MedG-KRP: Medical Graph Knowledge Representation Probing

Large language models (LLMs) have recently emerged as powerful tools, finding many medical applications. LLMs' ability to coalesce vast amounts of information from many sources to generate a response-a process similar to that of a human expert-has led many to see potential in deploying LLMs for clinical use. However, medicine is a setting where accurate reasoning is paramount. Many researchers are questioning the effectiveness of multiple choice question answering (MCQA) benchmarks, frequently used to test LLMs. Researchers and clinicians alike must have complete confidence in LLMs' abilities for them to be deployed in a medical setting. To address this need for understanding, we introduce a knowledge graph (KG)-based method to evaluate the biomedical reasoning abilities of LLMs. Essentially, we map how LLMs link medical concepts in order to better understand how they reason. We test GPT-4, Llama3-70b, and PalmyraMed-70b, a specialized medical model. We enlist a panel of medical students to review a total of 60 LLM-generated graphs and compare these graphs to BIOS, a large biomedical KG. We observe GPT-4 to perform best in our human review but worst in our ground truth comparison; vice-versa with PalmyraMed, the medical model. Our work provides a means of visualizing the medical reasoning pathways of LLMs so they can be implemented in clinical settings safely and effectively.

MedMobile: A mobile-sized language model with expert-level clinical capabilities

Language models (LMs) have demonstrated expert-level reasoning and recall abilities in medicine. However, computational costs and privacy concerns are mounting barriers to wide-scale implementation. We introduce a parsimonious adaptation of phi-3-mini, MedMobile, a 3.8 billion parameter LM capable of running on a mobile device, for medical applications. We demonstrate that MedMobile scores 75.7% on the MedQA (USMLE), surpassing the passing mark for physicians (~60%), and approaching the scores of models 100 times its size. We subsequently perform a careful set of ablations, and demonstrate that chain of thought, ensembling, and fine-tuning lead to the greatest performance gains, while unexpectedly retrieval augmented generation fails to demonstrate significant improvements

Refining Packing and Shuffling Strategies for Enhanced Performance in Generative Language Models

Packing and shuffling tokens is a common practice in training auto-regressive language models (LMs) to prevent overfitting and improve efficiency. Typically documents are concatenated to chunks of maximum sequence length (MSL) and then shuffled. However setting the atom size, the length for each data chunk accompanied by random shuffling, to MSL may lead to contextual incoherence due to tokens from different documents being packed into the same chunk. An alternative approach is to utilize padding, another common data packing strategy, to avoid contextual incoherence by only including one document in each shuffled chunk. To optimize both packing strategies (concatenation vs padding), we investigated the optimal atom size for shuffling and compared their performance and efficiency. We found that matching atom size to MSL optimizes performance for both packing methods (concatenation and padding), and padding yields lower final perplexity (higher performance) than concatenation at the cost of more training steps and lower compute efficiency. This trade-off informs the choice of packing methods in training language models.

Generalization in Healthcare AI: Evaluation of a Clinical Large Language Model

Advances in large language models (LLMs) provide new opportunities in healthcare for improved patient care, clinical decision-making, and enhancement of physician and administrator workflows. However, the potential of these models importantly depends on their ability to generalize effectively across clinical environments and populations, a challenge often underestimated in early development. To better understand reasons for these challenges and inform mitigation approaches, we evaluated ClinicLLM, an LLM trained on [HOSPITAL]'s clinical notes, analyzing its performance on 30-day all-cause readmission prediction focusing on variability across hospitals and patient characteristics. We found poorer generalization particularly in hospitals with fewer samples, among patients with government and unspecified insurance, the elderly, and those with high comorbidities. To understand reasons for lack of generalization, we investigated sample sizes for fine-tuning, note content (number of words per note), patient characteristics (comorbidity level, age, insurance type, borough), and health system aspects (hospital, all-cause 30-day readmission, and mortality rates). We used descriptive statistics and supervised classification to identify features. We found that, along with sample size, patient age, number of comorbidities, and the number of words in notes are all important factors related to generalization. Finally, we compared local fine-tuning (hospital specific), instance-based augmented fine-tuning and cluster-based fine-tuning for improving generalization. Among these, local fine-tuning proved most effective, increasing AUC by 0.25% to 11.74% (most helpful in settings with limited data). Overall, this study provides new insights for enhancing the deployment of large language models in the societally important domain of healthcare, and improving their performance for broader populations.

Making the Most Out of the Limited Context Length: Predictive Power Varies with Clinical Note Type and Note Section

Recent advances in large language models have led to renewed interest in natural language processing in healthcare using the free text of clinical notes. One distinguishing characteristic of clinical notes is their long time span over multiple long documents. The unique structure of clinical notes creates a new design choice: when the context length for a language model predictor is limited, which part of clinical notes should we choose as the input? Existing studies either choose the inputs with domain knowledge or simply truncate them. We propose a framework to analyze the sections with high predictive power. Using MIMIC-III, we show that: 1) predictive power distribution is different between nursing notes and discharge notes and 2) combining different types of notes could improve performance when the context length is large. Our findings suggest that a carefully selected sampling function could enable more efficient information extraction from clinical notes.

Identifying and mitigating bias in algorithms used to manage patients in a pandemic

Numerous COVID-19 clinical decision support systems have been developed. However many of these systems do not have the merit for validity due to methodological shortcomings including algorithmic bias. Methods Logistic regression models were created to predict COVID-19 mortality, ventilator status and inpatient status using a real-world dataset consisting of four hospitals in New York City and analyzed for biases against race, gender and age. Simple thresholding adjustments were applied in the training process to establish more equitable models. Results Compared to the naively trained models, the calibrated models showed a 57% decrease in the number of biased trials, while predictive performance, measured by area under the receiver/operating curve (AUC), remained unchanged. After calibration, the average sensitivity of the predictive models increased from 0.527 to 0.955. Conclusion We demonstrate that naively training and deploying machine learning models on real world data for predictive analytics of COVID-19 has a high risk of bias. Simple implemented adjustments or calibrations during model training can lead to substantial and sustained gains in fairness on subsequent deployment.