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.

One Panel Does Not Fit All: Case-Adaptive Multi-Agent Deliberation for Clinical Prediction

Large language models applied to clinical prediction exhibit case-level heterogeneity: simple cases yield consistent outputs, while complex cases produce divergent predictions under minor prompt changes. Existing single-agent strategies sample from one role-conditioned distribution, and multi-agent frameworks use fixed roles with flat majority voting, discarding the diagnostic signal in disagreement. We propose CAMP (Case-Adaptive Multi-agent Panel), where an attending-physician agent dynamically assembles a specialist panel tailored to each case's diagnostic uncertainty. Each specialist evaluates candidates via three-valued voting (KEEP/REFUSE/NEUTRAL), enabling principled abstention outside one's expertise. A hybrid router directs each diagnosis through strong consensus, fallback to the attending physician's judgment, or evidence-based arbitration that weighs argument quality over vote counts. On diagnostic prediction and brief hospital course generation from MIMIC-IV across four LLM backbones, CAMP consistently outperforms strong baselines while consuming fewer tokens than most competing multi-agent methods, with voting records and arbitration traces offering transparent decision audits.