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Unneeded elements in the attention's context degrade performance. We introduce Selective Attention, a simple parameter-free change to the standard attention mechanism which reduces attention to unneeded elements. Selective attention improves language modeling performance in a variety of model sizes and context lengths. For example, a range of transformers trained with the language modeling objective on C4 with selective attention perform equivalently to standard transformers with ~2X more heads and parameters in their attention modules. Selective attention also allows decreasing the size of the attention's context buffer, leading to meaningful reductions in the memory and compute requirements during inference. For example, transformers with 100M parameters trained on C4 with context sizes of 512, 1,024, and 2,048 need 16X, 25X, and 47X less memory for their attention module, respectively, when equipped with selective attention, as those without selective attention, with the same validation perplexity.

Earthquake occurrence is notoriously difficult to predict. While some aspects of their spatiotemporal statistics can be relatively well captured by point-process models, very little is known regarding the magnitude of future events, and it is deeply debated whether it is possible to predict the magnitude of an earthquake before it starts. This is due both to the lack of information about fault conditions and to the inherent complexity of rupture dynamics. Consequently, even state of the art forecasting models typically assume no knowledge about the magnitude of future events besides the time-independent Gutenberg Richter (GR) distribution, which describes the marginal distribution over large regions and long times. This approach implicitly assumes that earthquake magnitudes are independent of previous seismicity and are identically distributed. In this work we challenge this view by showing that information about the magnitude of an upcoming earthquake can be directly extracted from the seismic history. We present MAGNET - MAGnitude Neural EsTimation model, an open-source, geophysically-inspired neural-network model for probabilistic forecasting of future magnitudes from cataloged properties: hypocenter locations, occurrence times and magnitudes of past earthquakes. Our history-dependent model outperforms stationary and quasi-stationary state of the art GR-based benchmarks, in real catalogs in Southern California, Japan and New-Zealand. This demonstrates that earthquake catalogs contain information about the magnitude of future earthquakes, prior to their occurrence. We conclude by proposing methods to apply the model in characterization of the preparatory phase of earthquakes, and in operational hazard alert and earthquake forecasting systems., Comment: 4 main figure, 1 main table

Advances in Artificial Intelligence (AI) are helping tackle a growing number of societal challenges, demonstrating technology's increasing capability to address complex issues, including those outlined in the United Nations (UN) Sustainable Development Goals (SDGs). Despite global efforts, 80 percent of SDG targets have deviated, stalled, or regressed, and only 15 percent are on track as of 2023, illustrating the urgency of accelerating efforts to meet the goals by 2030. We draw on Google's internal and collaborative research, technical work, and social impact initiatives to show AI's potential to accelerate action on the SDGs and make substantive progress to help address humanity's most pressing challenges. The paper highlights AI capabilities (including computer vision, generative AI, natural language processing, and multimodal AI) and showcases how AI is altering how we approach problem-solving across all 17 SDGs through use cases, with a spotlight on AI-powered innovation in health, education, and climate. We then offer insights on AI development and deployment to drive bold and responsible innovation, enhance impact, close the accessibility gap, and ensure that everyone, everywhere, can benefit from AI., Comment: 12 pages

Microscopic interpretation of histopathology images underlies many important diagnostic and treatment decisions. While advances in vision-language modeling raise new opportunities for analysis of such images, the gigapixel-scale size of whole slide images (WSIs) introduces unique challenges. Additionally, pathology reports simultaneously highlight key findings from small regions while also aggregating interpretation across multiple slides, often making it difficult to create robust image-text pairs. As such, pathology reports remain a largely untapped source of supervision in computational pathology, with most efforts relying on region-of-interest annotations or self-supervision at the patch-level. In this work, we develop a vision-language model based on the BLIP-2 framework using WSIs paired with curated text from pathology reports. This enables applications utilizing a shared image-text embedding space, such as text or image retrieval for finding cases of interest, as well as integration of the WSI encoder with a frozen large language model (LLM) for WSI-based generative text capabilities such as report generation or AI-in-the-loop interactions. We utilize a de-identified dataset of over 350,000 WSIs and diagnostic text pairs, spanning a wide range of diagnoses, procedure types, and tissue types. We present pathologist evaluation of text generation and text retrieval using WSI embeddings, as well as results for WSI classification and workflow prioritization (slide-level triaging). Model-generated text for WSIs was rated by pathologists as accurate, without clinically significant error or omission, for 78% of WSIs on average. This work demonstrates exciting potential capabilities for language-aligned WSI embeddings., Comment: 9 main pages and 19 pages of supplemental material; 3 main tables, 3 main figures and 11 supplemental tables, 7 supplemental figures

