Daily Papers

Recent advancements in Large Language Models (LLMs) have positioned them as powerful tools for clinical decision-making, with rapidly expanding applications in healthcare. However, concerns about bias remain a significant challenge in the clinical implementation of LLMs, particularly regarding gender and ethnicity. This research investigates the evaluation and mitigation of bias in LLMs applied to complex clinical cases, focusing on gender and ethnicity biases. We introduce a novel Counterfactual Patient Variations (CPV) dataset derived from the JAMA Clinical Challenge. Using this dataset, we built a framework for bias evaluation, employing both Multiple Choice Questions (MCQs) and corresponding explanations. We explore prompting with eight LLMs and fine-tuning as debiasing methods. Our findings reveal that addressing social biases in LLMs requires a multidimensional approach as mitigating gender bias can occur while introducing ethnicity biases, and that gender bias in LLM embeddings varies significantly across medical specialities. We demonstrate that evaluating both MCQ response and explanation processes is crucial, as correct responses can be based on biased reasoning. We provide a framework for evaluating LLM bias in real-world clinical cases, offer insights into the complex nature of bias in these models, and present strategies for bias mitigation.

Counterfactual prompting (i.e., perturbing a single factor and measuring output change) is widely used to evaluate things like LLM bias and CoT faithfulness. But in this work we argue that observed effects cannot be attributed to the targeted factor without accounting for baseline ``meaning-preserving'' modifications to text that establish general model sensitivity. This is because every counterfactual edit is a compound treatment that bundles the variable of interest with incidental surface-form variation; this violates treatment variation irrelevance. We observe prediction flip rates on MedQA of 14.9% when we surgically change patient gender. However, this is statistically indistinguishable from the flip rates induced by simply paraphrasing inputs (14.1%). In this case, it would therefore be unwarranted to conclude that the LLM is especially sensitive to patient gender. To account for this and robustly measure the effects of targeted interventions, we propose a framework in which we compare (via statistical testing) differences observed under target interventions to those induced by paraphrasing inputs. We then use this framework to revisit a analysis done on the MedPerturb dataset, which reported evidence of model sensitivity to patient demographics and stylistic cues. We find that these effects largely dissipate when we account for general model sensitivity, with only 5 of 120 tests reaching statistical significance. Applying the same framework to occupational biography classification, we detect clearly significant directional gender bias, showing that the framework identifies real directional effects even when they are small. We evaluate a range of metrics -- aggregate, per-sample distributional, and regression -- and find that per-sample metrics are dramatically more powerful than aggregate metrics and regression powerfully and uniquely characterizes effect direction and magnitude.

Counterfactual medical image generation enables clinicians to explore clinical hypotheses, such as predicting disease progression, facilitating their decision-making. While existing methods can generate visually plausible images from disease progression prompts, they produce silent predictions that lack interpretation to verify how the generation reflects the hypothesized progression -- a critical gap for medical applications that require traceable reasoning. In this paper, we propose Interpretable Counterfactual Generation (ICG), a novel task requiring the joint generation of counterfactual images that reflect the clinical hypothesis and interpretation texts that outline the visual changes induced by the hypothesis. To enable ICG, we present ICG-CXR, the first dataset pairing longitudinal medical images with hypothetical progression prompts and textual interpretations. We further introduce ProgEmu, an autoregressive model that unifies the generation of counterfactual images and textual interpretations. We demonstrate the superiority of ProgEmu in generating progression-aligned counterfactuals and interpretations, showing significant potential in enhancing clinical decision support and medical education. Project page: https://progemu.github.io.

Despite achieving high accuracy on medical benchmarks, LLMs exhibit the Einstellung Effect in clinical diagnosis--relying on statistical shortcuts rather than patient-specific evidence, causing misdiagnosis in atypical cases. Existing benchmarks fail to detect this critical failure mode. We introduce MedEinst, a counterfactual benchmark with 5,383 paired clinical cases across 49 diseases. Each pair contains a control case and a "trap" case with altered discriminative evidence that flips the diagnosis. We measure susceptibility via Bias Trap Rate--probability of misdiagnosing traps despite correctly diagnosing controls. Extensive Evaluation of 17 LLMs shows frontier models achieve high baseline accuracy but severe bias trap rates. Thus, we propose ECR-Agent, aligning LLM reasoning with Evidence-Based Medicine standard via two components: (1) Dynamic Causal Inference (DCI) performs structured reasoning through dual-pathway perception, dynamic causal graph reasoning across three levels (association, intervention, counterfactual), and evidence audit for final diagnosis; (2) Critic-Driven Graph and Memory Evolution (CGME) iteratively refines the system by storing validated reasoning paths in an exemplar base and consolidating disease-specific knowledge into evolving illness graphs. Source code is to be released.

Counterfactual explanations are attracting significant attention due to the flourishing applications of machine learning models in consequential domains. A counterfactual plan consists of multiple possibilities to modify a given instance so that the model's prediction will be altered. As the predictive model can be updated subject to the future arrival of new data, a counterfactual plan may become ineffective or infeasible with respect to the future values of the model parameters. In this work, we study the counterfactual plans under model uncertainty, in which the distribution of the model parameters is partially prescribed using only the first- and second-moment information. First, we propose an uncertainty quantification tool to compute the lower and upper bounds of the probability of validity for any given counterfactual plan. We then provide corrective methods to adjust the counterfactual plan to improve the validity measure. The numerical experiments validate our bounds and demonstrate that our correction increases the robustness of the counterfactual plans in different real-world datasets.

This study evaluates the effect of counterfactual explanations on the interpretation of chest X-rays. We conduct a reader study with two radiologists assessing 240 chest X-ray predictions to rate their confidence that the model's prediction is correct using a 5 point scale. Half of the predictions are false positives. Each prediction is explained twice, once using traditional attribution methods and once with a counterfactual explanation. The overall results indicate that counterfactual explanations allow a radiologist to have more confidence in true positive predictions compared to traditional approaches (0.15pm0.95 with p=0.01) with only a small increase in false positive predictions (0.04pm1.06 with p=0.57). We observe the specific prediction tasks of Mass and Atelectasis appear to benefit the most compared to other tasks.

Counterfactual explanations enhance the interpretability of deep learning models in medical imaging, yet adapting them to 3D CT scans poses challenges due to volumetric complexity and resource demands. We extend the Latent Shift counterfactual generation method from 2D applications to explain 3D computed tomography (CT) scans classifiers. We address the challenges associated with 3D classifiers, such as limited training samples and high memory demands, by implementing a slice-based autoencoder and gradient blocking except for specific chunks of slices. This method leverages a 2D encoder trained on CT slices, which are subsequently combined to maintain 3D context. We demonstrate this technique on two models for clinical phenotype prediction and lung segmentation. Our approach is both memory-efficient and effective for generating interpretable counterfactuals in high-resolution 3D medical imaging.

This paper uncovers a critical yet overlooked phenomenon in multi-modal large language models (MLLMs): detrimental concept drift within chain-of-thought (CoT) reasoning during non-stationary reinforcement fine-tuning (RFT), where reasoning token distributions evolve unpredictably, thereby introducing significant biases in final predictions. To address this, we are pioneers in establishing the theoretical bridge between concept drift theory and RFT processes by formalizing CoT's autoregressive token streams as non-stationary distributions undergoing arbitrary temporal shifts. Leveraging this framework, we propose a novel counterfact-aware RFT that systematically decouples beneficial distribution adaptation from harmful concept drift through concept graph-empowered LLM experts generating counterfactual reasoning trajectories. Our solution, Counterfactual Preference Optimization (CPO), enables stable RFT in non-stationary environments, particularly within the medical domain, through custom-tuning of counterfactual-aware preference alignment. Extensive experiments demonstrate our superior performance of robustness, generalization and coordination within RFT. Besides, we also contributed a large-scale dataset CXR-CounterFact (CCF), comprising 320,416 meticulously curated counterfactual reasoning trajectories derived from MIMIC-CXR. Our code and data are public.

Causal inference plays a vital role in diverse domains like epidemiology, healthcare, and economics. De-confounding and counterfactual prediction in observational data has emerged as a prominent concern in causal inference research. While existing models tackle observed confounders, the presence of unobserved confounders remains a significant challenge, distorting causal inference and impacting counterfactual outcome accuracy. To address this, we propose a novel variational learning model of unobserved confounders for counterfactual inference (VLUCI), which generates the posterior distribution of unobserved confounders. VLUCI relaxes the unconfoundedness assumption often overlooked by most causal inference methods. By disentangling observed and unobserved confounders, VLUCI constructs a doubly variational inference model to approximate the distribution of unobserved confounders, which are used for inferring more accurate counterfactual outcomes. Extensive experiments on synthetic and semi-synthetic datasets demonstrate VLUCI's superior performance in inferring unobserved confounders. It is compatible with state-of-the-art counterfactual inference models, significantly improving inference accuracy at both group and individual levels. Additionally, VLUCI provides confidence intervals for counterfactual outcomes, aiding decision-making in risk-sensitive domains. We further clarify the considerations when applying VLUCI to cases where unobserved confounders don't strictly conform to our model assumptions using the public IHDP dataset as an example, highlighting the practical advantages of VLUCI.

Counterfactual data augmentation has recently emerged as a method to mitigate confounding biases in the training data for a machine learning model. These biases, such as spurious correlations, arise due to various observed and unobserved confounding variables in the data generation process. In this paper, we formally analyze how confounding biases impact downstream classifiers and present a causal viewpoint to the solutions based on counterfactual data augmentation. We explore how removing confounding biases serves as a means to learn invariant features, ultimately aiding in generalization beyond the observed data distribution. Additionally, we present a straightforward yet powerful algorithm for generating counterfactual images, which effectively mitigates the influence of confounding effects on downstream classifiers. Through experiments on MNIST variants and the CelebA datasets, we demonstrate the effectiveness and practicality of our approach.

Models driven by spurious correlations often yield poor generalization performance. We propose the counterfactual (CF) alignment method to detect and quantify spurious correlations of black box classifiers. Our methodology is based on counterfactual images generated with respect to one classifier being input into other classifiers to see if they also induce changes in the outputs of these classifiers. The relationship between these responses can be quantified and used to identify specific instances where a spurious correlation exists. This is validated by observing intuitive trends in face-attribute and waterbird classifiers, as well as by fabricating spurious correlations and detecting their presence, both visually and quantitatively. Furthermore, utilizing the CF alignment method, we demonstrate that we can evaluate robust optimization methods (GroupDRO, JTT, and FLAC) by detecting a reduction in spurious correlations.

Counterfactual medical image generation effectively addresses data scarcity and enhances the interpretability of medical images. However, due to the complex and diverse pathological features of medical images and the imbalanced class distribution in medical data, generating high-quality and diverse medical images from limited data is significantly challenging. Additionally, to fully leverage the information in limited data, such as anatomical structure information and generate more structurally stable medical images while avoiding distortion or inconsistency. In this paper, in order to enhance the clinical relevance of generated data and improve the interpretability of the model, we propose a novel medical image generation framework, which generates independent pathological and structural features based on causal disentanglement and utilizes text-guided modeling of pathological features to regulate the generation of counterfactual images. First, we achieve feature separation through causal disentanglement and analyze the interactions between features. Here, we introduce group supervision to ensure the independence of pathological and identity features. Second, we leverage a diffusion model guided by pathological findings to model pathological features, enabling the generation of diverse counterfactual images. Meanwhile, we enhance accuracy by leveraging a large language model to extract lesion severity and location from medical reports. Additionally, we improve the performance of the latent diffusion model on long-tailed categories through initial noise optimization.

We introduce Multi-Objective Counterfactuals for Design (MCD), a novel method for counterfactual optimization in design problems. Counterfactuals are hypothetical situations that can lead to a different decision or choice. In this paper, the authors frame the counterfactual search problem as a design recommendation tool that can help identify modifications to a design, leading to better functional performance. MCD improves upon existing counterfactual search methods by supporting multi-objective queries, which are crucial in design problems, and by decoupling the counterfactual search and sampling processes, thus enhancing efficiency and facilitating objective tradeoff visualization. The paper demonstrates MCD's core functionality using a two-dimensional test case, followed by three case studies of bicycle design that showcase MCD's effectiveness in real-world design problems. In the first case study, MCD excels at recommending modifications to query designs that can significantly enhance functional performance, such as weight savings and improvements to the structural safety factor. The second case study demonstrates that MCD can work with a pre-trained language model to suggest design changes based on a subjective text prompt effectively. Lastly, the authors task MCD with increasing a query design's similarity to a target image and text prompt while simultaneously reducing weight and improving structural performance, demonstrating MCD's performance on a complex multimodal query. Overall, MCD has the potential to provide valuable recommendations for practitioners and design automation researchers looking for answers to their ``What if'' questions by exploring hypothetical design modifications and their impact on multiple design objectives. The code, test problems, and datasets used in the paper are available to the public at decode.mit.edu/projects/counterfactuals/.

To address the interpretability challenge in machine learning (ML) systems, counterfactual explanations (CEs) have emerged as a promising solution. CEs are unique as they provide workable suggestions to users, in addition to explaining why a certain outcome was predicted. The application of CEs encounters two main challenges: general user preferences and variable ML systems. User preferences tend to be general rather than specific, and CEs need to be adaptable to variable ML models while maintaining robustness even as these models change. Facing these challenges, we present a solution rooted in validated general user preferences, which are derived from thorough user research. We map these preferences to the properties of CEs. Additionally, we introduce a novel method, Tree-based Conditions Optional Links (T-COL), which incorporates two optional structures and multiple condition groups for generating CEs adaptable to general user preferences. Meanwhile, we employ T-COL to enhance the robustness of CEs with specific conditions, making them more valid even when the ML model is replaced. Our experimental comparisons under different user preferences show that T-COL outperforms all baselines, including Large Language Models which are shown to be able to generate counterfactuals.

