by a wide margin. We also report examples of zero-shot generalization to novel medical concepts and tasks, positive transfer learning across tasks, and emergent zero-shot medical reasoning. To further probe the capabilities and limitations of Med-PaLM M, we conduct a radiologist evaluation of model-generated (and human) chest X-ray reports and observe encouraging performance across model scales. In a side-by-side ranking on 246 retrospective chest X-rays, clinicians express a pairwise preference for Med-PaLM M reports over those produced by radiologists in up to 40.50% of cases, suggesting potential clinical utility. While considerable work is needed to validate these models in real-world use cases, our results represent a milestone towards the development of generalist biomedical AI systems.