Gomez-Cabello, Cesar A.

Abstract Background/ Objectives: Agentic AI represents a promising evolution of AI technology applied to healthcare, with systems increasingly capable of operating autonomously to achieve defined clinical goals. However, the literature lacks conceptual clarity between “AI agents” and “agentic AI”, and few studies have rigorously explored their clinical applications. Therefore, this study aims to conduct a novel systematic review addressing this gap by examining agentic AI systems in healthcare settings, characterizing their applications, features, outcomes, and limitations, and clarifying the conceptual distinctions between AI agents and agentic AI systems using predefined and objective criteria. Methods A comprehensive search was conducted across PubMed, Embase, Cochrane, Scopus, and Google Scholar on April 6th, 2025. Studies were included if they involved AI systems in healthcare settings that demonstrated the following agentic features: autonomous operation, goal-directed behavior, and initiating action. Data on the clinical tasks achieved by the agents, key findings, features, and limitations were collected from the included studies. Screening and extraction followed PRISMA guidelines, with Risk of Bias assessed using ROBINS-I and Cochrane's Risk of Bias tools. Results Of 984 retrieved records, seven studies met the inclusion criteria, spanning domains such as emergency medicine, oncology, radiology, and rehabilitation. Multi-agent architecture was frequently used to decompose and coordinate complex workflows. Among the included studies, the AIs showed high accuracy in diagnosing cancer patients, conducting treatment plans, sending alerts, coaching messages, analysing image data, and adapting to challenging experimental scenarios. While demonstrating potential for improved efficiency, task accuracy, and patient engagement, significant limitations were noted: narrow task scope, lack of physical agency, limited clinical validation, and barriers to integration into real-world healthcare systems. Only one system had been deployed in a patient-facing trial setting. Conclusion The current literature suggests an emerging role and application of Agentic AI, holding promise with the potential to revolutionize diagnostics, triage, treatment planning, and patient management. However, real-world implementation and evaluations in the literature are limited. Future research must address critical validation, regulation, ethics, and clinical integration challenges to realize their full potential. Clear operational definitions and frameworks for evaluating agency are essential to support safe and effective deployment of these systems.

Background: Data accessibility remains a significant barrier in healthcare AI due to privacy constraints and logistical challenges. Synthetic data, which mimics real patient information while remaining both realistic and non-identifiable, offers a promising solution. Large Language Models (LLMs) create new opportunities to generate high-fidelity clinical conversations between patients and physicians. However, the value of this synthetic data depends on careful evaluation of its realism, accuracy, and practical relevance. Objective: To assess the performance of four leading LLMs: ChatGPT 4.5, ChatGPT 4o, Claude 3.7 Sonnet, and Gemini Pro 2.5 in generating synthetic transcripts of patient–physician interactions in plastic surgery scenarios. Methods: Each model generated transcripts for ten plastic surgery scenarios. Transcripts were independently evaluated by three clinically trained raters using a seven-criterion rubric: Medical Accuracy, Realism, Persona Consistency, Fidelity, Empathy, Relevancy, and Usability. Raters were blinded to the model identity to reduce bias. Each was rated on a 5-point Likert scale, yielding 840 total evaluations. Descriptive statistics were computed, and a two-way repeated measures ANOVA was used to test for differences across models and metrics. In addition, transcripts were analyzed using automated linguistic and content-based metrics. Results: All models achieved strong performance, with mean ratings exceeding 4.5 across all criteria. Gemini 2.5 Pro received mean scores (5.00 ± 0.00) in Medical Accuracy, Realism, Persona Consistency, Relevancy, and Usability. Claude 3.7 Sonnet matched the scores in Persona Consistency and Relevancy and led in Empathy (4.96 ± 0.18). ChatGPT 4.5 also achieved perfect scores in Relevancy, with high scores in Empathy (4.93 ± 0.25) and Usability (4.96 ± 0.18). ChatGPT 4o demonstrated consistently strong but slightly lower performance across most dimensions. ANOVA revealed no statistically significant differences across models (F(3, 6) = 0.85, p = 0.52). Automated analysis showed substantial variation in transcript length, style, and content richness: Gemini 2.5 Pro generated the longest and most emotionally expressive dialogues, while ChatGPT 4o produced the shortest and most concise outputs. Conclusions: Leading LLMs can generate medically accurate, emotionally appropriate synthetic dialogues suitable for educational and research use. Despite high performance, demographic homogeneity in generated patients highlights the need for improved diversity and bias mitigation in model outputs. These findings support the cautious, context-aware integration of LLM-generated dialogues into medical training, simulation, and research.

The increasing integration of large language models (LLMs) into healthcare presents significant opportunities, but also critical risks related to patient safety, accuracy, and ethical alignment. Despite these concerns, no standardized framework exists for systematically evaluating and stress testing LLM behavior in clinical decision-making. The PIEE cycle—Planning and Preparation, Information Gathering and Prompt Generation, Execution, and Evaluation—is a structured red-teaming framework developed specifically to address artificial intelligence (AI) safety risks in healthcare decision-making. PIEE enables clinicians and informatics teams to simulate adversarial prompts, including jailbreaking, social engineering, and distractor attacks, to stress-test language models in real-world clinical scenarios. Model performance is evaluated using specific metrics such as true positive and false positive rates for detecting harmful content, hallucination rates measured through adapted TruthfulQA scoring, safety and reliability assessments, bias detection via adapted BBQ benchmarks, and ethical evaluation using structured Likert-based scoring rubrics. The framework is illustrated using examples from plastic surgery, but is adaptable across specialties, and is intended for use by all medical providers, regardless of their backgrounds or familiarity with artificial intelligence. While the framework is currently conceptual and validation is ongoing, PIEE provides a practical foundation for assessing the clinical reliability and ethical robustness of LLMs in medicine.