Despite recent advancements in Large Language Models (LLMs), their performance on tasks involving long contexts remains sub-optimal. In-Context Learning (ICL) with few-shot examples may be an appealing solution to enhance LLM performance in this scenario; However, naively adding ICL examples with long context introduces challenges, including substantial token overhead added for each few-shot example and context mismatch between the demonstrations and the target query. In this work, we propose to automatically generate few-shot examples for long context QA tasks by recycling contexts. Specifically, given a long input context (1-3k tokens) and a query, we generate additional query-output pairs from the given context as few-shot examples, while introducing the context only once. This ensures that the demonstrations are leveraging the same context as the target query while only adding a small number of tokens to the prompt. We further enhance each demonstration by instructing the model to explicitly identify the relevant paragraphs before the answer, which improves performance while providing fine-grained attribution to the answer source. We apply our method on multiple LLMs and obtain substantial improvements (+23\% on average across models) on various QA datasets with long context, especially when the answer lies within the middle of the context. Surprisingly, despite introducing only single-hop ICL examples, LLMs also successfully generalize to multi-hop long-context QA using our approach.

In health, most large language model (LLM) research has focused on clinical tasks. However, mobile and wearable devices, which are rarely integrated into such tasks, provide rich, longitudinal data for personal health monitoring. Here we present Personal Health Large Language Model (PH-LLM), fine-tuned from Gemini for understanding and reasoning over numerical time-series personal health data. We created and curated three datasets that test 1) production of personalized insights and recommendations from sleep patterns, physical activity, and physiological responses, 2) expert domain knowledge, and 3) prediction of self-reported sleep outcomes. For the first task we designed 857 case studies in collaboration with domain experts to assess real-world scenarios in sleep and fitness. Through comprehensive evaluation of domain-specific rubrics, we observed that Gemini Ultra 1.0 and PH-LLM are not statistically different from expert performance in fitness and, while experts remain superior for sleep, fine-tuning PH-LLM provided significant improvements in using relevant domain knowledge and personalizing information for sleep insights. We evaluated PH-LLM domain knowledge using multiple choice sleep medicine and fitness examinations. PH-LLM achieved 79% on sleep and 88% on fitness, exceeding average scores from a sample of human experts. Finally, we trained PH-LLM to predict self-reported sleep quality outcomes from textual and multimodal encoding representations of wearable data, and demonstrate that multimodal encoding is required to match performance of specialized discriminative models. Although further development and evaluation are necessary in the safety-critical personal health domain, these results demonstrate both the broad knowledge and capabilities of Gemini models and the benefit of contextualizing physiological data for personal health applications as done with PH-LLM., Comment: 72 pages

Reinforcement Learning from Human Feedback (RLHF) has become the standard approach for aligning Large Language Models (LLMs) with human preferences, allowing LLMs to demonstrate remarkable abilities in various tasks. Existing methods work by emulating the preferences at the single decision (turn) level, limiting their capabilities in settings that require planning or multi-turn interactions to achieve a long-term goal. In this paper, we address this issue by developing novel methods for Reinforcement Learning (RL) from preference feedback between two full multi-turn conversations. In the tabular setting, we present a novel mirror-descent-based policy optimization algorithm for the general multi-turn preference-based RL problem, and prove its convergence to Nash equilibrium. To evaluate performance, we create a new environment, Education Dialogue, where a teacher agent guides a student in learning a random topic, and show that a deep RL variant of our algorithm outperforms RLHF baselines. Finally, we show that in an environment with explicit rewards, our algorithm recovers the same performance as a reward-based RL baseline, despite relying solely on a weaker preference signal.

