Ran D. Balicer

Ayush Noori, Adam Rodman, Alan Karthikesalingam et al.

Modern computer systems often rely on syslog, a simple, universal protocol that records every critical event across heterogeneous infrastructure. However, healthcare's rapidly growing clinical AI stack has no equivalent. As hospitals rush to pilot large language models and other AI-based clinical decision support tools, we still lack a standard way to record how, when, by whom, and for whom these AI models are used. Without that transparency and visibility, it is challenging to measure real-world performance and outcomes, detect adverse events, or correct bias or dataset drift. In the spirit of syslog, we introduce MedLog, a protocol for event-level logging of clinical AI. Any time an AI model is invoked to interact with a human, interface with another algorithm, or act independently, a MedLog record is created. This record consists of nine core fields: header, model, user, target, inputs, artifacts, outputs, outcomes, and feedback, providing a structured and consistent record of model activity. To encourage early adoption, especially in low-resource settings, and minimize the data footprint, MedLog supports risk-based sampling, lifecycle-aware retention policies, and write-behind caching; detailed traces for complex, agentic, or multi-stage workflows can also be captured under MedLog. MedLog can catalyze the development of new databases and software to store and analyze MedLog records. Realizing this vision would enable continuous surveillance, auditing, and iterative improvement of medical AI, laying the foundation for a new form of digital epidemiology.

Michelle M. Li, Ben Y. Reis, Adam Rodman et al.

Medical AI, including clinical language models, vision-language models, and multimodal health record models, already summarizes notes, answers questions, and supports decisions. Their adaptation to new populations, specialties, or care settings often relies on fine-tuning, prompting, or retrieval from external knowledge bases. These strategies can scale poorly and risk contextual errors: outputs that appear plausible but miss critical patient or situational information. We envision context switching as a solution. Context switching adjusts model reasoning at inference without retraining. Generative models can tailor outputs to patient biology, care setting, or disease. Multimodal models can reason on notes, laboratory results, imaging, and genomics, even when some data are missing or delayed. Agent models can coordinate tools and roles based on tasks and users. In each case, context switching enables medical AI to adapt across specialties, populations, and geographies. It requires advances in data design, model architectures, and evaluation frameworks, and establishes a foundation for medical AI that scales to infinitely many contexts while remaining reliable and suited to real-world care.