Architecting Clinical Intelligence: Agentic LLMs for Reliable Healthcare Dialogue

Executive Summary

The core challenge in applying Large Language Models (LLMs) to clinical settings is balancing linguistic fluency with factual accuracy and safety. Traditional LLMs are reactive and stateless, often prioritizing plausible text over evidence-based truth. This survey outlines a critical paradigm shift: moving from generative text prediction to agentic systems. These agents function as reasoning engines, incorporating deliberate planning, persistent memory, and action execution. This shift is essential for enabling LLMs to handle the complex duality of clinical dialogue, which demands both empathy and rigorous medical precision. The paper introduces a novel taxonomy to analyze architectures based on knowledge source and operational objective, providing a necessary framework for developing safer, more reliable AI assistants in medicine.

The Motivation: What Problem Does This Solve?

Clinical communication is highly nuanced. It requires an AI system to simultaneously understand complex medical terminology, adhere strictly to evidence-based protocols, and maintain an empathetic, human-like conversational flow. Prior approaches, relying on fine-tuned but fundamentally reactive LLMs, often suffer from critical failures like hallucination, lack of context persistence across turns, and inability to autonomously verify external information. This gap necessitates an architecture that can actively plan, retrieve grounding information, and execute actions- essentially shifting the AI from a mere predictor to a reliable, proactive clinical assistant.

Key Contributions

How the Method Works

The paper surveys existing and theoretical agentic models by analyzing their cognitive pipeline. Instead of simply generating the next likely token, these agents follow a structured reasoning process. This process begins with strategic planning, where the agent determines the steps needed to address a clinical query or task. Persistent memory management is crucial for maintaining historical context, simulating the long-term knowledge needed in patient care. Action execution involves the agent using external tools (like search engines or EMR interfaces) to gather verifiable evidence. Grounded Synthesizers, for example, heavily rely on accessing external clinical knowledge bases before formulating a response, ensuring factual veracity. In contrast, Latent Space Clinicians rely primarily on knowledge embedded during pre-training, favoring rapid responses but potentially lacking real-time evidence updates. The overall methodology emphasizes replacing probabilistic plausibility with structured, verifiable decision-making.

Results & Benchmarks

This paper serves as a comprehensive survey and architectural framework rather than a primary research piece presenting new benchmarks. The authors do not provide quantitative performance metrics comparing the four agent archetypes (Latent Space Clinicians, Emergent Planners, Grounded Synthesizers, Verifiable Workflow Automators) on specific clinical datasets. Therefore, we cannot report metrics such as F1 scores or accuracy improvements. However, the qualitative finding is that systems exhibiting higher Verifiable Workflow Automation capabilities are theoretically superior for high-stakes clinical dialogue due to their emphasis on factual grounding and safety protocols over creative inference.

Strengths: What This Research Achieves

The primary strength of this work is establishing a foundational, first-principles taxonomy for clinical AI agents. This framework moves the discussion beyond mere downstream applications to critically assess the underlying cognitive architectures. It forces developers and architects to consciously address the tension between necessary autonomy and required clinical safety. Additionally, the systematic pipeline analysis - covering planning, memory, and action - provides a robust blueprint for engineering reliable, multi-step dialogue systems in medicine.

Limitations & Failure Cases

Since this is a survey, the limitations are structural rather than empirical. The primary limitation is the lack of specific, reported quantitative data comparing the defined archetypes on unified clinical benchmarks. While the theoretical trade-offs are identified (e.g., Latent Space Clinicians may prioritize creativity over reliability), the true cost of autonomy versus safety remains unquantified without performance metrics. Additionally, the reliance on external knowledge sources (Grounded Synthesizers) introduces engineering challenges related to tool reliability, latency, and managing the dynamic nature of real-time clinical data streams. Edge cases related to complex, multi-modal patient data or rare disease diagnostics may still challenge even the most robust Verifiable Workflow Automators.

Real-World Implications & Applications

If agentic paradigms are successfully integrated into clinical workflows, the impact will be substantial. It transitions AI from being a passive information retrieval tool to an active diagnostic and procedural co-pilot. This shift promises to significantly reduce cognitive load on physicians by automating structured tasks like protocol adherence checking, complex longitudinal history summarization, and generating preliminary evidence-based differential diagnoses. Furthermore, agentic systems can facilitate more consistent and safer patient communication by ensuring all dialogue adheres strictly to verified clinical guidelines, potentially revolutionizing patient-facing interfaces and tele-health interactions.

Relation to Prior Work

Historically, medical LLMs focused on direct generative tasks, often leveraging fine-tuning techniques (like instruction tuning) on existing clinical datasets. This led to models like MedPaLM or various open-source models adapted for medical QA. However, these models were inherently reactive: responding based on internal weights without external verification or multi-step reasoning. This paper advances the field by establishing that the state-of-the-art now requires agency- the ability to plan, execute actions (RAG or tool use), and manage state. It systematically organizes this transition, filling the gap left by previous reviews that only cataloged the *what* (applications) instead of analyzing the *how* (architecture and cognitive process).

Conclusion: Why This Paper Matters

This research offers a critical architectural roadmap for the future of clinical AI. By rigorously defining the necessary components of agentic clinical systems- planning, memory, and execution - it provides the necessary technical scaffolding to move past the limitations of purely probabilistic generative AI. The key insight is that safety in healthcare AI is not merely a post-processing filter, but an intrinsic architectural requirement, best addressed through Verifiable Workflow Automators that prioritize grounded evidence over linguistic fluency. This taxonomy will guide responsible innovation in medical informatics.

Appendix

The cognitive pipeline described encompasses five key stages: strategic planning (breaking down the task), memory management (maintaining state and history), action execution (using external tools/APIs), collaboration (interacting with other agents or systems), and evolution (learning and adapting based on outcomes). The categorization of agents (Latent Space, Emergent, Grounded, Verifiable) helps identify where engineering resources must be allocated to enhance reliability and decrease clinical risk in high-stakes environments.