A major challenge facing the world is the provision of equitable and universal access to quality education. Recent advances in generative AI (gen AI) have created excitement about the potential of new technologies to offer a personal tutor for every learner and a teaching assistant for every teacher. The full extent of this dream, however, has not yet materialised. We argue that this is primarily due to the difficulties with verbalising pedagogical intuitions into gen AI prompts and the lack of good evaluation practices, reinforced by the challenges in defining excellent pedagogy. Here we present our work collaborating with learners and educators to translate high level principles from learning science into a pragmatic set of seven diverse educational benchmarks, spanning quantitative, qualitative, automatic and human evaluations; and to develop a new set of fine-tuning datasets to improve the pedagogical capabilities of Gemini, introducing LearnLM-Tutor. Our evaluations show that LearnLM-Tutor is consistently preferred over a prompt tuned Gemini by educators and learners on a number of pedagogical dimensions. We hope that this work can serve as a first step towards developing a comprehensive educational evaluation framework, and that this can enable rapid progress within the AI and EdTech communities towards maximising the positive impact of gen AI in education.

Many clinical tasks require an understanding of specialized data, such as medical images and genomics, which is not typically found in general-purpose large multimodal models. Building upon Gemini's multimodal models, we develop several models within the new Med-Gemini family that inherit core capabilities of Gemini and are optimized for medical use via fine-tuning with 2D and 3D radiology, histopathology, ophthalmology, dermatology and genomic data. Med-Gemini-2D sets a new standard for AI-based chest X-ray (CXR) report generation based on expert evaluation, exceeding previous best results across two separate datasets by an absolute margin of 1% and 12%, where 57% and 96% of AI reports on normal cases, and 43% and 65% on abnormal cases, are evaluated as "equivalent or better" than the original radiologists' reports. We demonstrate the first ever large multimodal model-based report generation for 3D computed tomography (CT) volumes using Med-Gemini-3D, with 53% of AI reports considered clinically acceptable, although additional research is needed to meet expert radiologist reporting quality. Beyond report generation, Med-Gemini-2D surpasses the previous best performance in CXR visual question answering (VQA) and performs well in CXR classification and radiology VQA, exceeding SoTA or baselines on 17 of 20 tasks. In histopathology, ophthalmology, and dermatology image classification, Med-Gemini-2D surpasses baselines across 18 out of 20 tasks and approaches task-specific model performance. Beyond imaging, Med-Gemini-Polygenic outperforms the standard linear polygenic risk score-based approach for disease risk prediction and generalizes to genetically correlated diseases for which it has never been trained. Although further development and evaluation are necessary in the safety-critical medical domain, our results highlight the potential of Med-Gemini across a wide range of medical tasks.

Excellence in a wide variety of medical applications poses considerable challenges for AI, requiring advanced reasoning, access to up-to-date medical knowledge and understanding of complex multimodal data. Gemini models, with strong general capabilities in multimodal and long-context reasoning, offer exciting possibilities in medicine. Building on these core strengths of Gemini, we introduce Med-Gemini, a family of highly capable multimodal models that are specialized in medicine with the ability to seamlessly use web search, and that can be efficiently tailored to novel modalities using custom encoders. We evaluate Med-Gemini on 14 medical benchmarks, establishing new state-of-the-art (SoTA) performance on 10 of them, and surpass the GPT-4 model family on every benchmark where a direct comparison is viable, often by a wide margin. On the popular MedQA (USMLE) benchmark, our best-performing Med-Gemini model achieves SoTA performance of 91.1% accuracy, using a novel uncertainty-guided search strategy. On 7 multimodal benchmarks including NEJM Image Challenges and MMMU (health & medicine), Med-Gemini improves over GPT-4V by an average relative margin of 44.5%. We demonstrate the effectiveness of Med-Gemini's long-context capabilities through SoTA performance on a needle-in-a-haystack retrieval task from long de-identified health records and medical video question answering, surpassing prior bespoke methods using only in-context learning. Finally, Med-Gemini's performance suggests real-world utility by surpassing human experts on tasks such as medical text summarization, alongside demonstrations of promising potential for multimodal medical dialogue, medical research and education. Taken together, our results offer compelling evidence for Med-Gemini's potential, although further rigorous evaluation will be crucial before real-world deployment in this safety-critical domain.