As humans increasingly rely on multiround conversational AI for high stakes decisions, principled frameworks are needed to ensure such interactions reliably improve decision quality. We adopt a human centric view governed by two principles: counterfactual harm, ensuring the AI does not undermine human strengths, and complementarity, ensuring it adds value where the human is prone to err. We formalize these concepts via user defined rules, allowing users to specify exactly what harm and complementarity mean for their specific task. We then introduce an online, distribution free algorithm with finite sample guarantees that enforces the user-specified constraints over the collaboration dynamics. We evaluate our framework across two interactive settings: LLM simulated collaboration on a medical diagnostic task and a human crowdsourcing study on a pictorial reasoning task. We show that our online procedure maintains prescribed counterfactual harm and complementarity violation rates even under nonstationary interaction dynamics. Moreover, tightening or loosening these constraints produces predictable shifts in downstream human accuracy, confirming that the two principles serve as practical levers for steering multi-round collaboration toward better decision quality without the need to model or constrain human behavior.

Machine learning plays a role in many deployed decision systems, often in ways that are difficult or impossible to understand by human stakeholders. Explaining, in a human-understandable way, the relationship between the input and output of machine learning models is essential to the development of trustworthy machine learning based systems. A burgeoning body of research seeks to define the goals and methods of explainability in machine learning. In this paper, we seek to review and categorize research on counterfactual explanations, a specific class of explanation that provides a link between what could have happened had input to a model been changed in a particular way. Modern approaches to counterfactual explainability in machine learning draw connections to the established legal doctrine in many countries, making them appealing to fielded systems in high-impact areas such as finance and healthcare. Thus, we design a rubric with desirable properties of counterfactual explanation algorithms and comprehensively evaluate all currently proposed algorithms against that rubric. Our rubric provides easy comparison and comprehension of the advantages and disadvantages of different approaches and serves as an introduction to major research themes in this field. We also identify gaps and discuss promising research directions in the space of counterfactual explainability.

Personalized treatment effect estimates are often of interest in high-stakes applications -- thus, before deploying a model estimating such effects in practice, one needs to be sure that the best candidate from the ever-growing machine learning toolbox for this task was chosen. Unfortunately, due to the absence of counterfactual information in practice, it is usually not possible to rely on standard validation metrics for doing so, leading to a well-known model selection dilemma in the treatment effect estimation literature. While some solutions have recently been investigated, systematic understanding of the strengths and weaknesses of different model selection criteria is still lacking. In this paper, instead of attempting to declare a global `winner', we therefore empirically investigate success- and failure modes of different selection criteria. We highlight that there is a complex interplay between selection strategies, candidate estimators and the data used for comparing them, and provide interesting insights into the relative (dis)advantages of different criteria alongside desiderata for the design of further illuminating empirical studies in this context.

Foundation models (FMs) trained on electronic health records (EHRs) have shown strong performance on a range of clinical prediction tasks. However, adapting these models to local health systems remains challenging due to limited data availability and resource constraints. In this study, we investigated what these models learn and evaluated the transferability of an FM trained on MIMIC-IV to an institutional EHR dataset at the University of Chicago Medical Center. We assessed their ability to identify outlier patients and examined representation-space patient trajectories in relation to future clinical outcomes. We also evaluated the performance of supervised fine-tuned classifiers on both source and target datasets. Our findings offer insights into the adaptability of FMs across different healthcare systems, highlight considerations for their effective implementation, and provide an empirical analysis of the underlying factors that contribute to their predictive performance.

Counterfactual explanations is one of the post-hoc methods used to provide explainability to machine learning models that have been attracting attention in recent years. Most examples in the literature, address the problem of generating post-hoc explanations for black-box machine learning models after the rejection of a loan application. In contrast, in this work, we investigate mathematical programming formulations for scorecard models, a type of interpretable model predominant within the banking industry for lending. The proposed mixed-integer programming formulations combine objective functions to ensure close, realistic and sparse counterfactuals using multi-objective optimization techniques for a binary, probability or continuous outcome. Moreover, we extend these formulations to generate multiple optimal counterfactuals simultaneously while guaranteeing diversity. Experiments on two real-world datasets confirm that the presented approach can generate optimal diverse counterfactuals addressing desired properties with assumable CPU times for practice use.

Causal effects are usually studied in terms of the means of counterfactual distributions, which may be insufficient in many scenarios. Given a class of densities known up to normalizing constants, we propose to model counterfactual distributions by minimizing kernel Stein discrepancies in a doubly robust manner. This enables the estimation of counterfactuals over large classes of distributions while exploiting the desired double robustness. We present a theoretical analysis of the proposed estimator, providing sufficient conditions for consistency and asymptotic normality, as well as an examination of its empirical performance.

Users of music streaming, video streaming, news recommendation, and e-commerce services often engage with content in a sequential manner. Providing and evaluating good sequences of recommendations is therefore a central problem for these services. Prior reweighting-based counterfactual evaluation methods either suffer from high variance or make strong independence assumptions about rewards. We propose a new counterfactual estimator that allows for sequential interactions in the rewards with lower variance in an asymptotically unbiased manner. Our method uses graphical assumptions about the causal relationships of the slate to reweight the rewards in the logging policy in a way that approximates the expected sum of rewards under the target policy. Extensive experiments in simulation and on a live recommender system show that our approach outperforms existing methods in terms of bias and data efficiency for the sequential track recommendations problem.

We consider the task of evaluating policies of algorithmic resource allocation through randomized controlled trials (RCTs). Such policies are tasked with optimizing the utilization of limited intervention resources, with the goal of maximizing the benefits derived. Evaluation of such allocation policies through RCTs proves difficult, notwithstanding the scale of the trial, because the individuals' outcomes are inextricably interlinked through resource constraints controlling the policy decisions. Our key contribution is to present a new estimator leveraging our proposed novel concept, that involves retrospective reshuffling of participants across experimental arms at the end of an RCT. We identify conditions under which such reassignments are permissible and can be leveraged to construct counterfactual trials, whose outcomes can be accurately ascertained, for free. We prove theoretically that such an estimator is more accurate than common estimators based on sample means -- we show that it returns an unbiased estimate and simultaneously reduces variance. We demonstrate the value of our approach through empirical experiments on synthetic, semi-synthetic as well as real case study data and show improved estimation accuracy across the board.

Machine learning models, particularly deep neural networks, have demonstrated strong performance in classifying complex time series data. However, their black-box nature limits trust and adoption, especially in high-stakes domains such as healthcare. To address this challenge, we introduce UniCoMTE, a model-agnostic framework for generating counterfactual explanations for multivariate time series classifiers. The framework identifies temporal features that most heavily influence a model's prediction by modifying the input sample and assessing its impact on the model's prediction. UniCoMTE is compatible with a wide range of model architectures and operates directly on raw time series inputs. In this study, we evaluate UniCoMTE's explanations on a time series ECG classifier. We quantify explanation quality by comparing our explanations' comprehensibility to comprehensibility of established techniques (LIME and SHAP) and assessing their generalizability to similar samples. Furthermore, clinical utility is assessed through a questionnaire completed by medical experts who review counterfactual explanations presented alongside original ECG samples. Results show that our approach produces concise, stable, and human-aligned explanations that outperform existing methods in both clarity and applicability. By linking model predictions to meaningful signal patterns, the framework advances the interpretability of deep learning models for real-world time series applications.

A good model for action-effect prediction, named environment model, is important to achieve sample-efficient decision-making policy learning in many domains like robot control, recommender systems, and patients' treatment selection. We can take unlimited trials with such a model to identify the appropriate actions so that the costs of queries in the real world can be saved. It requires the model to handle unseen data correctly, also called counterfactual data. However, standard data fitting techniques do not automatically achieve such generalization ability and commonly result in unreliable models. In this work, we introduce counterfactual-query risk minimization (CQRM) in model learning for generalizing to a counterfactual dataset queried by a specific target policy. Since the target policies can be various and unknown in policy learning, we propose an adversarial CQRM objective in which the model learns on counterfactual data queried by adversarial policies, and finally derive a tractable solution GALILEO. We also discover that adversarial CQRM is closely related to the adversarial model learning, explaining the effectiveness of the latter. We apply GALILEO in synthetic tasks and a real-world application. The results show that GALILEO makes accurate predictions on counterfactual data and thus significantly improves policies in real-world testing.

As machine learning models evolve, maintaining transparency demands more human-centric explainable AI techniques. Counterfactual explanations, with roots in human reasoning, identify the minimal input changes needed to obtain a given output and, hence, are crucial for supporting decision-making. Despite their importance, the evaluation of these explanations often lacks grounding in user studies and remains fragmented, with existing metrics not fully capturing human perspectives. To address this challenge, we developed a diverse set of 30 counterfactual scenarios and collected ratings across 8 evaluation metrics from 206 respondents. Subsequently, we fine-tuned different Large Language Models (LLMs) to predict average or individual human judgment across these metrics. Our methodology allowed LLMs to achieve an accuracy of up to 63% in zero-shot evaluations and 85% (over a 3-classes prediction) with fine-tuning across all metrics. The fine-tuned models predicting human ratings offer better comparability and scalability in evaluating different counterfactual explanation frameworks.

Databases of electronic health records (EHRs) are increasingly used to inform clinical decisions. Machine learning methods can find patterns in EHRs that are predictive of future adverse outcomes. However, statistical models may be built upon patterns of health-seeking behavior that vary across patient subpopulations, leading to poor predictive performance when training on one patient population and predicting on another. This note proposes two tests to better measure and understand model generalization. We use these tests to compare models derived from two data sources: (i) historical medical records, and (ii) electrocardiogram (EKG) waveforms. In a predictive task, we show that EKG-based models can be more stable than EHR-based models across different patient populations.

Machine learning models are often used to inform real world risk assessment tasks: predicting consumer default risk, predicting whether a person suffers from a serious illness, or predicting a person's risk to appear in court. Given multiple models that perform almost equally well for a prediction task, to what extent do predictions vary across these models? If predictions are relatively consistent for similar models, then the standard approach of choosing the model that optimizes a penalized loss suffices. But what if predictions vary significantly for similar models? In machine learning, this is referred to as predictive multiplicity i.e. the prevalence of conflicting predictions assigned by near-optimal competing models. In this paper, we present a framework for measuring predictive multiplicity in probabilistic classification (predicting the probability of a positive outcome). We introduce measures that capture the variation in risk estimates over the set of competing models, and develop optimization-based methods to compute these measures efficiently and reliably for convex empirical risk minimization problems. We demonstrate the incidence and prevalence of predictive multiplicity in real-world tasks. Further, we provide insight into how predictive multiplicity arises by analyzing the relationship between predictive multiplicity and data set characteristics (outliers, separability, and majority-minority structure). Our results emphasize the need to report predictive multiplicity more widely.

Large language models (LLMs) are increasingly applied to clinical decision-making. However, their potential to exhibit bias poses significant risks to clinical equity. Currently, there is a lack of benchmarks that systematically evaluate such clinical bias in LLMs. While in downstream tasks, some biases of LLMs can be avoided such as by instructing the model to answer "I'm not sure...", the internal bias hidden within the model still lacks deep studies. We introduce CLIMB (shorthand for A Benchmark of Clinical Bias in Large Language Models), a pioneering comprehensive benchmark to evaluate both intrinsic (within LLMs) and extrinsic (on downstream tasks) bias in LLMs for clinical decision tasks. Notably, for intrinsic bias, we introduce a novel metric, AssocMAD, to assess the disparities of LLMs across multiple demographic groups. Additionally, we leverage counterfactual intervention to evaluate extrinsic bias in a task of clinical diagnosis prediction. Our experiments across popular and medically adapted LLMs, particularly from the Mistral and LLaMA families, unveil prevalent behaviors with both intrinsic and extrinsic bias. This work underscores the critical need to mitigate clinical bias and sets a new standard for future evaluations of LLMs' clinical bias.

We provide an optimization-based framework to perform counterfactual analysis in a dynamic model with hidden states. Our framework is grounded in the ``abduction, action, and prediction'' approach to answer counterfactual queries and handles two key challenges where (1) the states are hidden and (2) the model is dynamic. Recognizing the lack of knowledge on the underlying causal mechanism and the possibility of infinitely many such mechanisms, we optimize over this space and compute upper and lower bounds on the counterfactual quantity of interest. Our work brings together ideas from causality, state-space models, simulation, and optimization, and we apply it on a breast cancer case study. To the best of our knowledge, we are the first to compute lower and upper bounds on a counterfactual query in a dynamic latent-state model.

Purpose. Patients with advanced cancer may undergo multiple lines of treatment, switching therapies as their disease progresses. Motivated by a study of metastatic prostate cancer, we develop a microsimulation framework to study therapy sequence. Methods. We propose a discrete-time state transition model to study two lines of anti-cancer therapy. Based on digitized published progression-free survival (PFS) and overall survival (OS) curves, we infer event types (progression or death), and estimate transition probabilities using cumulative incidence functions with competing risks. Our model incorporates within-patient dependence over time, such that response to first-line therapy informs subsequent event probabilities. Parameters governing the degree of within-patient dependence can be used to calibrate the model-based results to those of a target trial. We demonstrate these methods in a study of two therapy sequences for metastatic prostate cancer, where Docetaxel (DCT) and Abiraterone Acetate (AA) are both appropriate for use in either first or second line treatment. We assess costs, Quality-Adjusted Life Years (QALYs) and Incremental Cost Effectiveness Ratio (ICER) for two treatment strategies: DCT then AA vs AA then DCT. Results. Using digitized survival curves from relevant clinical trials, we identified 8.6-13.9% of PFS times that should be categorized as deaths, allowing for estimation of cumulative incidence functions. Models assuming within-patient independence overestimated OS time, corrected with our calibration approach. Correction resulted in meaningful changes in the difference in QALYs between treatment strategies (0.07 vs 0.15) and the ICER (-\76,836/QALY vs -21,030/QALY). Conclusions. Microsimulation models can be successfully used to study cost-effectiveness of therapy sequences, taking care to account correctly for within-patient dependence.

