Jonathan Amar
Publications
The complexities of patient-centred conversational artificial intelligence
Consumer-facing health chatbots powered by large language models (LLMs) are increasingly used for symptom assessment. However, chatbot development and evaluation often rely on cooperative, articulate, simulated patients. We analysed 2,053 real patient-chatbot conversations and found that communication patterns and expression of emotions vary widely across users. We developed a patient simulator that separately models clinical content, emotional state, conversational strategy, and communication style. In a Turing-inspired evaluation of realism with 15 human graders, simulated conversations were nearly indistinguishable from real ones, with human graders achieving an accuracy of 55%. We used five distinct patient personae, across 1,164 clinician-graded cases, to evaluate the performance of four LLMs in urgency assessment. We found that communication style can significantly alter triage outcomes. Patient-centred conversational artificial intelligence must accommodate communication diversity: systems designed for idealised, rather than realistic, interactions risk underperforming and amplifying health disparities when deployed in the real world.
STEER: Inference-Time Risk Control via Constrained Quality-Diversity Search
Large Language Models (LLMs) trained for average correctness often exhibit mode collapse, producing narrow decision behaviors on tasks where multiple responses may be reasonable. This limitation is particularly problematic in ordinal decision settings such as clinical triage, where standard alignment removes the ability to trade off specificity and sensitivity (the ROC operating point) based on contextual constraints. We propose STEER (Steerable Tuning via Evolutionary Ensemble Refinement), a training-free framework that reintroduces this tunable control. STEER constructs a population of natural-language personas through an offline, constrained quality-diversity search that promotes behavioral coverage while enforcing minimum safety, reasoning, and stability thresholds. At inference time, STEER exposes a single, interpretable control parameter that maps a user-specified risk percentile to a selected persona, yielding a monotonic adjustment of decision conservativeness. On two clinical triage benchmarks, STEER achieves broader behavioral coverage compared to temperature-based sampling and static persona ensembles. Compared to a representative post-training method, STEER maintains substantially higher accuracy on unambiguous urgent cases while providing comparable control over ambiguous decisions. These results demonstrate STEER as a safety-preserving paradigm for risk control, capable of steering behavior without compromising domain competence.