Large language models (LLMs) hold promise to serve complex health information needs but also have the potential to introduce harm and exacerbate health disparities. Reliably evaluating equity-related model failures is a critical step toward developing systems that promote health equity. We present resources and methodologies for surfacing biases with potential to precipitate equity-related harms in long-form, LLM-generated answers to medical questions and conduct a large-scale empirical case study with the Med-PaLM 2 LLM. Our contributions include a multifactorial framework for human assessment of LLM-generated answers for biases, and EquityMedQA, a collection of seven datasets enriched for adversarial queries. Both our human assessment framework and dataset design process are grounded in an iterative participatory approach and review of Med-PaLM 2 answers. Through our empirical study, we find that our approach surfaces biases that may be missed via narrower evaluation approaches. Our experience underscores the importance of using diverse assessment methodologies and involving raters of varying backgrounds and expertise. While our approach is not sufficient to holistically assess whether the deployment of an AI system promotes equitable health outcomes, we hope that it can be leveraged and built upon towards a shared goal of LLMs that promote accessible and equitable healthcare.

Large language models hold significant promise in multilingual applications. However, inherent biases stemming from predominantly English-centric pre-training have led to the widespread practice of pre-translation, i.e., translating non-English inputs to English before inference, leading to complexity and information loss. This study re-evaluates the need for pre-translation in the context of PaLM2 models (Anil et al., 2023), which have been established as highly performant in multilingual tasks. We offer a comprehensive investigation across 108 languages and 6 diverse benchmarks, including open-end generative tasks, which were excluded from previous similar studies. Our findings challenge the pre-translation paradigm established in prior research, highlighting the advantages of direct inference in PaLM2. Specifically, PaLM2-L consistently outperforms pre-translation in 94 out of 108 languages. These findings pave the way for more efficient and effective multilingual applications, alleviating the limitations associated with pre-translation and unlocking linguistic authenticity.

Health acoustic sounds such as coughs and breaths are known to contain useful health signals with significant potential for monitoring health and disease, yet are underexplored in the medical machine learning community. The existing deep learning systems for health acoustics are often narrowly trained and evaluated on a single task, which is limited by data and may hinder generalization to other tasks. To mitigate these gaps, we develop HeAR, a scalable self-supervised learning-based deep learning system using masked autoencoders trained on a large dataset of 313 million two-second long audio clips. Through linear probes, we establish HeAR as a state-of-the-art health audio embedding model on a benchmark of 33 health acoustic tasks across 6 datasets. By introducing this work, we hope to enable and accelerate further health acoustics research., Comment: 4 tables, 4 figures, 6 supplementary tables, 3 supplementary figures

Background: Health datasets from clinical sources do not reflect the breadth and diversity of disease in the real world, impacting research, medical education, and artificial intelligence (AI) tool development. Dermatology is a suitable area to develop and test a new and scalable method to create representative health datasets. Methods: We used Google Search advertisements to invite contributions to an open access dataset of images of dermatology conditions, demographic and symptom information. With informed contributor consent, we describe and release this dataset containing 10,408 images from 5,033 contributions from internet users in the United States over 8 months starting March 2023. The dataset includes dermatologist condition labels as well as estimated Fitzpatrick Skin Type (eFST) and Monk Skin Tone (eMST) labels for the images. Results: We received a median of 22 submissions/day (IQR 14-30). Female (66.72%) and younger (52% < age 40) contributors had a higher representation in the dataset compared to the US population, and 32.6% of contributors reported a non-White racial or ethnic identity. Over 97.5% of contributions were genuine images of skin conditions. Dermatologist confidence in assigning a differential diagnosis increased with the number of available variables, and showed a weaker correlation with image sharpness (Spearman's P values <0.001 and 0.01 respectively). Most contributions were short-duration (54% with onset < 7 days ago ) and 89% were allergic, infectious, or inflammatory conditions. eFST and eMST distributions reflected the geographical origin of the dataset. The dataset is available at github.com/google-research-datasets/scin . Conclusion: Search ads are effective at crowdsourcing images of health conditions. The SCIN dataset bridges important gaps in the availability of representative images of common skin conditions.