A prominent challenge of offline reinforcement learning (RL) is the issue of hidden confounding: unobserved variables may influence both the actions taken by the agent and the observed outcomes. Hidden confounding can compromise the validity of any causal conclusion drawn from data and presents a major obstacle to effective offline RL. In the present paper, we tackle the problem of hidden confounding in the nonidentifiable setting. We propose a definition of uncertainty due to hidden confounding bias, termed delphic uncertainty, which uses variation over world models compatible with the observations, and differentiate it from the well-known epistemic and aleatoric uncertainties. We derive a practical method for estimating the three types of uncertainties, and construct a pessimistic offline RL algorithm to account for them. Our method does not assume identifiability of the unobserved confounders, and attempts to reduce the amount of confounding bias. We demonstrate through extensive experiments and ablations the efficacy of our approach on a sepsis management benchmark, as well as on electronic health records. Our results suggest that nonidentifiable hidden confounding bias can be mitigated to improve offline RL solutions in practice.

One well motivated explanation method for classifiers leverages counterfactuals which are hypothetical events identical to real observations in all aspects except for one categorical feature. Constructing such counterfactual poses specific challenges for texts, however, as some attribute values may not necessarily align with plausible real-world events. In this paper we propose a simple method for generating counterfactuals by intervening in the space of text representations which bypasses this limitation. We argue that our interventions are minimally disruptive and that they are theoretically sound as they align with counterfactuals as defined in Pearl's causal inference framework. To validate our method, we first conduct experiments on a synthetic dataset of counterfactuals, allowing for a direct comparison between classifier predictions based on ground truth counterfactuals (obtained through explicit text interventions) and our counterfactuals, derived through interventions in the representation space. Second, we study a real world scenario where our counterfactuals can be leveraged both for explaining a classifier and for bias mitigation.

Answering counterfactual queries has many important applications such as knowledge discovery and explainability, but is challenging when causal variables are unobserved and we only see a projection onto an observation space, for instance, image pixels. One approach is to recover the latent Structural Causal Model (SCM), but this typically needs unrealistic assumptions, such as linearity of the causal mechanisms. Another approach is to use na\"ive ML approximations, such as generative models, to generate counterfactual samples; however, these lack guarantees of accuracy. In this work, we strive to strike a balance between practicality and theoretical guarantees by focusing on a specific type of causal query called domain counterfactuals, which hypothesizes what a sample would have looked like if it had been generated in a different domain (or environment). Concretely, by only assuming invertibility, sparse domain interventions and access to observational data from different domains, we aim to improve domain counterfactual estimation both theoretically and practically with less restrictive assumptions. We define domain counterfactually equivalent models and prove necessary and sufficient properties for equivalent models that provide a tight characterization of the domain counterfactual equivalence classes. Building upon this result, we prove that every equivalence class contains a model where all intervened variables are at the end when topologically sorted by the causal DAG. This surprising result suggests that a model design that only allows intervention in the last k latent variables may improve model estimation for counterfactuals. We then test this model design on extensive simulated and image-based experiments which show the sparse canonical model indeed improves counterfactual estimation over baseline non-sparse models.

Recent advancements in recommender systems have focused on leveraging Large Language Models (LLMs) to improve user preference modeling, yielding promising outcomes. However, current LLM-based approaches struggle to fully leverage user behavior sequences, resulting in suboptimal preference modeling for personalized recommendations. In this study, we propose a novel Counterfactual Fine-Tuning (CFT) method to address this issue by explicitly emphasizing the role of behavior sequences when generating recommendations. Specifically, we employ counterfactual reasoning to identify the causal effects of behavior sequences on model output and introduce a task that directly fits the ground-truth labels based on these effects, achieving the goal of explicit emphasis. Additionally, we develop a token-level weighting mechanism to adjust the emphasis strength for different item tokens, reflecting the diminishing influence of behavior sequences from earlier to later tokens during predicting an item. Extensive experiments on real-world datasets demonstrate that CFT effectively improves behavior sequence modeling. Our codes are available at https://github.com/itsmeyjt/CFT.

Concept-based explanations quantify how high-level concepts (e.g., gender or experience) influence model behavior, which is crucial for decision-makers in high-stakes domains. Recent work evaluates the faithfulness of such explanations by comparing them to reference causal effects estimated from counterfactuals. In practice, existing benchmarks rely on costly human-written counterfactuals that serve as an imperfect proxy. To address this, we introduce a framework for constructing datasets containing structural counterfactual pairs: LIBERTy (LLM-based Interventional Benchmark for Explainability with Reference Targets). LIBERTy is grounded in explicitly defined Structured Causal Models (SCMs) of the text generation, interventions on a concept propagate through the SCM until an LLM generates the counterfactual. We introduce three datasets (disease detection, CV screening, and workplace violence prediction) together with a new evaluation metric, order-faithfulness. Using them, we evaluate a wide range of methods across five models and identify substantial headroom for improving concept-based explanations. LIBERTy also enables systematic analysis of model sensitivity to interventions: we find that proprietary LLMs show markedly reduced sensitivity to demographic concepts, likely due to post-training mitigation. Overall, LIBERTy provides a much-needed benchmark for developing faithful explainability methods.

Patient education materials for solid-organ transplantation vary substantially across U.S. centers, yet no systematic method exists to quantify this heterogeneity at scale. We introduce a framework that grounds the same patient questions in different centers' handbooks using retrieval-augmented language models and compares the resulting answers using a five-label consistency taxonomy. Applied to 102 handbooks from 23 centers and 1,115 benchmark questions, the framework quantifies heterogeneity across four dimensions: question, topic, organ, and center. We find that 20.8% of non-absent pairwise comparisons exhibit clinically meaningful divergence, concentrated in condition monitoring and lifestyle topics. Coverage gaps are even more prominent: 96.2% of question-handbook pairs miss relevant content, with reproductive health at 95.1% absence. Center-level divergence profiles are stable and interpretable, where heterogeneity reflects systematic institutional differences, likely due to patient diversity. These findings expose an information gap in transplant patient education materials, with document-grounded medical question answering highlighting opportunities for content improvement.

Background: Electronic Health Records hold detailed longitudinal information about each patient's health status and general clinical history, a large portion of which is stored within the unstructured text. Existing approaches focus mostly on structured data and a subset of single-domain outcomes. We explore how temporal modelling of patients from free text and structured data, using deep generative transformers can be used to forecast a wide range of future disorders, substances, procedures or findings. Methods: We present Foresight, a novel transformer-based pipeline that uses named entity recognition and linking tools to convert document text into structured, coded concepts, followed by providing probabilistic forecasts for future medical events such as disorders, substances, procedures and findings. We processed the entire free-text portion from three different hospital datasets totalling 811336 patients covering both physical and mental health. Findings: On tests in two UK hospitals (King's College Hospital, South London and Maudsley) and the US MIMIC-III dataset precision@10 0.68, 0.76 and 0.88 was achieved for forecasting the next disorder in a patient timeline, while precision@10 of 0.80, 0.81 and 0.91 was achieved for forecasting the next biomedical concept. Foresight was also validated on 34 synthetic patient timelines by five clinicians and achieved relevancy of 97% for the top forecasted candidate disorder. As a generative model, it can forecast follow-on biomedical concepts for as many steps as required. Interpretation: Foresight is a general-purpose model for biomedical concept modelling that can be used for real-world risk forecasting, virtual trials and clinical research to study the progression of disorders, simulate interventions and counterfactuals, and educational purposes.

Recent advances in large language models (LLMs) have demonstrated significant progress in performing complex tasks. While Reinforcement Learning from Human Feedback (RLHF) has been effective in aligning LLMs with human preferences, it is susceptible to spurious correlations in reward modeling. Consequently, it often introduces biases-such as length bias, sycophancy, conceptual bias, and discrimination that hinder the model's ability to capture true causal relationships. To address this, we propose a novel causal reward modeling approach that integrates causal inference to mitigate these spurious correlations. Our method enforces counterfactual invariance, ensuring reward predictions remain consistent when irrelevant variables are altered. Through experiments on both synthetic and real-world datasets, we show that our approach mitigates various types of spurious correlations effectively, resulting in more reliable and fair alignment of LLMs with human preferences. As a drop-in enhancement to the existing RLHF workflow, our causal reward modeling provides a practical way to improve the trustworthiness and fairness of LLM finetuning.

While state-of-the-art NLP models have been achieving the excellent performance of a wide range of tasks in recent years, important questions are being raised about their robustness and their underlying sensitivity to systematic biases that may exist in their training and test data. Such issues come to be manifest in performance problems when faced with out-of-distribution data in the field. One recent solution has been to use counterfactually augmented datasets in order to reduce any reliance on spurious patterns that may exist in the original data. Producing high-quality augmented data can be costly and time-consuming as it usually needs to involve human feedback and crowdsourcing efforts. In this work, we propose an alternative by describing and evaluating an approach to automatically generating counterfactual data for data augmentation and explanation. A comprehensive evaluation on several different datasets and using a variety of state-of-the-art benchmarks demonstrate how our approach can achieve significant improvements in model performance when compared to models training on the original data and even when compared to models trained with the benefit of human-generated augmented data.

Doctor-patient consultations require multi-turn, context-aware communication tailored to diverse patient personas. Training or evaluating doctor LLMs in such settings requires realistic patient interaction systems. However, existing simulators often fail to reflect the full range of personas seen in clinical practice. To address this, we introduce PatientSim, a patient simulator that generates realistic and diverse patient personas for clinical scenarios, grounded in medical expertise. PatientSim operates using: 1) clinical profiles, including symptoms and medical history, derived from real-world data in the MIMIC-ED and MIMIC-IV datasets, and 2) personas defined by four axes: personality, language proficiency, medical history recall level, and cognitive confusion level, resulting in 37 unique combinations. We evaluated eight LLMs for factual accuracy and persona consistency. The top-performing open-source model, Llama 3.3, was validated by four clinicians to confirm the robustness of our framework. As an open-source, customizable platform, PatientSim provides a reproducible and scalable solution that can be customized for specific training needs. Offering a privacy-compliant environment, it serves as a robust testbed for evaluating medical dialogue systems across diverse patient presentations and shows promise as an educational tool for healthcare.

Healthcare foundation models have largely followed paradigms from natural language processing and computer vision, emphasizing large scale pretraining and deterministic representations over heterogeneous clinical data. However, clinical observations are inherently incomplete, reflecting sparse, irregular, and modality dependent measurements of an underlying physiologic state. In this work, we propose a framework for uncertainty aware foundation modeling that represents each patient not as a point embedding, but as a distribution over plausible latent states. By learning set valued representations and enforcing consistency across partial views of the same patient, the model captures what is invariantly inferable while explicitly encoding epistemic uncertainty. We integrate this formulation with multimodal encoders and scalable self supervised objectives, combining reconstruction, contrastive alignment, and distributional regularization. Across diverse clinical tasks, our approach improves predictive performance, robustness under missing data, and uncertainty calibration relative to strong baselines. These results suggest that modeling what is not observed rather than only what is constitutes a critical inductive bias for healthcare foundation models.

Visual counterfactual explanation (CF) methods modify image concepts, e.g, shape, to change a prediction to a predefined outcome while closely resembling the original query image. Unlike self-explainable models (SEMs) and heatmap techniques, they grant users the ability to examine hypothetical "what-if" scenarios. Previous CF methods either entail post-hoc training, limiting the balance between transparency and CF quality, or demand optimization during inference. To bridge the gap between transparent SEMs and CF methods, we introduce the GdVAE, a self-explainable model based on a conditional variational autoencoder (CVAE), featuring a Gaussian discriminant analysis (GDA) classifier and integrated CF explanations. Full transparency is achieved through a generative classifier that leverages class-specific prototypes for the downstream task and a closed-form solution for CFs in the latent space. The consistency of CFs is improved by regularizing the latent space with the explainer function. Extensive comparisons with existing approaches affirm the effectiveness of our method in producing high-quality CF explanations while preserving transparency. Code and models are public.

Generative diffusion models are increasingly used for medical imaging data augmentation, but text prompting cannot produce causal training data. Re-prompting rerolls the entire generation trajectory, altering anatomy, texture, and background. Inversion-based editing methods introduce reconstruction error that causes structural drift. We propose MedSteer, a training-free activation-steering framework for endoscopic synthesis. MedSteer identifies a pathology vector for each contrastive prompt pair in the cross-attention layers of a diffusion transformer. At inference time, it steers image activations along this vector, generating counterfactual pairs from scratch where the only difference is the steered concept. All other structure is preserved by construction. We evaluate MedSteer across three experiments on Kvasir v3 and HyperKvasir. On counterfactual generation across three clinical concept pairs, MedSteer achieves flip rates of 0.800, 0.925, and 0.950, outperforming the best inversion-based baseline in both concept flip rate and structural preservation. On dye disentanglement, MedSteer achieves 75% dye removal against 20% (PnP) and 10% (h-Edit). On downstream polyp detection, augmenting with MedSteer counterfactual pairs achieves ViT AUC of 0.9755 versus 0.9083 for quantity-matched re-prompting, confirming that counterfactual structure drives the gain. Code is at link https://github.com/phamtrongthang123/medsteer

There is an emerging interest in generating robust counterfactual explanations that would remain valid if the model is updated or changed even slightly. Towards finding robust counterfactuals, existing literature often assumes that the original model m and the new model M are bounded in the parameter space, i.e., |Params(M){-}Params(m)|{<}Delta. However, models can often change significantly in the parameter space with little to no change in their predictions or accuracy on the given dataset. In this work, we introduce a mathematical abstraction termed naturally-occurring model change, which allows for arbitrary changes in the parameter space such that the change in predictions on points that lie on the data manifold is limited. Next, we propose a measure -- that we call Stability -- to quantify the robustness of counterfactuals to potential model changes for differentiable models, e.g., neural networks. Our main contribution is to show that counterfactuals with sufficiently high value of Stability as defined by our measure will remain valid after potential ``naturally-occurring'' model changes with high probability (leveraging concentration bounds for Lipschitz function of independent Gaussians). Since our quantification depends on the local Lipschitz constant around a data point which is not always available, we also examine practical relaxations of our proposed measure and demonstrate experimentally how they can be incorporated to find robust counterfactuals for neural networks that are close, realistic, and remain valid after potential model changes.