(1) Burn injuries demand multidisciplinary, evidence-based care, yet the extensive literature complicates timely decision making. Retrieval-augmented generation (RAG) synthesizes research while addressing inaccuracies in pretrained models. However, citation bias in sourcing for RAG often prioritizes highly cited studies, overlooking less-cited but valuable research. This study examines RAG’s performance in burn management, comparing citation levels to enhance evidence synthesis, reduce selection bias, and guide decisions. (2) Two burn management datasets were assembled: 30 highly cited (mean: 303) and 30 less-cited (mean: 21). The Gemini-1.0-Pro-002 RAG model addressed 30 questions, ranging from foundational principles to advanced surgical approaches. Responses were evaluated for accuracy (5-point scale), readability (Flesch–Kincaid metrics), and response time with Wilcoxon rank sum tests (p < 0.05). (3) RAG achieved comparable accuracy (4.6 vs. 4.2, p = 0.49), readability (Flesch Reading Ease: 42.8 vs. 46.5, p = 0.26; Grade Level: 9.9 vs. 9.5, p = 0.29), and response time (2.8 vs. 2.5 s, p = 0.39) for the highly and less-cited datasets. (4) Less-cited research performed similarly to highly cited sources. This equivalence broadens clinicians’ access to novel, diverse insights without sacrificing quality. As plastic surgery evolves, RAG’s inclusive approach fosters innovation, improves patient care, and reduces cognitive burden by integrating underutilized studies. Embracing RAG could propel the field toward dynamic, forward-thinking care.

Background/Objectives: Facial analysis is critical for preoperative planning in facial plastic surgery, but traditional methods can be time consuming and subjective. This study investigated the potential of Artificial Intelligence (AI) for objective and efficient facial analysis in plastic surgery, with a specific focus on Multimodal Large Language Models (MLLMs). We evaluated their ability to analyze facial skin quality, volume, symmetry, and adherence to aesthetic standards such as neoclassical facial canons and the golden ratio. Methods: We evaluated four MLLMs—ChatGPT-4o, ChatGPT-4, Gemini 1.5 Pro, and Claude 3.5 Sonnet—using two evaluation forms and 15 diverse facial images generated by a Generative Adversarial Network (GAN). The general analysis form evaluated qualitative skin features (texture, type, thickness, wrinkling, photoaging, and overall symmetry). The facial ratios form assessed quantitative structural proportions, including division into equal fifths, adherence to the rule of thirds, and compatibility with the golden ratio. MLLM assessments were compared with evaluations from a plastic surgeon and manual measurements of facial ratios. Results: The MLLMs showed promise in analyzing qualitative features, but they struggled with precise quantitative measurements of facial ratios. Mean accuracy for general analysis were ChatGPT-4o (0.61 ± 0.49), Gemini 1.5 Pro (0.60 ± 0.49), ChatGPT-4 (0.57 ± 0.50), and Claude 3.5 Sonnet (0.52 ± 0.50). In facial ratio assessments, scores were lower, with Gemini 1.5 Pro achieving the highest mean accuracy (0.39 ± 0.49). Inter-rater reliability, based on Cohen’s Kappa values, ranged from poor to high for qualitative assessments (κ > 0.7 for some questions) but was generally poor (near or below zero) for quantitative assessments. Conclusions: Current general purpose MLLMs are not yet ready to replace manual clinical assessments but may assist in general facial feature analysis. These findings are based on testing models not specifically trained for facial analysis and serve to raise awareness among clinicians regarding the current capabilities and inherent limitations of readily available MLLMs in this specialized domain. This limitation may stem from challenges with spatial reasoning and fine-grained detail extraction, which are inherent limitations of current MLLMs. Future research should focus on enhancing the numerical accuracy and reliability of MLLMs for broader application in plastic surgery, potentially through improved training methods and integration with other AI technologies such as specialized computer vision algorithms for precise landmark detection and measurement.

Background: Anatomically accurate illustrations are imperative in medical education, serving as crucial tools to facilitate comprehension of complex anatomical structures. While traditional illustration methods involving human artists remain the gold standard, the rapid advancement of Generative Artificial Intelligence (GAI) models presents a new opportunity to automate and accelerate this process. This study evaluated the potential of GAI models to produce craniofacial anatomy illustrations for educational purposes. Methods: Four GAI models, including Midjourney v6.0, DALL-E 3, Gemini Ultra 1.0, and Stable Diffusion 2.0 were used to generate 736 images across multiple views of surface anatomy, bones, muscles, blood vessels, and nerves of the cranium in both oil painting and realistic photograph styles. Four reviewers evaluated the images for anatomical detail, aesthetic quality, usability, and cost-effectiveness. Inter-rater reliability analysis assessed evaluation consistency. Results: Midjourney v6.0 scored highest for aesthetic quality and cost-effectiveness, and DALL-E 3 performed best for anatomical detail and usability. The inter-rater reliability analysis demonstrated a high level of agreement among reviewers (ICC = 0.858, 95% CI). However, all models showed significant flaws in depicting crucial anatomical details such as foramina, suture lines, muscular origins/insertions, and neurovascular structures. These limitations were further characterized by abstract depictions, mixing of layers, shadowing, abnormal muscle arrangements, and labeling errors. Conclusions: These findings highlight GAI’s potential for rapidly creating craniofacial anatomy illustrations but also its current limitations due to inadequate training data and incomplete understanding of complex anatomy. Refining these models through precise training data and expert feedback is vital. Ethical considerations, such as potential biases, copyright challenges, and the risks of propagating inaccurate information, must also be carefully navigated. Further refinement of GAI models and ethical safeguards are essential for safe use.