Recently, there has been great progress in the ability of artificial intelligence (AI) algorithms to classify dermatological conditions from clinical photographs. However, little is known about the robustness of these algorithms in real-world settings where several factors can lead to a loss of generalizability. Understanding and overcoming these limitations will permit the development of generalizable AI that can aid in the diagnosis of skin conditions across a variety of clinical settings. In this retrospective study, we demonstrate that differences in skin condition distribution, rather than in demographics or image capture mode are the main source of errors when an AI algorithm is evaluated on data from a previously unseen source. We demonstrate a series of steps to close this generalization gap, requiring progressively more information about the new source, ranging from the condition distribution to training data enriched for data less frequently seen during training. Our results also suggest comparable performance from end-to-end fine tuning versus fine tuning solely the classification layer on top of a frozen embedding model. Our approach can inform the adaptation of AI algorithms to new settings, based on the information and resources available.

At the heart of medicine lies the physician-patient dialogue, where skillful history-taking paves the way for accurate diagnosis, effective management, and enduring trust. Artificial Intelligence (AI) systems capable of diagnostic dialogue could increase accessibility, consistency, and quality of care. However, approximating clinicians' expertise is an outstanding grand challenge. Here, we introduce AMIE (Articulate Medical Intelligence Explorer), a Large Language Model (LLM) based AI system optimized for diagnostic dialogue. AMIE uses a novel self-play based simulated environment with automated feedback mechanisms for scaling learning across diverse disease conditions, specialties, and contexts. We designed a framework for evaluating clinically-meaningful axes of performance including history-taking, diagnostic accuracy, management reasoning, communication skills, and empathy. We compared AMIE's performance to that of primary care physicians (PCPs) in a randomized, double-blind crossover study of text-based consultations with validated patient actors in the style of an Objective Structured Clinical Examination (OSCE). The study included 149 case scenarios from clinical providers in Canada, the UK, and India, 20 PCPs for comparison with AMIE, and evaluations by specialist physicians and patient actors. AMIE demonstrated greater diagnostic accuracy and superior performance on 28 of 32 axes according to specialist physicians and 24 of 26 axes according to patient actors. Our research has several limitations and should be interpreted with appropriate caution. Clinicians were limited to unfamiliar synchronous text-chat which permits large-scale LLM-patient interactions but is not representative of usual clinical practice. While further research is required before AMIE could be translated to real-world settings, the results represent a milestone towards conversational diagnostic AI., Comment: 46 pages, 5 figures in main text, 19 figures in appendix

An accurate differential diagnosis (DDx) is a cornerstone of medical care, often reached through an iterative process of interpretation that combines clinical history, physical examination, investigations and procedures. Interactive interfaces powered by Large Language Models (LLMs) present new opportunities to both assist and automate aspects of this process. In this study, we introduce an LLM optimized for diagnostic reasoning, and evaluate its ability to generate a DDx alone or as an aid to clinicians. 20 clinicians evaluated 302 challenging, real-world medical cases sourced from the New England Journal of Medicine (NEJM) case reports. Each case report was read by two clinicians, who were randomized to one of two assistive conditions: either assistance from search engines and standard medical resources, or LLM assistance in addition to these tools. All clinicians provided a baseline, unassisted DDx prior to using the respective assistive tools. Our LLM for DDx exhibited standalone performance that exceeded that of unassisted clinicians (top-10 accuracy 59.1% vs 33.6%, [p = 0.04]). Comparing the two assisted study arms, the DDx quality score was higher for clinicians assisted by our LLM (top-10 accuracy 51.7%) compared to clinicians without its assistance (36.1%) (McNemar's Test: 45.7, p < 0.01) and clinicians with search (44.4%) (4.75, p = 0.03). Further, clinicians assisted by our LLM arrived at more comprehensive differential lists than those without its assistance. Our study suggests that our LLM for DDx has potential to improve clinicians' diagnostic reasoning and accuracy in challenging cases, meriting further real-world evaluation for its ability to empower physicians and widen patients' access to specialist-level expertise.