Counterfactual statements describe events that did not or cannot take place. We consider the problem of counterfactual detection (CFD) in product reviews. For this purpose, we annotate a multilingual CFD dataset from Amazon product reviews covering counterfactual statements written in English, German, and Japanese languages. The dataset is unique as it contains counterfactuals in multiple languages, covers a new application area of e-commerce reviews, and provides high quality professional annotations. We train CFD models using different text representation methods and classifiers. We find that these models are robust against the selectional biases introduced due to cue phrase-based sentence selection. Moreover, our CFD dataset is compatible with prior datasets and can be merged to learn accurate CFD models. Applying machine translation on English counterfactual examples to create multilingual data performs poorly, demonstrating the language-specificity of this problem, which has been ignored so far.

We develop and evaluate a data-driven approach for detecting unusual (anomalous) patient-management actions using past patient cases stored in an electronic health record (EHR) system. Our hypothesis is that patient-management actions that are unusual with respect to past patients may be due to a potential error and that it is worthwhile to raise an alert if such a condition is encountered. We evaluate this hypothesis using data obtained from the electronic health records of 4,486 post-cardiac surgical patients. We base the evaluation on the opinions of a panel of experts. The results support that anomaly-based alerting can have reasonably low false alert rates and that stronger anomalies are correlated with higher alert rates.

In this paper, we consider the problem of conditional anomaly detection that aims to identify data instances with an unusual response or a class label. We develop a new non-parametric approach for conditional anomaly detection based on the soft harmonic solution, with which we estimate the confidence of the label to detect anomalous mislabeling. We further regularize the solution to avoid the detection of isolated examples and examples on the boundary of the distribution support. We demonstrate the efficacy of the proposed method on several synthetic and UCI ML datasets in detecting unusual labels when compared to several baseline approaches. We also evaluate the performance of our method on a real-world electronic health record dataset where we seek to identify unusual patient-management decisions.

Recent model editing techniques promise to mitigate the problem of memorizing false or outdated associations during LLM training. However, we show that these techniques can introduce large unwanted side effects which are not detected by existing specificity benchmarks. We extend the existing CounterFact benchmark to include a dynamic component and dub our benchmark CounterFact+. Additionally, we extend the metrics used for measuring specificity by a principled KL divergence-based metric. We use this improved benchmark to evaluate recent model editing techniques and find that they suffer from low specificity. Our findings highlight the need for improved specificity benchmarks that identify and prevent unwanted side effects.

Small sample sizes are common in many disciplines, which necessitates pooling roughly similar datasets across multiple institutions to study weak but relevant associations between images and disease outcomes. Such data often manifest shift/imbalance in covariates (i.e., secondary non-imaging data). Controlling for such nuisance variables is common within standard statistical analysis, but the ideas do not directly apply to overparameterized models. Consequently, recent work has shown how strategies from invariant representation learning provides a meaningful starting point, but the current repertoire of methods is limited to accounting for shifts/imbalances in just a couple of covariates at a time. In this paper, we show how viewing this problem from the perspective of Category theory provides a simple and effective solution that completely avoids elaborate multi-stage training pipelines that would otherwise be needed. We show the effectiveness of this approach via extensive experiments on real datasets. Further, we discuss how this style of formulation offers a unified perspective on at least 5+ distinct problem settings, from self-supervised learning to matching problems in 3D reconstruction.

Counterfactual reasoning, a hallmark of intelligence, consists of three steps: inferring latent variables from observations (abduction), constructing alternatives (interventions), and predicting their outcomes (prediction). This skill is essential for advancing LLMs' causal understanding and expanding their applications in high-stakes domains such as scientific research. However, existing efforts in assessing LLM's counterfactual reasoning capabilities tend to skip the abduction step, effectively reducing to interventional reasoning and leading to overestimation of LLM performance. To address this, we introduce executable counterfactuals, a novel framework that operationalizes causal reasoning through code and math problems. Our framework explicitly requires all three steps of counterfactual reasoning and enables scalable synthetic data creation with varying difficulty, creating a frontier for evaluating and improving LLM's reasoning. Our results reveal substantial drop in accuracy (25-40%) from interventional to counterfactual reasoning for SOTA models like o4-mini and Claude-4-Sonnet. To address this gap, we construct a training set comprising counterfactual code problems having if-else condition and test on out-of-domain code structures (e.g. having while-loop); we also test whether a model trained on code would generalize to counterfactual math word problems. While supervised finetuning on stronger models' reasoning traces improves in-domain performance of Qwen models, it leads to a decrease in accuracy on OOD tasks such as counterfactual math problems. In contrast, reinforcement learning induces the core cognitive behaviors and generalizes to new domains, yielding gains over the base model on both code (improvement of 1.5x-2x) and math problems. Analysis of the reasoning traces reinforces these findings and highlights the promise of RL for improving LLMs' counterfactual reasoning.

Pathology Foundation Models (FMs) hold great promise for healthcare. Before they can be used in clinical practice, it is essential to ensure they are robust to variations between medical centers. We measure whether pathology FMs focus on biological features like tissue and cancer type, or on the well known confounding medical center signatures introduced by staining procedure and other differences. We introduce the Robustness Index. This novel robustness metric reflects to what degree biological features dominate confounding features. Ten current publicly available pathology FMs are evaluated. We find that all current pathology foundation models evaluated represent the medical center to a strong degree. Significant differences in the robustness index are observed. Only one model so far has a robustness index greater than one, meaning biological features dominate confounding features, but only slightly. A quantitative approach to measure the influence of medical center differences on FM-based prediction performance is described. We analyze the impact of unrobustness on classification performance of downstream models, and find that cancer-type classification errors are not random, but specifically attributable to same-center confounders: images of other classes from the same medical center. We visualize FM embedding spaces, and find these are more strongly organized by medical centers than by biological factors. As a consequence, the medical center of origin is predicted more accurately than the tissue source and cancer type. The robustness index introduced here is provided with the aim of advancing progress towards clinical adoption of robust and reliable pathology FMs.

We study the problem of model selection in causal inference, specifically for the case of conditional average treatment effect (CATE) estimation under binary treatments. Unlike model selection in machine learning, there is no perfect analogue of cross-validation as we do not observe the counterfactual potential outcome for any data point. Towards this, there have been a variety of proxy metrics proposed in the literature, that depend on auxiliary nuisance models estimated from the observed data (propensity score model, outcome regression model). However, the effectiveness of these metrics has only been studied on synthetic datasets as we can access the counterfactual data for them. We conduct an extensive empirical analysis to judge the performance of these metrics introduced in the literature, and novel ones introduced in this work, where we utilize the latest advances in generative modeling to incorporate multiple realistic datasets. Our analysis suggests novel model selection strategies based on careful hyperparameter tuning of CATE estimators and causal ensembling.

Large language models (LLMs) are rapidly transitioning into medical clinical use, yet their reliability under realistic, multi-turn interactions remains poorly understood. Existing evaluation frameworks typically assess single-turn question answering under idealized conditions, overlooking the complexities of medical consultations where conflicting input, misleading context, and authority influence are common. We introduce MedQA-Followup, a framework for systematically evaluating multi-turn robustness in medical question answering. Our approach distinguishes between shallow robustness (resisting misleading initial context) and deep robustness (maintaining accuracy when answers are challenged across turns), while also introducing an indirect-direct axis that separates contextual framing (indirect) from explicit suggestion (direct). Using controlled interventions on the MedQA dataset, we evaluate five state-of-the-art LLMs and find that while models perform reasonably well under shallow perturbations, they exhibit severe vulnerabilities in multi-turn settings, with accuracy dropping from 91.2% to as low as 13.5% for Claude Sonnet 4. Counterintuitively, indirect, context-based interventions are often more harmful than direct suggestions, yielding larger accuracy drops across models and exposing a significant vulnerability for clinical deployment. Further compounding analyses reveal model differences, with some showing additional performance drops under repeated interventions while others partially recovering or even improving. These findings highlight multi-turn robustness as a critical but underexplored dimension for safe and reliable deployment of medical LLMs.

Synthetic data generation offers a promising solution to enhance the usefulness of Electronic Healthcare Records (EHR) by generating realistic de-identified data. However, the existing literature primarily focuses on the quality of synthetic health data, neglecting the crucial aspect of fairness in downstream predictions. Consequently, models trained on synthetic EHR have faced criticism for producing biased outcomes in target tasks. These biases can arise from either spurious correlations between features or the failure of models to accurately represent sub-groups. To address these concerns, we present Bias-transforming Generative Adversarial Networks (Bt-GAN), a GAN-based synthetic data generator specifically designed for the healthcare domain. In order to tackle spurious correlations (i), we propose an information-constrained Data Generation Process that enables the generator to learn a fair deterministic transformation based on a well-defined notion of algorithmic fairness. To overcome the challenge of capturing exact sub-group representations (ii), we incentivize the generator to preserve sub-group densities through score-based weighted sampling. This approach compels the generator to learn from underrepresented regions of the data manifold. We conduct extensive experiments using the MIMIC-III database. Our results demonstrate that Bt-GAN achieves SOTA accuracy while significantly improving fairness and minimizing bias amplification. We also perform an in-depth explainability analysis to provide additional evidence supporting the validity of our study. In conclusion, our research introduces a novel and professional approach to addressing the limitations of synthetic data generation in the healthcare domain. By incorporating fairness considerations and leveraging advanced techniques such as GANs, we pave the way for more reliable and unbiased predictions in healthcare applications.

Large language models (LLMs) have demonstrated remarkable capabilities in natural language understanding and generation across various domains, including medicine. We present a comprehensive evaluation of GPT-4, a state-of-the-art LLM, on medical competency examinations and benchmark datasets. GPT-4 is a general-purpose model that is not specialized for medical problems through training or engineered to solve clinical tasks. Our analysis covers two sets of official practice materials for the USMLE, a three-step examination program used to assess clinical competency and grant licensure in the United States. We also evaluate performance on the MultiMedQA suite of benchmark datasets. Beyond measuring model performance, experiments were conducted to investigate the influence of test questions containing both text and images on model performance, probe for memorization of content during training, and study probability calibration, which is of critical importance in high-stakes applications like medicine. Our results show that GPT-4, without any specialized prompt crafting, exceeds the passing score on USMLE by over 20 points and outperforms earlier general-purpose models (GPT-3.5) as well as models specifically fine-tuned on medical knowledge (Med-PaLM, a prompt-tuned version of Flan-PaLM 540B). In addition, GPT-4 is significantly better calibrated than GPT-3.5, demonstrating a much-improved ability to predict the likelihood that its answers are correct. We also explore the behavior of the model qualitatively through a case study that shows the ability of GPT-4 to explain medical reasoning, personalize explanations to students, and interactively craft new counterfactual scenarios around a medical case. Implications of the findings are discussed for potential uses of GPT-4 in medical education, assessment, and clinical practice, with appropriate attention to challenges of accuracy and safety.

We study counterfactual identifiability in causal models with bijective generation mechanisms (BGM), a class that generalizes several widely-used causal models in the literature. We establish their counterfactual identifiability for three common causal structures with unobserved confounding, and propose a practical learning method that casts learning a BGM as structured generative modeling. Learned BGMs enable efficient counterfactual estimation and can be obtained using a variety of deep conditional generative models. We evaluate our techniques in a visual task and demonstrate its application in a real-world video streaming simulation task.

Dynamic treatment regimes (DTRs) are personalized, adaptive, multi-stage treatment plans that adapt treatment decisions both to an individual's initial features and to intermediate outcomes and features at each subsequent stage, which are affected by decisions in prior stages. Examples include personalized first- and second-line treatments of chronic conditions like diabetes, cancer, and depression, which adapt to patient response to first-line treatment, disease progression, and individual characteristics. While existing literature mostly focuses on estimating the optimal DTR from offline data such as from sequentially randomized trials, we study the problem of developing the optimal DTR in an online manner, where the interaction with each individual affect both our cumulative reward and our data collection for future learning. We term this the DTR bandit problem. We propose a novel algorithm that, by carefully balancing exploration and exploitation, is guaranteed to achieve rate-optimal regret when the transition and reward models are linear. We demonstrate our algorithm and its benefits both in synthetic experiments and in a case study of adaptive treatment of major depressive disorder using real-world data.

Anomaly detection methods can be very useful in identifying interesting or concerning events. In this work, we develop and examine new probabilistic anomaly detection methods that let us evaluate management decisions for a specific patient and identify those decisions that are highly unusual with respect to patients with the same or similar condition. The statistics used in this detection are derived from probabilistic models such as Bayesian networks that are learned from a database of past patient cases. We apply our methods to the problem of identifying unusual patient-management decisions in post-surgical cardiac patients.

Machine learning models are often trained to predict the outcome resulting from a human decision. For example, if a doctor decides to test a patient for disease, will the patient test positive? A challenge is that historical decision-making determines whether the outcome is observed: we only observe test outcomes for patients doctors historically tested. Untested patients, for whom outcomes are unobserved, may differ from tested patients along observed and unobserved dimensions. We propose a Bayesian model class which captures this setting. The purpose of the model is to accurately estimate risk for both tested and untested patients. Estimating this model is challenging due to the wide range of possibilities for untested patients. To address this, we propose two domain constraints which are plausible in health settings: a prevalence constraint, where the overall disease prevalence is known, and an expertise constraint, where the human decision-maker deviates from purely risk-based decision-making only along a constrained feature set. We show theoretically and on synthetic data that domain constraints improve parameter inference. We apply our model to a case study of cancer risk prediction, showing that the model's inferred risk predicts cancer diagnoses, its inferred testing policy captures known public health policies, and it can identify suboptimalities in test allocation. Though our case study is in healthcare, our analysis reveals a general class of domain constraints which can improve model estimation in many settings.

Interpretable time series prediction is crucial for safety-critical areas such as healthcare and autonomous driving. Most existing methods focus on interpreting predictions by assigning important scores to segments of time series. In this paper, we take a different and more challenging route and aim at developing a self-interpretable model, dubbed Counterfactual Time Series (CounTS), which generates counterfactual and actionable explanations for time series predictions. Specifically, we formalize the problem of time series counterfactual explanations, establish associated evaluation protocols, and propose a variational Bayesian deep learning model equipped with counterfactual inference capability of time series abduction, action, and prediction. Compared with state-of-the-art baselines, our self-interpretable model can generate better counterfactual explanations while maintaining comparable prediction accuracy.

