Designing a Large Language Model Architecture for Shared Decision Making and Informed Intentions

Background & Current State of Research Shared Decision-Making is widely recognized as the gold standard of patient-centered care. However, its successful implementation in clinical practice is frequently hindered by systemic time and budget constraints. Consequently, patients are increasingly turning to Large Language Models to independently access health information and navigate their medical options.

The Problem: Limitations of Standard LLMs Recent studies indicate that using standard LLMs can digitally reproduce existing health inequalities and participation gaps. These models struggle to adapt to different reading levels without a significant loss in quality. While highly developed prompting techniques can enhance clinical accuracy, the results remain highly variable depending on the specific model and technique used.

A central deficit becomes apparent in multi-turn interactions, which are essential for a natural SDM workflow. In these prolonged conversations, standard LLMs tend to exhibit "context rot," leading to a sharp decline in accuracy as the dialogue progresses. This issue is further exacerbated by model sycophancy (an uncritical tendency to agree with the user) and completion eagerness (a tendency to prematurely conclude the conversation). Because current LLMs often fail to meet evidence-based reporting standards and lack systematic validation of user comprehension, the burden of fact-checking remains entirely on the user. This dynamic significantly disadvantages vulnerable groups, particularly those with lower health literacy.

Project Objectives and Research Questions

This project proposes a technical and clinical solution to these challenges through the following core research questions:

Technical-Conceptual Framework: How can we develop a transparent and replicable workflow that formalizes the SDM process through an agentic state-machine, thereby eliminating structural deficits of LLMs (e.g., context rot and sycophancy) in prolonged interactions?

Clinical Evaluation (Primary Objective): Does this newly developed agentic LLM architecture achieve higher scores in participatory conversation management and demonstrate a significantly greater objective increase in informed decision-making among users during multi-turn interactions, compared to a standard baseline LLM?

Health Equity (Secondary Objective): To what extent can this agentic LLM architecture guarantee effective participatory conversation management for vulnerable patient groups with low health literacy?

Inclusion criteria

• Biological sex: Female.
• Age: 40 to 70 years old.
• Country of residence: United States (US) or United Kingdom (UK).
• Language: Native English speaker (English as first language).
• Registered and verified user on the academic research platform Prolific.
• Able to read, understand, and provide informed consent digitally.

Exclusion criteria

• Individuals who do not meet the automated pre-screening criteria on the Prolific platform.
• Inability to use or access a computer, smartphone, or internet browser required to complete the digital study.

Note: Quotas will be enforced during recruitment to ensure a 50/50 stratified split between participants with and without university entrance qualifications to guarantee variance in educational backgrounds. Once a quota is filled, further participants matching that educational profile will be excluded.

-