Radiology reports are an instrumental part of modern medicine, informing key clinical decisions such as diagnosis and treatment. The worldwide shortage of radiologists, however, restricts access to expert care and imposes heavy workloads, contributing to avoidable errors and delays in report delivery. While recent progress in automated report generation with vision-language models offer clear potential in ameliorating the situation, the path to real-world adoption has been stymied by the challenge of evaluating the clinical quality of AI-generated reports. In this study, we build a state-of-the-art report generation system for chest radiographs, $\textit{Flamingo-CXR}$, by fine-tuning a well-known vision-language foundation model on radiology data. To evaluate the quality of the AI-generated reports, a group of 16 certified radiologists provide detailed evaluations of AI-generated and human written reports for chest X-rays from an intensive care setting in the United States and an inpatient setting in India. At least one radiologist (out of two per case) preferred the AI report to the ground truth report in over 60$\%$ of cases for both datasets. Amongst the subset of AI-generated reports that contain errors, the most frequently cited reasons were related to the location and finding, whereas for human written reports, most mistakes were related to severity and finding. This disparity suggested potential complementarity between our AI system and human experts, prompting us to develop an assistive scenario in which Flamingo-CXR generates a first-draft report, which is subsequently revised by a clinician. This is the first demonstration of clinician-AI collaboration for report writing, and the resultant reports are assessed to be equivalent or preferred by at least one radiologist to reports written by experts alone in 80$\%$ of in-patient cases and 60$\%$ of intensive care cases.

Text-to-image diffusion models achieved a remarkable leap in capabilities over the last few years, enabling high-quality and diverse synthesis of images from a textual prompt. However, even the most advanced models often struggle to precisely follow all of the directions in their prompts. The vast majority of these models are trained on datasets consisting of (image, caption) pairs where the images often come from the web, and the captions are their HTML alternate text. A notable example is the LAION dataset, used by Stable Diffusion and other models. In this work we observe that these captions are often of low quality, and argue that this significantly affects the model's capability to understand nuanced semantics in the textual prompts. We show that by relabeling the corpus with a specialized automatic captioning model and training a text-to-image model on the recaptioned dataset, the model benefits substantially across the board. First, in overall image quality: e.g. FID 14.84 vs. the baseline of 17.87, and 64.3% improvement in faithful image generation according to human evaluation. Second, in semantic alignment, e.g. semantic object accuracy 84.34 vs. 78.90, counting alignment errors 1.32 vs. 1.44 and positional alignment 62.42 vs. 57.60. We analyze various ways to relabel the corpus and provide evidence that this technique, which we call RECAP, both reduces the train-inference discrepancy and provides the model with more information per example, increasing sample efficiency and allowing the model to better understand the relations between captions and images.

Task-specific deep learning models in histopathology offer promising opportunities for improving diagnosis, clinical research, and precision medicine. However, development of such models is often limited by availability of high-quality data. Foundation models in histopathology that learn general representations across a wide range of tissue types, diagnoses, and magnifications offer the potential to reduce the data, compute, and technical expertise necessary to develop task-specific deep learning models with the required level of model performance. In this work, we describe the development and evaluation of foundation models for histopathology via self-supervised learning (SSL). We first establish a diverse set of benchmark tasks involving 17 unique tissue types and 12 unique cancer types and spanning different optimal magnifications and task types. Next, we use this benchmark to explore and evaluate histopathology-specific SSL methods followed by further evaluation on held out patch-level and weakly supervised tasks. We found that standard SSL methods thoughtfully applied to histopathology images are performant across our benchmark tasks and that domain-specific methodological improvements can further increase performance. Our findings reinforce the value of using domain-specific SSL methods in pathology, and establish a set of high quality foundation models to enable further research across diverse applications., Comment: 4 main tables, 3 main figures, additional supplemental tables and figures

Health-related acoustic signals, such as cough and breathing sounds, are relevant for medical diagnosis and continuous health monitoring. Most existing machine learning approaches for health acoustics are trained and evaluated on specific tasks, limiting their generalizability across various healthcare applications. In this paper, we leverage a self-supervised learning framework, SimCLR with a Slowfast NFNet backbone, for contrastive learning of health acoustics. A crucial aspect of optimizing Slowfast NFNet for this application lies in identifying effective audio augmentations. We conduct an in-depth analysis of various audio augmentation strategies and demonstrate that an appropriate augmentation strategy enhances the performance of the Slowfast NFNet audio encoder across a diverse set of health acoustic tasks. Our findings reveal that when augmentations are combined, they can produce synergistic effects that exceed the benefits seen when each is applied individually., Comment: 7 pages, 2 pages appendix, 2 figures, 5 appendix tables