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.

Attribution is a key concept in large language models (LLMs) as it enables control over information sources and enhances the factuality of LLMs. While existing approaches utilize open book question answering to improve attribution, factual datasets may reward language models to recall facts that they already know from their pretraining data, not attribution. In contrast, counterfactual open book QA datasets would further improve attribution because the answer could only be grounded in the given text. We propose Hallucination Augmented Recitations (HAR) for creating counterfactual datasets by utilizing hallucination in LLMs to improve attribution. For open book QA as a case study, we demonstrate that models finetuned with our counterfactual datasets improve text grounding, leading to better open book QA performance, with up to an 8.0% increase in F1 score. Our counterfactual dataset leads to significantly better performance than using humanannotated factual datasets, even with 4x smaller datasets and 4x smaller models. We observe that improvements are consistent across various model sizes and datasets, including multi-hop, biomedical, and adversarial QA datasets.

Timely detection of concerning events is an important problem in clinical practice. In this paper, we consider the problem of conditional anomaly detection that aims to identify data instances with an unusual response, such as the omission of an important lab test. We develop a new non-parametric approach for conditional anomaly detection based on the soft harmonic solution, with which we estimate the confidence of the label to detect anomalous mislabeling. We further regularize the solution to avoid the detection of isolated examples and examples on the boundary of the distribution support. We demonstrate the efficacy of the proposed method in detecting unusual labels on a real-world electronic health record dataset and compare it to several baseline approaches.

Counterfactual reasoning is widely recognized as one of the most challenging and intricate aspects of causality in artificial intelligence. In this paper, we evaluate the performance of large language models (LLMs) in counterfactual reasoning. In contrast to previous studies that primarily focus on commonsense causal reasoning, where LLMs often rely on prior knowledge for inference, we specifically assess their ability to perform counterfactual inference using a set of formal rules. To support this evaluation, we introduce a new benchmark dataset, CounterBench, comprising 1K counterfactual reasoning questions. The dataset is designed with varying levels of difficulty, diverse causal graph structures, distinct types of counterfactual questions, and multiple nonsensical name variants. Our experiments demonstrate that counterfactual reasoning poses a significant challenge for LLMs, with most models performing at levels comparable to random guessing. To enhance LLM's counterfactual reasoning ability, we propose a novel reasoning paradigm, CoIn, which guides LLMs through iterative reasoning and backtracking to systematically explore counterfactual solutions. Experimental results show that our method significantly improves LLM performance on counterfactual reasoning tasks and consistently enhances performance across different LLMs.Our dataset is available at https://huggingface.co/datasets/CounterBench/CounterBench.

Large language model (LLM)-powered agents can translate high-level user intents into plans and actions in an environment. Yet after observing an outcome, users may wonder: What if I had phrased my intent differently? We introduce a framework that enables such counterfactual reasoning in agentic LLM-driven control scenarios, while providing formal reliability guarantees. Our approach models the closed-loop interaction between a user, an LLM-based agent, and an environment as a structural causal model (SCM), and leverages test-time scaling to generate multiple candidate counterfactual outcomes via probabilistic abduction. Through an offline calibration phase, the proposed conformal counterfactual generation (CCG) yields sets of counterfactual outcomes that are guaranteed to contain the true counterfactual outcome with high probability. We showcase the performance of CCG on a wireless network control use case, demonstrating significant advantages compared to naive re-execution baselines.

Large Language Models have demonstrated remarkable capabilities across diverse tasks, yet they frequently generate hallucinations outputs that are fluent but factually incorrect or unsupported. We propose Counterfactual Probing, a novel approach for detecting and mitigating hallucinations in LLM outputs. Our method dynamically generates counterfactual statements that appear plausible but contain subtle factual errors, then evaluates the model's sensitivity to these perturbations. We hypothesize that genuine knowledge exhibits robustness to counterfactual variations, while hallucinated content shows inconsistent confidence patterns when confronted with plausible alternatives. Our comprehensive evaluation on TruthfulQA, factual statement datasets, and curated hallucination examples demonstrates that counterfactual probing achieves superior detection performance compared to baseline methods, while our adaptive mitigation strategies reduce hallucination scores by an average of 24.5%. The approach requires no model retraining and can be integrated into existing LLM pipelines as a realtime verification mechanism.

Unfairness in mortgage lending has created generational inequality among racial and ethnic groups in the US. Many studies address this problem, but most existing work focuses on correlation-based techniques. In our work, we use the framework of counterfactual fairness to train fair machine learning models. We propose a new causal graph for the variables available in the Home Mortgage Disclosure Act (HMDA) data. We use a matching-based approach instead of the latent variable modeling approach, because the former approach does not rely on any modeling assumptions. Furthermore, matching provides us with counterfactual pairs in which the race variable is isolated. We first demonstrate the unfairness in mortgage approval and interest rates between African-American and non-Hispanic White sub-populations. Then, we show that having balanced data using matching does not guarantee perfect counterfactual fairness of the machine learning models.

Spurious correlations in the data, where multiple cues are predictive of the target labels, often lead to a phenomenon known as simplicity bias, where a model relies on erroneous, easy-to-learn cues while ignoring reliable ones. In this work, we propose an ensemble diversification framework exploiting Diffusion Probabilistic Models (DPMs) for shortcut bias mitigation. We show that at particular training intervals, DPMs can generate images with novel feature combinations, even when trained on images displaying correlated input features. We leverage this crucial property to generate synthetic counterfactuals to increase model diversity via ensemble disagreement. We show that DPM-guided diversification is sufficient to remove dependence on primary shortcut cues, without a need for additional supervised signals. We further empirically quantify its efficacy on several diversification objectives, and finally show improved generalization and diversification performance on par with prior work that relies on auxiliary data collection.

How many experimental studies would have come to different conclusions had they been run on larger samples? I show how to estimate the expected number of statistically significant results that a set of experiments would have reported had their sample sizes all been counterfactually increased. The proposed deconvolution estimator is asymptotically normal and adjusts for publication bias. Unlike related methods, this approach requires no assumptions of any kind about the distribution of true intervention treatment effects and allows for point masses. Simulations find good coverage even when the t-score is only approximately normal. An application to randomized trials (RCTs) published in economics journals finds that doubling every sample would increase the power of t-tests by 7.2 percentage points on average. This effect is smaller than for non-RCTs and comparable to systematic replications in laboratory psychology where previous studies enabled more accurate power calculations. This suggests that RCTs are on average relatively insensitive to sample size increases. Research funders who wish to raise power should generally consider sponsoring better-measured and higher quality experiments -- rather than only larger ones.

In recent years, there has been a rapidly expanding focus on explaining the predictions made by black-box AI systems that handle image and tabular data. However, considerably less attention has been paid to explaining the predictions of opaque AI systems handling time series data. In this paper, we advance a novel model-agnostic, case-based technique -- Native Guide -- that generates counterfactual explanations for time series classifiers. Given a query time series, T_{q}, for which a black-box classification system predicts class, c, a counterfactual time series explanation shows how T_{q} could change, such that the system predicts an alternative class, c'. The proposed instance-based technique adapts existing counterfactual instances in the case-base by highlighting and modifying discriminative areas of the time series that underlie the classification. Quantitative and qualitative results from two comparative experiments indicate that Native Guide generates plausible, proximal, sparse and diverse explanations that are better than those produced by key benchmark counterfactual methods.

Medical image classification is a critical problem for healthcare, with the potential to alleviate the workload of doctors and facilitate diagnoses of patients. However, two challenges arise when deploying deep learning models to real-world healthcare applications. First, neural models tend to learn spurious correlations instead of desired features, which could fall short when generalizing to new domains (e.g., patients with different ages). Second, these black-box models lack interpretability. When making diagnostic predictions, it is important to understand why a model makes a decision for trustworthy and safety considerations. In this paper, to address these two limitations, we propose a new paradigm to build robust and interpretable medical image classifiers with natural language concepts. Specifically, we first query clinical concepts from GPT-4, then transform latent image features into explicit concepts with a vision-language model. We systematically evaluate our method on eight medical image classification datasets to verify its effectiveness. On challenging datasets with strong confounding factors, our method can mitigate spurious correlations thus substantially outperform standard visual encoders and other baselines. Finally, we show how classification with a small number of concepts brings a level of interpretability for understanding model decisions through case studies in real medical data.

When deploying machine learning models in high-stakes real-world environments such as health care, it is crucial to accurately assess the uncertainty concerning a model's prediction on abnormal inputs. However, there is a scarcity of literature analyzing this problem on medical data, especially on mixed-type tabular data such as Electronic Health Records. We close this gap by presenting a series of tests including a large variety of contemporary uncertainty estimation techniques, in order to determine whether they are able to identify out-of-distribution (OOD) patients. In contrast to previous work, we design tests on realistic and clinically relevant OOD groups, and run experiments on real-world medical data. We find that almost all techniques fail to achieve convincing results, partly disagreeing with earlier findings.

When the performance of a machine learning model varies over groups defined by sensitive attributes (e.g., gender or ethnicity), the performance disparity can be expressed in terms of the probability distributions of the input and output variables over each group. In this paper, we exploit this fact to reduce the disparate impact of a fixed classification model over a population of interest. Given a black-box classifier, we aim to eliminate the performance gap by perturbing the distribution of input variables for the disadvantaged group. We refer to the perturbed distribution as a counterfactual distribution, and characterize its properties for common fairness criteria. We introduce a descent algorithm to learn a counterfactual distribution from data. We then discuss how the estimated distribution can be used to build a data preprocessor that can reduce disparate impact without training a new model. We validate our approach through experiments on real-world datasets, showing that it can repair different forms of disparity without a significant drop in accuracy.

While counterfactual examples are useful for analysis and training of NLP models, current generation methods either rely on manual labor to create very few counterfactuals, or only instantiate limited types of perturbations such as paraphrases or word substitutions. We present Polyjuice, a general-purpose counterfactual generator that allows for control over perturbation types and locations, trained by finetuning GPT-2 on multiple datasets of paired sentences. We show that Polyjuice produces diverse sets of realistic counterfactuals, which in turn are useful in various distinct applications: improving training and evaluation on three different tasks (with around 70% less annotation effort than manual generation), augmenting state-of-the-art explanation techniques, and supporting systematic counterfactual error analysis by revealing behaviors easily missed by human experts.

We develop graph-based methods for semi-supervised learning based on label propagation on a data similarity graph. When data is abundant or arrive in a stream, the problems of computation and data storage arise for any graph-based method. We propose a fast approximate online algorithm that solves for the harmonic solution on an approximate graph. We show, both empirically and theoretically, that good behavior can be achieved by collapsing nearby points into a set of local representative points that minimize distortion. Moreover, we regularize the harmonic solution to achieve better stability properties. We also present graph-based methods for detecting conditional anomalies and apply them to the identification of unusual clinical actions in hospitals. Our hypothesis is that patient-management actions that are unusual with respect to the past patients may be due to errors and that it is worthwhile to raise an alert if such a condition is encountered. Conditional anomaly detection extends standard unconditional anomaly framework but also faces new problems known as fringe and isolated points. We devise novel nonparametric graph-based methods to tackle these problems. Our methods rely on graph connectivity analysis and soft harmonic solution. Finally, we conduct an extensive human evaluation study of our conditional anomaly methods by 15 experts in critical care.

Class imbalance poses a fundamental challenge in machine learning, frequently leading to unreliable classification performance. While prior methods focus on data- or loss-reweighting schemes, we view imbalance as a data condition that amplifies Clever Hans (CH) effects by underspecification of minority classes. In a counterfactual explanations-based approach, we propose to leverage Explainable AI to jointly identify and eliminate CH effects emerging under imbalance. Our method achieves competitive classification performance on three datasets and demonstrates how CH effects emerge under imbalance, a perspective largely overlooked by existing approaches.

Alzheimer's Disease (AD) is marked by significant inter-individual variability in its progression, complicating accurate prognosis and personalized care planning. This heterogeneity underscores the critical need for predictive models capable of forecasting patient-specific disease trajectories. Artificial Intelligence (AI) offers powerful tools to address this challenge by analyzing complex, multi-modal, and longitudinal patient data. This paper provides a comprehensive survey of AI methodologies applied to personalized AD progression prediction. We review key approaches including state-space models for capturing temporal dynamics, deep learning techniques like Recurrent Neural Networks for sequence modeling, Graph Neural Networks (GNNs) for leveraging network structures, and the emerging concept of AI-driven digital twins for individualized simulation. Recognizing that data limitations often impede progress, we examine common challenges such as high dimensionality, missing data, and dataset imbalance. We further discuss AI-driven mitigation strategies, with a specific focus on synthetic data generation using Variational Autoencoders (VAEs) and Generative Adversarial Networks (GANs) to augment and balance datasets. The survey synthesizes the strengths and limitations of current approaches, emphasizing the trend towards multimodal integration and the persistent need for model interpretability and generalizability. Finally, we identify critical open challenges, including robust external validation, clinical integration, and ethical considerations, and outline promising future research directions such as hybrid models, causal inference, and federated learning. This review aims to consolidate current knowledge and guide future efforts in developing clinically relevant AI tools for personalized AD prognostication.

Large language models (LLMs) are now widely deployed in user-facing applications, reaching hundreds of millions worldwide. As they become integrated into everyday tasks, growing reliance on their outputs raises significant concerns. In particular, users may unknowingly be exposed to model-inherent biases that systematically disadvantage or stereotype certain groups. However, existing bias benchmarks continue to rely on templated prompts or restrictive multiple-choice questions that are suggestive, simplistic, and fail to capture the complexity of real-world user interactions. In this work, we address this gap by introducing a counterfactual bias evaluation framework that automatically generates realistic, open-ended questions over sensitive attributes such as sex, race, or religion. By iteratively mutating and selecting bias-inducing questions, our approach systematically explores areas where models are most susceptible to biased behavior. Beyond detecting harmful biases, we also capture distinct response dimensions that are increasingly relevant in user interactions, such as asymmetric refusals and explicit acknowledgment of bias. Leveraging our framework, we construct CAB, a human-verified benchmark spanning diverse topics, designed to enable cross-model comparisons. Using CAB, we analyze a range of LLMs across multiple bias dimensions, revealing nuanced insights into how different models manifest bias. For instance, while GPT-5 outperforms other models, it nonetheless exhibits persistent biases in specific scenarios. These findings underscore the need for continual improvements to ensure fair model behavior.

