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.

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.

Large language models (LLMs) have revolutionized natural language processing. However, effectively incorporating complex and potentially noisy user interaction data remains a challenge. To address this, we propose User-LLM, a novel framework that leverages user embeddings to contextualize LLMs. These embeddings, distilled from diverse user interactions using self-supervised pretraining, capture latent user preferences and their evolution over time. We integrate these user embeddings with LLMs through cross-attention and soft-prompting, enabling LLMs to dynamically adapt to user context. Our comprehensive experiments on MovieLens, Amazon Review, and Google Local Review datasets demonstrate significant performance gains across various tasks. Notably, our approach outperforms text-prompt-based contextualization on long sequence tasks and tasks that require deep user understanding while being computationally efficient. We further incorporate Perceiver layers to streamline the integration between user encoders and LLMs, reducing computational demands.

Answering complex natural language questions often necessitates multi-step reasoning and integrating external information. Several systems have combined knowledge retrieval with a large language model (LLM) to answer such questions. These systems, however, suffer from various failure cases, and we cannot directly train them end-to-end to fix such failures, as interaction with external knowledge is non-differentiable. To address these deficiencies, we define a ReAct-style LLM agent with the ability to reason and act upon external knowledge. We further refine the agent through a ReST-like method that iteratively trains on previous trajectories, employing growing-batch reinforcement learning with AI feedback for continuous self-improvement and self-distillation. Starting from a prompted large model and after just two iterations of the algorithm, we can produce a fine-tuned small model that achieves comparable performance on challenging compositional question-answering benchmarks with two orders of magnitude fewer parameters.

Reinforcement learning from human feedback (RLHF) has proven effective in aligning large language models (LLMs) with human preferences. However, gathering high-quality human preference labels can be a time-consuming and expensive endeavor. RL from AI Feedback (RLAIF), introduced by Bai et al., offers a promising alternative that leverages a powerful off-the-shelf LLM to generate preferences in lieu of human annotators. Across the tasks of summarization, helpful dialogue generation, and harmless dialogue generation, RLAIF achieves comparable or superior performance to RLHF, as rated by human evaluators. Furthermore, RLAIF demonstrates the ability to outperform a supervised fine-tuned baseline even when the LLM preference labeler is the same size as the policy. In another experiment, directly prompting the LLM for reward scores achieves superior performance to the canonical RLAIF setup, where LLM preference labels are first distilled into a reward model. Finally, we conduct extensive studies on techniques for generating aligned AI preferences. Our results suggest that RLAIF can achieve human-level performance, offering a potential solution to the scalability limitations of RLHF.

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.

Self-consistency with chain-of-thought prompting (CoT) has demonstrated remarkable performance gains on various challenging tasks, by utilizing multiple reasoning paths sampled from large language models (LLMs). However, self-consistency relies on the answer extraction process to aggregate multiple solutions, which is not applicable to free-form answers. In this work, we propose Universal Self-Consistency (USC), which leverages LLMs themselves to select the most consistent answer among multiple candidates. We evaluate USC on a variety of benchmarks, including mathematical reasoning, code generation, long-context summarization, and open-ended question answering. On open-ended generation tasks where the original self-consistency method is not applicable, USC effectively utilizes multiple samples and improves the performance. For mathematical reasoning, USC matches the standard self-consistency performance without requiring the answer formats to be similar. Finally, without access to execution results, USC also matches the execution-based voting performance on code generation.

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.

Recent artificial intelligence (AI) systems have reached milestones in "grand challenges" ranging from Go to protein-folding. The capability to retrieve medical knowledge, reason over it, and answer medical questions comparably to physicians has long been viewed as one such grand challenge. Large language models (LLMs) have catalyzed significant progress in medical question answering; Med-PaLM was the first model to exceed a "passing" score in US Medical Licensing Examination (USMLE) style questions with a score of 67.2% on the MedQA dataset. However, this and other prior work suggested significant room for improvement, especially when models' answers were compared to clinicians' answers. Here we present Med-PaLM 2, which bridges these gaps by leveraging a combination of base LLM improvements (PaLM 2), medical domain finetuning, and prompting strategies including a novel ensemble refinement approach. Med-PaLM 2 scored up to 86.5% on the MedQA dataset, improving upon Med-PaLM by over 19% and setting a new state-of-the-art. We also observed performance approaching or exceeding state-of-the-art across MedMCQA, PubMedQA, and MMLU clinical topics datasets. We performed detailed human evaluations on long-form questions along multiple axes relevant to clinical applications. In pairwise comparative ranking of 1066 consumer medical questions, physicians preferred Med-PaLM 2 answers to those produced by physicians on eight of nine axes pertaining to clinical utility (p < 0.001). We also observed significant improvements compared to Med-PaLM on every evaluation axis (p < 0.001) on newly introduced datasets of 240 long-form "adversarial" questions to probe LLM limitations. While further studies are necessary to validate the efficacy of these models in real-world settings, these results highlight rapid progress towards physician-level performance in medical question answering.

In human-human conversations, Context Tracking deals with identifying important entities and keeping track of their properties and relationships. This is a challenging problem that encompasses several subtasks such as slot tagging, coreference resolution, resolving plural mentions and entity linking. We approach this problem as an end-to-end modeling task where the conversational context is represented by an entity repository containing the entity references mentioned so far, their properties and the relationships between them. The repository is updated turn-by-turn, thus making training and inference computationally efficient even for long conversations. This paper lays the groundwork for an investigation of this framework in two ways. First, we release Contrack, a large scale human-human conversation corpus for context tracking with people and location annotations. It contains over 7000 conversations with an average of 11.8 turns, 5.8 entities and 15.2 references per conversation. Second, we open-source a neural network architecture for context tracking. Finally we compare this network to state-of-the-art approaches for the subtasks it subsumes and report results on the involved tradeoffs.