In this work, we present an approach, which we call Embeddings for Language/Image-aligned X-Rays, or ELIXR, that leverages a language-aligned image encoder combined or grafted onto a fixed LLM, PaLM 2, to perform a broad range of chest X-ray tasks. We train this lightweight adapter architecture using images paired with corresponding free-text radiology reports from the MIMIC-CXR dataset. ELIXR achieved state-of-the-art performance on zero-shot chest X-ray (CXR) classification (mean AUC of 0.850 across 13 findings), data-efficient CXR classification (mean AUCs of 0.893 and 0.898 across five findings (atelectasis, cardiomegaly, consolidation, pleural effusion, and pulmonary edema) for 1% (~2,200 images) and 10% (~22,000 images) training data), and semantic search (0.76 normalized discounted cumulative gain (NDCG) across nineteen queries, including perfect retrieval on twelve of them). Compared to existing data-efficient methods including supervised contrastive learning (SupCon), ELIXR required two orders of magnitude less data to reach similar performance. ELIXR also showed promise on CXR vision-language tasks, demonstrating overall accuracies of 58.7% and 62.5% on visual question answering and report quality assurance tasks, respectively. These results suggest that ELIXR is a robust and versatile approach to CXR AI.

Medicine is inherently multimodal, with rich data modalities spanning text, imaging, genomics, and more. Generalist biomedical artificial intelligence (AI) systems that flexibly encode, integrate, and interpret this data at scale can potentially enable impactful applications ranging from scientific discovery to care delivery. To enable the development of these models, we first curate MultiMedBench, a new multimodal biomedical benchmark. MultiMedBench encompasses 14 diverse tasks such as medical question answering, mammography and dermatology image interpretation, radiology report generation and summarization, and genomic variant calling. We then introduce Med-PaLM Multimodal (Med-PaLM M), our proof of concept for a generalist biomedical AI system. Med-PaLM M is a large multimodal generative model that flexibly encodes and interprets biomedical data including clinical language, imaging, and genomics with the same set of model weights. Med-PaLM M reaches performance competitive with or exceeding the state of the art on all MultiMedBench tasks, often surpassing specialist models by a wide margin. We also report examples of zero-shot generalization to novel medical concepts and tasks, positive transfer learning across tasks, and emergent zero-shot medical reasoning. To further probe the capabilities and limitations of Med-PaLM M, we conduct a radiologist evaluation of model-generated (and human) chest X-ray reports and observe encouraging performance across model scales. In a side-by-side ranking on 246 retrospective chest X-rays, clinicians express a pairwise preference for Med-PaLM M reports over those produced by radiologists in up to 40.50% of cases, suggesting potential clinical utility. While considerable work is needed to validate these models in real-world use cases, our results represent a milestone towards the development of generalist biomedical AI systems.

For safety, AI systems in health undergo thorough evaluations before deployment, validating their predictions against a ground truth that is assumed certain. However, this is actually not the case and the ground truth may be uncertain. Unfortunately, this is largely ignored in standard evaluation of AI models but can have severe consequences such as overestimating the future performance. To avoid this, we measure the effects of ground truth uncertainty, which we assume decomposes into two main components: annotation uncertainty which stems from the lack of reliable annotations, and inherent uncertainty due to limited observational information. This ground truth uncertainty is ignored when estimating the ground truth by deterministically aggregating annotations, e.g., by majority voting or averaging. In contrast, we propose a framework where aggregation is done using a statistical model. Specifically, we frame aggregation of annotations as posterior inference of so-called plausibilities, representing distributions over classes in a classification setting, subject to a hyper-parameter encoding annotator reliability. Based on this model, we propose a metric for measuring annotation uncertainty and provide uncertainty-adjusted metrics for performance evaluation. We present a case study applying our framework to skin condition classification from images where annotations are provided in the form of differential diagnoses. The deterministic adjudication process called inverse rank normalization (IRN) from previous work ignores ground truth uncertainty in evaluation. Instead, we present two alternative statistical models: a probabilistic version of IRN and a Plackett-Luce-based model. We find that a large portion of the dataset exhibits significant ground truth uncertainty and standard IRN-based evaluation severely over-estimates performance without providing uncertainty estimates.