Advancements in large language models (LLMs) have demonstrated remarkable capabilities across a diverse range of applications. These models excel in generating text completions that are contextually coherent and cover an extensive array of subjects. However, the vast datasets required for their training make aligning response styles during the pretraining and instruction tuning phases challenging. Consequently, an additional alignment phase is typically employed, wherein the model is further trained with human preference data to better align its outputs with human expectations. While this process doesn't introduce new capabilities per se, it does accentuate generation styles innate to the model. This paper explores the utilization of counterfactual prompting within the framework of Direct Preference Optimization (DPO) to align the model's style without relying on human intervention. We demonstrate that this method effectively instils desirable behaviour, mitigates undesirable ones, and encourages the model to disregard inappropriate instructions. Our findings suggest that counterfactual prompting with DPO presents a low-resource way to fine-tune LLMs to meet the demands for responsible and ethically aligned AI systems.

We develop and evaluate a data-driven approach for detecting unusual (anomalous) patient-management decisions using past patient cases stored in electronic health records (EHRs). Our hypothesis is that a patient-management decision that is unusual with respect to past patient care may be due to an error and that it is worthwhile to generate an alert if such a decision is encountered. We evaluate this hypothesis using data obtained from EHRs of 4486 post-cardiac surgical patients and a subset of 222 alerts generated from the data. We base the evaluation on the opinions of a panel of experts. The results of the study support our hypothesis that the outlier-based alerting can lead to promising true alert rates. We observed true alert rates that ranged from 25\% to 66\% for a variety of patient-management actions, with 66\% corresponding to the strongest outliers.

For safety, medical AI systems undergo thorough evaluations before deployment, validating their predictions against a ground truth which is assumed to be fixed and certain. However, this ground truth is often curated in the form of differential diagnoses. While a single differential diagnosis reflects the uncertainty in one expert assessment, multiple experts introduce another layer of uncertainty through disagreement. Both forms of uncertainty are ignored in standard evaluation which aggregates these differential diagnoses to a single label. In this paper, we show that ignoring uncertainty leads to overly optimistic estimates of model performance, therefore underestimating risk associated with particular diagnostic decisions. To this end, we propose a statistical aggregation approach, where we infer a distribution on probabilities of underlying medical condition candidates themselves, based on observed annotations. This formulation naturally accounts for the potential disagreements between different experts, as well as uncertainty stemming from individual differential diagnoses, capturing the entire ground truth uncertainty. Our approach boils down to generating multiple samples of medical condition probabilities, then evaluating and averaging performance metrics based on these sampled probabilities. In skin condition classification, we find that a large portion of the dataset exhibits significant ground truth uncertainty and standard evaluation severely over-estimates performance without providing uncertainty estimates. In contrast, our framework provides uncertainty estimates on common metrics of interest such as top-k accuracy and average overlap, showing that performance can change multiple percentage points. We conclude that, while assuming a crisp ground truth can be acceptable for many AI applications, a more nuanced evaluation protocol should be utilized in medical diagnosis.

In the field of medical sciences, reliable detection and classification of brain tumors from images remains a formidable challenge due to the rarity of tumors within the population of patients. Therefore, the ability to detect tumors in anomaly scenarios is paramount for ensuring timely interventions and improved patient outcomes. This study addresses the issue by leveraging deep learning (DL) techniques to detect and classify brain tumors in challenging situations. The curated data set from the National Brain Mapping Lab (NBML) comprises 81 patients, including 30 Tumor cases and 51 Normal cases. The detection and classification pipelines are separated into two consecutive tasks. The detection phase involved comprehensive data analysis and pre-processing to modify the number of image samples and the number of patients of each class to anomaly distribution (9 Normal per 1 Tumor) to comply with real world scenarios. Next, in addition to common evaluation metrics for the testing, we employed a novel performance evaluation method called Patient to Patient (PTP), focusing on the realistic evaluation of the model. In the detection phase, we fine-tuned a YOLOv8n detection model to detect the tumor region. Subsequent testing and evaluation yielded competitive performance both in Common Evaluation Metrics and PTP metrics. Furthermore, using the Data Efficient Image Transformer (DeiT) module, we distilled a Vision Transformer (ViT) model from a fine-tuned ResNet152 as a teacher in the classification phase. This approach demonstrates promising strides in reliable tumor detection and classification, offering potential advancements in tumor diagnosis for real-world medical imaging scenarios.

The promise of LLM-based user simulators to improve conversational AI is hindered by a critical "realism gap," leading to systems that are optimized for simulated interactions, but may fail to perform well in the real world. We introduce ConvApparel, a new dataset of human-AI conversations designed to address this gap. Its unique dual-agent data collection protocol -- using both "good" and "bad" recommenders -- enables counterfactual validation by capturing a wide spectrum of user experiences, enriched with first-person annotations of user satisfaction. We propose a comprehensive validation framework that combines statistical alignment, a human-likeness score, and counterfactual validation to test for generalization. Our experiments reveal a significant realism gap across all simulators. However, the framework also shows that data-driven simulators outperform a prompted baseline, particularly in counterfactual validation where they adapt more realistically to unseen behaviors, suggesting they embody more robust, if imperfect, user models.

Counterfactual text generation aims to minimally change a text, such that it is classified differently. Judging advancements in method development for counterfactual text generation is hindered by a non-uniform usage of data sets and metrics in related work. We propose CEval, a benchmark for comparing counterfactual text generation methods. CEval unifies counterfactual and text quality metrics, includes common counterfactual datasets with human annotations, standard baselines (MICE, GDBA, CREST) and the open-source language model LLAMA-2. Our experiments found no perfect method for generating counterfactual text. Methods that excel at counterfactual metrics often produce lower-quality text while LLMs with simple prompts generate high-quality text but struggle with counterfactual criteria. By making CEval available as an open-source Python library, we encourage the community to contribute more methods and maintain consistent evaluation in future work.

Causal explanations of the predictions of NLP systems are essential to ensure safety and establish trust. Yet, existing methods often fall short of explaining model predictions effectively or efficiently and are often model-specific. In this paper, we address model-agnostic explanations, proposing two approaches for counterfactual (CF) approximation. The first approach is CF generation, where a large language model (LLM) is prompted to change a specific text concept while keeping confounding concepts unchanged. While this approach is demonstrated to be very effective, applying LLM at inference-time is costly. We hence present a second approach based on matching, and propose a method that is guided by an LLM at training-time and learns a dedicated embedding space. This space is faithful to a given causal graph and effectively serves to identify matches that approximate CFs. After showing theoretically that approximating CFs is required in order to construct faithful explanations, we benchmark our approaches and explain several models, including LLMs with billions of parameters. Our empirical results demonstrate the excellent performance of CF generation models as model-agnostic explainers. Moreover, our matching approach, which requires far less test-time resources, also provides effective explanations, surpassing many baselines. We also find that Top-K techniques universally improve every tested method. Finally, we showcase the potential of LLMs in constructing new benchmarks for model explanation and subsequently validate our conclusions. Our work illuminates new pathways for efficient and accurate approaches to interpreting NLP systems.

Radiology reports are crucial for planning treatment strategies and enhancing doctor-patient communication, yet manually writing these reports is burdensome for radiologists. While automatic report generation offers a solution, existing methods often rely on single-view radiographs, limiting diagnostic accuracy. To address this problem, we propose MCL, a Multi-view enhanced Contrastive Learning method for chest X-ray report generation. Specifically, we first introduce multi-view enhanced contrastive learning for visual representation by maximizing agreements between multi-view radiographs and their corresponding report. Subsequently, to fully exploit patient-specific indications (e.g., patient's symptoms) for report generation, we add a transitional ``bridge" for missing indications to reduce embedding space discrepancies caused by their presence or absence. Additionally, we construct Multi-view CXR and Two-view CXR datasets from public sources to support research on multi-view report generation. Our proposed MCL surpasses recent state-of-the-art methods across multiple datasets, achieving a 5.0% F1 RadGraph improvement on MIMIC-CXR, a 7.3% BLEU-1 improvement on MIMIC-ABN, a 3.1% BLEU-4 improvement on Multi-view CXR, and an 8.2% F1 CheXbert improvement on Two-view CXR.

Counterfactual Risk Minimization (CRM) is a framework for dealing with the logged bandit feedback problem, where the goal is to improve a logging policy using offline data. In this paper, we explore the case where it is possible to deploy learned policies multiple times and acquire new data. We extend the CRM principle and its theory to this scenario, which we call "Sequential Counterfactual Risk Minimization (SCRM)." We introduce a novel counterfactual estimator and identify conditions that can improve the performance of CRM in terms of excess risk and regret rates, by using an analysis similar to restart strategies in accelerated optimization methods. We also provide an empirical evaluation of our method in both discrete and continuous action settings, and demonstrate the benefits of multiple deployments of CRM.

The impressive performance of recent language models across a wide range of tasks suggests that they possess a degree of abstract reasoning skills. Are these skills general and transferable, or specialized to specific tasks seen during pretraining? To disentangle these effects, we propose an evaluation framework based on "counterfactual" task variants that deviate from the default assumptions underlying standard tasks. Across a suite of 11 tasks, we observe nontrivial performance on the counterfactual variants, but nevertheless find that performance substantially and consistently degrades compared to the default conditions. This suggests that while current LMs may possess abstract task-solving skills to a degree, they often also rely on narrow, non-transferable procedures for task-solving. These results motivate a more careful interpretation of language model performance that teases apart these aspects of behavior.

Advances in artificial intelligence (AI) have achieved expert-level performance in medical imaging applications. Notably, self-supervised vision-language foundation models can detect a broad spectrum of pathologies without relying on explicit training annotations. However, it is crucial to ensure that these AI models do not mirror or amplify human biases, thereby disadvantaging historically marginalized groups such as females or Black patients. The manifestation of such biases could systematically delay essential medical care for certain patient subgroups. In this study, we investigate the algorithmic fairness of state-of-the-art vision-language foundation models in chest X-ray diagnosis across five globally-sourced datasets. Our findings reveal that compared to board-certified radiologists, these foundation models consistently underdiagnose marginalized groups, with even higher rates seen in intersectional subgroups, such as Black female patients. Such demographic biases present over a wide range of pathologies and demographic attributes. Further analysis of the model embedding uncovers its significant encoding of demographic information. Deploying AI systems with these biases in medical imaging can intensify pre-existing care disparities, posing potential challenges to equitable healthcare access and raising ethical questions about their clinical application.

Online medical consultation (OMC) restricts doctors to gathering patient information solely through inquiries, making the already complex sequential decision-making process of diagnosis even more challenging. Recently, the rapid advancement of large language models has demonstrated a significant potential to transform OMC. However, most studies have primarily focused on improving diagnostic accuracy under conditions of relatively sufficient information, while paying limited attention to the "inquiry" phase of the consultation process. This lack of focus has left the relationship between "inquiry" and "diagnosis" insufficiently explored. In this paper, we first extract real patient interaction strategies from authentic doctor-patient conversations and use these strategies to guide the training of a patient simulator that closely mirrors real-world behavior. By inputting medical records into our patient simulator to simulate patient responses, we conduct extensive experiments to explore the relationship between "inquiry" and "diagnosis" in the consultation process. Experimental results demonstrate that inquiry and diagnosis adhere to the Liebig's law: poor inquiry quality limits the effectiveness of diagnosis, regardless of diagnostic capability, and vice versa. Furthermore, the experiments reveal significant differences in the inquiry performance of various models. To investigate this phenomenon, we categorize the inquiry process into four types: (1) chief complaint inquiry; (2) specification of known symptoms; (3) inquiry about accompanying symptoms; and (4) gathering family or medical history. We analyze the distribution of inquiries across the four types for different models to explore the reasons behind their significant performance differences. We plan to open-source the weights and related code of our patient simulator at https://github.com/LIO-H-ZEN/PatientSimulator.

We consider the problem of predicting how the likelihood of an outcome of interest for a patient changes over time as we observe more of the patient data. To solve this problem, we propose a supervised contrastive learning framework that learns an embedding representation for each time step of a patient time series. Our framework learns the embedding space to have the following properties: (1) nearby points in the embedding space have similar predicted class probabilities, (2) adjacent time steps of the same time series map to nearby points in the embedding space, and (3) time steps with very different raw feature vectors map to far apart regions of the embedding space. To achieve property (3), we employ a nearest neighbor pairing mechanism in the raw feature space. This mechanism also serves as an alternative to data augmentation, a key ingredient of contrastive learning, which lacks a standard procedure that is adequately realistic for clinical tabular data, to our knowledge. We demonstrate that our approach outperforms state-of-the-art baselines in predicting mortality of septic patients (MIMIC-III dataset) and tracking progression of cognitive impairment (ADNI dataset). Our method also consistently recovers the correct synthetic dataset embedding structure across experiments, a feat not achieved by baselines. Our ablation experiments show the pivotal role of our nearest neighbor pairing.

This paper presents a way of enhancing the reliability of Large Multimodal Models (LMMs) in addressing hallucination effects, where models generate incorrect or unrelated responses. Without additional instruction tuning paradigm, we introduce Counterfactual Inception, a novel method that implants counterfactual thoughts into LMMs using carefully chosen, misaligned counterfactual keywords. This method is grounded in the concept of counterfactual thinking, a cognitive process where humans consider alternative realities and outcomes. By applying this human-like reasoning mechanism to LMMs, we aim to reduce hallucination effects and improve the models' trustworthiness. We also propose Dual-modality Verification Process (DVP), a rigorous framework for selecting optimal counterfactual keywords to trigger counterfactual thinking into LMMs, concurrently considering visual and linguistic context. Our extensive experiments across various LMMs, including both open-source and proprietary models, corroborate that our method significantly mitigates hallucination phenomena across different datasets.

Interpretability research on large language models (LLMs) has yielded important insights into model behaviour, yet recurring pitfalls persist: findings that do not generalise, and causal interpretations that outrun the evidence. Our position is that causal inference specifies what constitutes a valid mapping from model activations to invariant high-level structures, the data or assumptions needed to achieve it, and the inferences it can support. Specifically, Pearl's causal hierarchy clarifies what an interpretability study can justify. Observations establish associations between model behaviour and internal components. Interventions (e.g., ablations or activation patching) support claims how these edits affect a behavioural metric (e.g., average change in token probabilities) over a set of prompts. However, counterfactual claims -- i.e., asking what the model output would have been for the same prompt under an unobserved intervention -- remain largely unverifiable without controlled supervision. We show how causal representation learning (CRL) operationalises this hierarchy, specifying which variables are recoverable from activations and under what assumptions. Together, these motivate a diagnostic framework that helps practitioners select methods and evaluations matching claims to evidence such that findings generalise.

Foundation Models that are capable of processing and generating multi-modal data have transformed AI's role in medicine. However, a key limitation of their reliability is hallucination, where inaccurate or fabricated information can impact clinical decisions and patient safety. We define medical hallucination as any instance in which a model generates misleading medical content. This paper examines the unique characteristics, causes, and implications of medical hallucinations, with a particular focus on how these errors manifest themselves in real-world clinical scenarios. Our contributions include (1) a taxonomy for understanding and addressing medical hallucinations, (2) benchmarking models using medical hallucination dataset and physician-annotated LLM responses to real medical cases, providing direct insight into the clinical impact of hallucinations, and (3) a multi-national clinician survey on their experiences with medical hallucinations. Our results reveal that inference techniques such as Chain-of-Thought (CoT) and Search Augmented Generation can effectively reduce hallucination rates. However, despite these improvements, non-trivial levels of hallucination persist. These findings underscore the ethical and practical imperative for robust detection and mitigation strategies, establishing a foundation for regulatory policies that prioritize patient safety and maintain clinical integrity as AI becomes more integrated into healthcare. The feedback from clinicians highlights the urgent need for not only technical advances but also for clearer ethical and regulatory guidelines to ensure patient safety. A repository organizing the paper resources, summaries, and additional information is available at https://github.com/mitmedialab/medical hallucination.

Diagnosing and managing a patient is a complex, sequential decision making process that requires physicians to obtain information -- such as which tests to perform -- and to act upon it. Recent advances in artificial intelligence (AI) and large language models (LLMs) promise to profoundly impact clinical care. However, current evaluation schemes overrely on static medical question-answering benchmarks, falling short on interactive decision-making that is required in real-life clinical work. Here, we present AgentClinic: a multimodal benchmark to evaluate LLMs in their ability to operate as agents in simulated clinical environments. In our benchmark, the doctor agent must uncover the patient's diagnosis through dialogue and active data collection. We present two open medical agent benchmarks: a multimodal image and dialogue environment, AgentClinic-NEJM, and a dialogue-only environment, AgentClinic-MedQA. We embed cognitive and implicit biases both in patient and doctor agents to emulate realistic interactions between biased agents. We find that introducing bias leads to large reductions in diagnostic accuracy of the doctor agents, as well as reduced compliance, confidence, and follow-up consultation willingness in patient agents. Evaluating a suite of state-of-the-art LLMs, we find that several models that excel in benchmarks like MedQA are performing poorly in AgentClinic-MedQA. We find that the LLM used in the patient agent is an important factor for performance in the AgentClinic benchmark. We show that both having limited interactions as well as too many interaction reduces diagnostic accuracy in doctor agents. The code and data for this work is publicly available at https://AgentClinic.github.io.

Large Language Models (LLMs) have great potential in the field of health care, yet they face great challenges in adapting to rapidly evolving medical knowledge. This can lead to outdated or contradictory treatment suggestions. This study investigated how LLMs respond to evolving clinical guidelines, focusing on concept drift and internal inconsistencies. We developed the DriftMedQA benchmark to simulate guideline evolution and assessed the temporal reliability of various LLMs. Our evaluation of seven state-of-the-art models across 4,290 scenarios demonstrated difficulties in rejecting outdated recommendations and frequently endorsing conflicting guidance. Additionally, we explored two mitigation strategies: Retrieval-Augmented Generation and preference fine-tuning via Direct Preference Optimization. While each method improved model performance, their combination led to the most consistent and reliable results. These findings underscore the need to improve LLM robustness to temporal shifts to ensure more dependable applications in clinical practice.

Personalized recommendation systems shape much of user choice online, yet their targeted nature makes separating out the value of recommendation and the underlying goods challenging. We build a discrete choice model that embeds recommendation-induced utility, low-rank heterogeneity, and flexible state dependence and apply the model to viewership data at Netflix. We exploit idiosyncratic variation introduced by the recommendation algorithm to identify and separately value these components as well as to recover model-free diversion ratios that we can use to validate our structural model. We use the model to evaluate counterfactuals that quantify the incremental engagement generated by personalized recommendations. First, we show that replacing the current recommender system with a matrix factorization or popularity-based algorithm would lead to 4% and 12% reduction in engagement, respectively, and decreased consumption diversity. Second, most of the consumption increase from recommendations comes from effective targeting, not mechanical exposure, with the largest gains for mid-popularity goods (as opposed to broadly appealing or very niche goods).

Language models are known to absorb biases from their training data, leading to predictions driven by statistical regularities rather than semantic relevance. We investigate the impact of these biases on answer choice preferences in the Massive Multi-Task Language Understanding (MMLU) task. Our findings reveal that differences in learned regularities across answer options are predictive of model preferences and mirror human test-taking strategies. To address this issue, we introduce two novel methods: Counterfactual Prompting with Chain of Thought (CoT) and Counterfactual Prompting with Agnostically Primed CoT (APriCoT). We demonstrate that while Counterfactual Prompting with CoT alone is insufficient to mitigate bias, our novel Primed Counterfactual Prompting with CoT approach effectively reduces the influence of base-rate probabilities while improving overall accuracy. Our results suggest that mitigating bias requires a "System-2" like process and that CoT reasoning is susceptible to confirmation bias under some prompting methodologies. Our contributions offer practical solutions for developing more robust and fair language models.

Alzheimer's disease (AD) is a degenerative brain disease impairing a person's ability to perform day to day activities. The clinical manifestations of Alzheimer's disease are characterized by heterogeneity in age, disease span, progression rate, impairment of memory and cognitive abilities. Due to these variabilities, personalized care and treatment planning, as well as patient counseling about their individual progression is limited. Recent developments in machine learning to detect hidden patterns in complex, multi-dimensional datasets provides significant opportunities to address this critical need. In this work, we use unsupervised and supervised machine learning approaches for subtype identification and prediction. We apply machine learning methods to the extensive clinical observations available at the Alzheimer's Disease Neuroimaging Initiative (ADNI) data set to identify patient subtypes and to predict disease progression. Our analysis depicts the progression space for the Alzheimer's disease into low, moderate and high disease progression zones. The proposed work will enable early detection and characterization of distinct disease subtypes based on clinical heterogeneity. We anticipate that our models will enable patient counseling, clinical trial design, and ultimately individualized clinical care.

Understanding and manipulating the causal generation mechanisms in language models is essential for controlling their behavior. Previous work has primarily relied on techniques such as representation surgery -- e.g., model ablations or manipulation of linear subspaces tied to specific concepts -- to intervene on these models. To understand the impact of interventions precisely, it is useful to examine counterfactuals -- e.g., how a given sentence would have appeared had it been generated by the model following a specific intervention. We highlight that counterfactual reasoning is conceptually distinct from interventions, as articulated in Pearl's causal hierarchy. Based on this observation, we propose a framework for generating true string counterfactuals by reformulating language models as Generalized Structural-equation. Models using the Gumbel-max trick. This allows us to model the joint distribution over original strings and their counterfactuals resulting from the same instantiation of the sampling noise. We develop an algorithm based on hindsight Gumbel sampling that allows us to infer the latent noise variables and generate counterfactuals of observed strings. Our experiments demonstrate that the approach produces meaningful counterfactuals while at the same time showing that commonly used intervention techniques have considerable undesired side effects.

The objective of this paper is to understand what characteristics and features of clinical data influence physician's decision about ordering laboratory tests or prescribing medications the most. We conduct our analysis on data and decisions extracted from electronic health records of 4486 post-surgical cardiac patients. The summary statistics for 335 different lab order decisions and 407 medication decisions are reported. We show that in many cases, physician's lab-order and medication decisions can be well predicted from a small subset of all features.

Synthetic medical data generation has opened up new possibilities in the healthcare domain, offering a powerful tool for simulating clinical scenarios, enhancing diagnostic and treatment quality, gaining granular medical knowledge, and accelerating the development of unbiased algorithms. In this context, we present a novel approach called ViewXGen, designed to overcome the limitations of existing methods that rely on general domain pipelines using only radiology reports to generate frontal-view chest X-rays. Our approach takes into consideration the diverse view positions found in the dataset, enabling the generation of chest X-rays with specific views, which marks a significant advancement in the field. To achieve this, we introduce a set of specially designed tokens for each view position, tailoring the generation process to the user's preferences. Furthermore, we leverage multi-view chest X-rays as input, incorporating valuable information from different views within the same study. This integration rectifies potential errors and contributes to faithfully capturing abnormal findings in chest X-ray generation. To validate the effectiveness of our approach, we conducted statistical analyses, evaluating its performance in a clinical efficacy metric on the MIMIC-CXR dataset. Also, human evaluation demonstrates the remarkable capabilities of ViewXGen, particularly in producing realistic view-specific X-rays that closely resemble the original images.

Although counterfactual reasoning is a fundamental aspect of intelligence, the lack of large-scale counterfactual open-domain question-answering (QA) benchmarks makes it difficult to evaluate and improve models on this ability. To address this void, we introduce the first such dataset, named IfQA, where each question is based on a counterfactual presupposition via an "if" clause. For example, if Los Angeles was on the east coast of the U.S., what would be the time difference between Los Angeles and Paris? Such questions require models to go beyond retrieving direct factual knowledge from the Web: they must identify the right information to retrieve and reason about an imagined situation that may even go against the facts built into their parameters. The IfQA dataset contains over 3,800 questions that were annotated annotated by crowdworkers on relevant Wikipedia passages. Empirical analysis reveals that the IfQA dataset is highly challenging for existing open-domain QA methods, including supervised retrieve-then-read pipeline methods (EM score 36.2), as well as recent few-shot approaches such as chain-of-thought prompting with GPT-3 (EM score 27.4). The unique challenges posed by the IfQA benchmark will push open-domain QA research on both retrieval and counterfactual reasoning fronts.

Clinical trial matching is the task of identifying trials for which patients may be potentially eligible. Typically, this task is labor-intensive and requires detailed verification of patient electronic health records (EHRs) against the stringent inclusion and exclusion criteria of clinical trials. This process is manual, time-intensive, and challenging to scale up, resulting in many patients missing out on potential therapeutic options. Recent advancements in Large Language Models (LLMs) have made automating patient-trial matching possible, as shown in multiple concurrent research studies. However, the current approaches are confined to constrained, often synthetic datasets that do not adequately mirror the complexities encountered in real-world medical data. In this study, we present the first, end-to-end large-scale empirical evaluation of clinical trial matching using real-world EHRs. Our study showcases the capability of LLMs to accurately match patients with appropriate clinical trials. We perform experiments with proprietary LLMs, including GPT-4 and GPT-3.5, as well as our custom fine-tuned model called OncoLLM and show that OncoLLM, despite its significantly smaller size, not only outperforms GPT-3.5 but also matches the performance of qualified medical doctors. All experiments were carried out on real-world EHRs that include clinical notes and available clinical trials from a single cancer center in the United States.

Diffusion probabilistic models (DPMs) have become the state-of-the-art in high-quality image generation. However, DPMs have an arbitrary noisy latent space with no interpretable or controllable semantics. Although there has been significant research effort to improve image sample quality, there is little work on representation-controlled generation using diffusion models. Specifically, causal modeling and controllable counterfactual generation using DPMs is an underexplored area. In this work, we propose CausalDiffAE, a diffusion-based causal representation learning framework to enable counterfactual generation according to a specified causal model. Our key idea is to use an encoder to extract high-level semantically meaningful causal variables from high-dimensional data and model stochastic variation using reverse diffusion. We propose a causal encoding mechanism that maps high-dimensional data to causally related latent factors and parameterize the causal mechanisms among latent factors using neural networks. To enforce the disentanglement of causal variables, we formulate a variational objective and leverage auxiliary label information in a prior to regularize the latent space. We propose a DDIM-based counterfactual generation procedure subject to do-interventions. Finally, to address the limited label supervision scenario, we also study the application of CausalDiffAE when a part of the training data is unlabeled, which also enables granular control over the strength of interventions in generating counterfactuals during inference. We empirically show that CausalDiffAE learns a disentangled latent space and is capable of generating high-quality counterfactual images.

Objective: To propose and retrospectively validate an integrated framework addressing three barriers to clinical translation of readmission prediction: lack of explainability, absence of deployment reliability infrastructure, and inadequate demographic fairness evaluation. Materials and Methods: We constructed a cohort of 415231 adult admissions from the MIMIC-IV database (30-day readmission prevalence 18.0%), split 70/15/15. Logistic regression, XGBoost, and LightGBM models were trained on 26 features. SHAP provided per-patient explanations. Fairness was evaluated across 16 subgroups using AUC-ROC, false negative rate (FNR), and positive predictive value (PPV). Calibration was assessed using Brier scores and calibration curves. Results: XGBoost achieved AUC-ROC 0.696 (95% CI 0.691-0.701), outperforming or matching the LACE baseline (AUC 0.60-0.68). LightGBM achieved best calibration (Brier 0.146). Prior admissions were the dominant predictor. All subgroups met equity thresholds (delta AUC <= 0.05, delta FNR <= 0.10). Conclusion: This framework delivers competitive performance, clinically actionable explanations, and strong demographic equity. Code is publicly available at https://github.com/Tomisin92/readmission-prediction.

Counterfactual learning to rank (CLTR) aims to learn a ranking policy from user interactions while correcting for the inherent biases in interaction data, such as position bias. Existing CLTR methods assume a single ranking policy that selects top-K ranking from the entire document candidate set. In real-world applications, the candidate document set is on the order of millions, making a single-stage ranking policy impractical. In order to scale to millions of documents, real-world ranking systems are designed in a two-stage fashion, with a candidate generator followed by a ranker. The existing CLTR method for a two-stage offline ranking system only considers the top-1 ranking set-up and only focuses on training the candidate generator, with the ranker fixed. A CLTR method for training both the ranker and candidate generator jointly is missing from the existing literature. In this paper, we propose a two-stage CLTR estimator that considers the interaction between the two stages and estimates the joint value of the two policies offline. In addition, we propose a novel joint optimization method to train the candidate and ranker policies, respectively. To the best of our knowledge, we are the first to propose a CLTR estimator and learning method for two-stage ranking. Experimental results on a semi-synthetic benchmark demonstrate the effectiveness of the proposed joint CLTR method over baselines.

Vision Language Models (VLMs) have recently shown significant advancements in video understanding, especially in feature alignment, event reasoning, and instruction-following tasks. However, their capability for counterfactual reasoning, inferring alternative outcomes under hypothetical conditions, remains underexplored. This capability is essential for robust video understanding, as it requires identifying underlying causal structures and reasoning about unobserved possibilities, rather than merely recognizing observed patterns. To systematically evaluate this capability, we introduce CounterVQA, a video-based benchmark featuring three progressive difficulty levels that assess different aspects of counterfactual reasoning. Through comprehensive evaluation of both state-of-the-art open-source and closed-source models, we uncover a substantial performance gap: while these models achieve reasonable accuracy on simple counterfactual questions, performance degrades significantly on complex multi-hop causal chains. To address these limitations, we develop a post-training method, CFGPT, that enhances a model's visual counterfactual reasoning ability by distilling its counterfactual reasoning capability from the language modality, yielding consistent improvements across all CounterVQA difficulty levels. Dataset and code will be further released.

This paper proposes one of the first clinical applications of multimodal large language models (LLMs) as an assistant for radiologists to check errors in their reports. We created an evaluation dataset from two real-world radiology datasets (MIMIC-CXR and IU-Xray), with 1,000 subsampled reports each. A subset of original reports was modified to contain synthetic errors by introducing various type of mistakes. The evaluation contained two difficulty levels: SIMPLE for binary error-checking and COMPLEX for identifying error types. LLaVA (Large Language and Visual Assistant) variant models, including our instruction-tuned model, were used for the evaluation. Additionally, a domain expert evaluation was conducted on a small test set. At the SIMPLE level, the LLaVA v1.5 model outperformed other publicly available models. Instruction tuning significantly enhanced performance by 47.4% and 25.4% on MIMIC-CXR and IU-Xray data, respectively. The model also surpassed the domain experts accuracy in the MIMIC-CXR dataset by 1.67%. Notably, among the subsets (N=21) of the test set where a clinician did not achieve the correct conclusion, the LLaVA ensemble mode correctly identified 71.4% of these cases. This study marks a promising step toward utilizing multi-modal LLMs to enhance diagnostic accuracy in radiology. The ensemble model demonstrated comparable performance to clinicians, even capturing errors overlooked by humans. Nevertheless, future work is needed to improve the model ability to identify the types of inconsistency.

Predicting how different interventions will causally affect a specific individual is important in a variety of domains such as personalized medicine, public policy, and online marketing. There are a large number of methods to predict the effect of an existing intervention based on historical data from individuals who received it. However, in many settings it is important to predict the effects of novel interventions (e.g., a newly invented drug), which these methods do not address. Here, we consider zero-shot causal learning: predicting the personalized effects of a novel intervention. We propose CaML, a causal meta-learning framework which formulates the personalized prediction of each intervention's effect as a task. CaML trains a single meta-model across thousands of tasks, each constructed by sampling an intervention, along with its recipients and nonrecipients. By leveraging both intervention information (e.g., a drug's attributes) and individual features~(e.g., a patient's history), CaML is able to predict the personalized effects of novel interventions that do not exist at the time of training. Experimental results on real world datasets in large-scale medical claims and cell-line perturbations demonstrate the effectiveness of our approach. Most strikingly, CaML's zero-shot predictions outperform even strong baselines trained directly on data from the test interventions.

As large language models (LLMs) advance in conversational and reasoning capabilities, their practical application in healthcare has become a critical research focus. However, there is a notable gap between the performance of medical LLMs on static benchmarks such as USMLE and their utility in real-world clinical decision-making. This discrepancy arises because traditional exams fail to capture the dynamic, interactive nature of medical consultations. To address this challenge, we introduce a novel dynamic verification framework that moves beyond static answer verifier, establishing a large-scale, high-fidelity interactive reinforcement learning system. Our framework comprises two key components: a Patient Simulator that creates realistic clinical environments using de-identified medical records, and a Clinical Rubrics Generator that dynamically produces multi-dimensional evaluation metrics. Building on this foundation, we develop Baichuan-M2, a 32B-parameter medical augmented reasoning model trained through a multi-stage reinforcement learning strategy with an improved Group Relative Policy Optimization (GRPO) algorithm. Evaluated on HealthBench, Baichuan-M2 outperforms all other open-source models and most advanced closed-source counterparts, achieving a score above 32 on the challenging HealthBench Hard benchmark-previously exceeded only by GPT-5. Our work demonstrates that robust dynamic verifier system is essential for aligning LLM capabilities with practical clinical applications, establishing a new Pareto front in the performance-parameter trade-off for medical AI deployment.

Heterogeneity and comorbidity are two interwoven challenges associated with various healthcare problems that greatly hampered research on developing effective treatment and understanding of the underlying neurobiological mechanism. Very few studies have been conducted to investigate heterogeneous causal effects (HCEs) in graphical contexts due to the lack of statistical methods. To characterize this heterogeneity, we first conceptualize heterogeneous causal graphs (HCGs) by generalizing the causal graphical model with confounder-based interactions and multiple mediators. Such confounders with an interaction with the treatment are known as moderators. This allows us to flexibly produce HCGs given different moderators and explicitly characterize HCEs from the treatment or potential mediators on the outcome. We establish the theoretical forms of HCEs and derive their properties at the individual level in both linear and nonlinear models. An interactive structural learning is developed to estimate the complex HCGs and HCEs with confidence intervals provided. Our method is empirically justified by extensive simulations and its practical usefulness is illustrated by exploring causality among psychiatric disorders for trauma survivors.

Large Language Models (LLMs) are now increasingly widely used to simulate personas in virtual environments, leveraging their instruction-following capability. However, we discovered that even state-of-the-art LLMs cannot simulate personas with reversed performance (e.g., student personas with low proficiency in educational settings), which impairs the simulation diversity and limits the practical applications of the simulated environments. In this work, using mathematical reasoning as a representative scenario, we propose the first benchmark dataset for evaluating LLMs on simulating personas with reversed performance, a capability that we dub "counterfactual instruction following". We evaluate both open-weight and closed-source LLMs on this task and find that LLMs, including the OpenAI o1 reasoning model, all struggle to follow counterfactual instructions for simulating reversedly performing personas. Intersectionally simulating both the performance level and the race population of a persona worsens the effect even further. These results highlight the challenges of counterfactual instruction following and the need for further research.

Brain tumor growth is unique to each glioma patient and extends beyond what is visible in imaging scans, infiltrating surrounding brain tissue. Understanding these hidden patient-specific progressions is essential for effective therapies. Current treatment plans for brain tumors, such as radiotherapy, typically involve delineating a uniform margin around the visible tumor on pre-treatment scans to target this invisible tumor growth. This "one size fits all" approach is derived from population studies and often fails to account for the nuances of individual patient conditions. We present the GliODIL framework, which infers the full spatial distribution of tumor cell concentration from available multi-modal imaging, leveraging a Fisher-Kolmogorov type physics model to describe tumor growth. This is achieved through the newly introduced method of Optimizing the Discrete Loss (ODIL), where both data and physics-based constraints are softly assimilated into the solution. Our test dataset comprises 152 glioblastoma patients with pre-treatment imaging and post-treatment follow-ups for tumor recurrence monitoring. By blending data-driven techniques with physics-based constraints, GliODIL enhances recurrence prediction in radiotherapy planning, challenging traditional uniform margins and strict adherence to the Fisher-Kolmogorov partial differential equation (PDE) model, which is adapted for complex cases.

Mental illness remains one of the most critical public health issues. Despite its importance, many mental health professionals highlight a disconnect between their training and actual real-world patient practice. To help bridge this gap, we propose PATIENT-{\Psi}, a novel patient simulation framework for cognitive behavior therapy (CBT) training. To build PATIENT-{\Psi}, we construct diverse patient cognitive models based on CBT principles and use large language models (LLMs) programmed with these cognitive models to act as a simulated therapy patient. We propose an interactive training scheme, PATIENT-{\Psi}-TRAINER, for mental health trainees to practice a key skill in CBT -- formulating the cognitive model of the patient -- through role-playing a therapy session with PATIENT-{\Psi}. To evaluate PATIENT-{\Psi}, we conducted a comprehensive user study of 13 mental health trainees and 20 experts. The results demonstrate that practice using PATIENT-{\Psi}-TRAINER enhances the perceived skill acquisition and confidence of the trainees beyond existing forms of training such as textbooks, videos, and role-play with non-patients. Based on the experts' perceptions, PATIENT-{\Psi} is perceived to be closer to real patient interactions than GPT-4, and PATIENT-{\Psi}-TRAINER holds strong promise to improve trainee competencies. Our code and data are released at https://github.com/ruiyiw/patient-psi.

Despite the increasing effectiveness of language models, their reasoning capabilities remain underdeveloped. In particular, causal reasoning through counterfactual question answering is lacking. This work aims to bridge this gap. We first derive novel metrics that balance accuracy in factual and counterfactual questions, capturing a more complete view of the reasoning abilities of language models than traditional factual-only based metrics. Second, we propose several fine-tuning approaches that aim to elicit better reasoning mechanisms, in the sense of the proposed metrics. Finally, we evaluate the performance of the fine-tuned language models in a variety of realistic scenarios. In particular, we investigate to what extent our fine-tuning approaches systemically achieve better generalization with respect to the base models in several problems that require, among others, inductive and deductive reasoning capabilities.

Medical reasoning models (MRMs) achieve superior performance on medical benchmarks compared to medical LLMs; however, high accuracy alone is insufficient for practical deployment. One of such requirements for real-world application is robustness to varying output constraints. Specifically, posing the same medical question while requesting different answer formats should not affect the underlying correctness of the response. We investigate this phenomenon in this paper, focusing on MRMs. To quantify this behavior, we propose the metric answer-format robustness: the ability to reliably generate correct outputs across varying specified formats. We examine three representative formats: multiple-choice, open-ended question-answering, and ranked lists. Across 15 proprietary and open-weight models, we observe substantial variation in format robustness (35-100%). Furthermore, we conduct controlled fine-tuning experiments on a shared backbone with matched training data to isolate the effects of the fine-tuning paradigm. We find that supervised fine-tuning yields more stable behavior across formats, whereas reinforcement fine-tuning often exhibits higher cross-format brittleness, with the degree of instability strongly dependent on reward design. Overall, answer-format robustness in MRMs is trainable yet brittle and requires careful evaluation for practical medical use.

Counterfactual examples are widely employed to enhance the performance and robustness of large language models (LLMs) through counterfactual data augmentation (CDA). However, the selection of the judge model used to evaluate label flipping, the primary metric for assessing the validity of generated counterfactuals for CDA, yields inconsistent results. To decipher this, we define four types of relationships between the counterfactual generator and judge models. Through extensive experiments involving two state-of-the-art LLM-based methods, three datasets, five generator models, and 15 judge models, complemented by a user study (n = 90), we demonstrate that judge models with an independent, non-fine-tuned relationship to the generator model provide the most reliable label flipping evaluations. Relationships between the generator and judge models, which are closely aligned with the user study for CDA, result in better model performance and robustness. Nevertheless, we find that the gap between the most effective judge models and the results obtained from the user study remains considerably large. This suggests that a fully automated pipeline for CDA may be inadequate and requires human intervention.

Simulating human clients in mental health counseling is crucial for training and evaluating counselors (both human or simulated) in a scalable manner. Nevertheless, past research on client simulation did not focus on complex conversation tasks such as mental health counseling. In these tasks, the challenge is to ensure that the client's actions (i.e., interactions with the counselor) are consistent with with its stipulated profiles and negative behavior settings. In this paper, we propose a novel framework that supports consistent client simulation for mental health counseling. Our framework tracks the mental state of a simulated client, controls its state transitions, and generates for each state behaviors consistent with the client's motivation, beliefs, preferred plan to change, and receptivity. By varying the client profile and receptivity, we demonstrate that consistent simulated clients for different counseling scenarios can be effectively created. Both our automatic and expert evaluations on the generated counseling sessions also show that our client simulation method achieves higher consistency than previous methods.

False assumptions about sex and gender are deeply embedded in the medical system, including that they are binary, static, and concordant. Machine learning researchers must understand the nature of these assumptions in order to avoid perpetuating them. In this perspectives piece, we identify three common mistakes that researchers make when dealing with sex/gender data: "sex confusion", the failure to identity what sex in a dataset does or doesn't mean; "sex obsession", the belief that sex, specifically sex assigned at birth, is the relevant variable for most applications; and "sex/gender slippage", the conflation of sex and gender even in contexts where only one or the other is known. We then discuss how these pitfalls show up in machine learning studies based on electronic health record data, which is commonly used for everything from retrospective analysis of patient outcomes to the development of algorithms to predict risk and administer care. Finally, we offer a series of recommendations about how machine learning researchers can produce both research and algorithms that more carefully engage with questions of sex/gender, better serving all patients, including transgender people.