We present Face0, a novel way to instantaneously condition a text-to-image generation model on a face, in sample time, without any optimization procedures such as fine-tuning or inversions. We augment a dataset of annotated images with embeddings of the included faces and train an image generation model, on the augmented dataset. Once trained, our system is practically identical at inference time to the underlying base model, and is therefore able to generate images, given a user-supplied face image and a prompt, in just a couple of seconds. Our method achieves pleasing results, is remarkably simple, extremely fast, and equips the underlying model with new capabilities, like controlling the generated images both via text or via direct manipulation of the input face embeddings. In addition, when using a fixed random vector instead of a face embedding from a user supplied image, our method essentially solves the problem of consistent character generation across images. Finally, while requiring further research, we hope that our method, which decouples the model's textual biases from its biases on faces, might be a step towards some mitigation of biases in future text-to-image models.

AI models have shown promise in many medical imaging tasks. However, our ability to explain what signals these models have learned is severely lacking. Explanations are needed in order to increase the trust in AI-based models, and could enable novel scientific discovery by uncovering signals in the data that are not yet known to experts. In this paper, we present a method for automatic visual explanations leveraging team-based expertise by generating hypotheses of what visual signals in the images are correlated with the task. We propose the following 4 steps: (i) Train a classifier to perform a given task (ii) Train a classifier guided StyleGAN-based image generator (StylEx) (iii) Automatically detect and visualize the top visual attributes that the classifier is sensitive towards (iv) Formulate hypotheses for the underlying mechanisms, to stimulate future research. Specifically, we present the discovered attributes to an interdisciplinary panel of experts so that hypotheses can account for social and structural determinants of health. We demonstrate results on eight prediction tasks across three medical imaging modalities: retinal fundus photographs, external eye photographs, and chest radiographs. We showcase examples of attributes that capture clinically known features, confounders that arise from factors beyond physiological mechanisms, and reveal a number of physiologically plausible novel attributes. Our approach has the potential to enable researchers to better understand, improve their assessment, and extract new knowledge from AI-based models. Importantly, we highlight that attributes generated by our framework can capture phenomena beyond physiology or pathophysiology, reflecting the real world nature of healthcare delivery and socio-cultural factors. Finally, we intend to release code to enable researchers to train their own StylEx models and analyze their predictive tasks., Comment: 43 pages, 1 figure

Recent artificial intelligence (AI) systems have reached milestones in "grand challenges" ranging from Go to protein-folding. The capability to retrieve medical knowledge, reason over it, and answer medical questions comparably to physicians has long been viewed as one such grand challenge. Large language models (LLMs) have catalyzed significant progress in medical question answering; Med-PaLM was the first model to exceed a "passing" score in US Medical Licensing Examination (USMLE) style questions with a score of 67.2% on the MedQA dataset. However, this and other prior work suggested significant room for improvement, especially when models' answers were compared to clinicians' answers. Here we present Med-PaLM 2, which bridges these gaps by leveraging a combination of base LLM improvements (PaLM 2), medical domain finetuning, and prompting strategies including a novel ensemble refinement approach. Med-PaLM 2 scored up to 86.5% on the MedQA dataset, improving upon Med-PaLM by over 19% and setting a new state-of-the-art. We also observed performance approaching or exceeding state-of-the-art across MedMCQA, PubMedQA, and MMLU clinical topics datasets. We performed detailed human evaluations on long-form questions along multiple axes relevant to clinical applications. In pairwise comparative ranking of 1066 consumer medical questions, physicians preferred Med-PaLM 2 answers to those produced by physicians on eight of nine axes pertaining to clinical utility (p < 0.001). We also observed significant improvements compared to Med-PaLM on every evaluation axis (p < 0.001) on newly introduced datasets of 240 long-form "adversarial" questions to probe LLM limitations. While further studies are necessary to validate the efficacy of these models in real-world settings, these results highlight rapid progress towards physician-level performance in medical question answering.

Cardiovascular diseases (CVDs) are responsible for a large proportion of premature deaths in low- and middle-income countries. Early CVD detection and intervention is critical in these populations, yet many existing CVD risk scores require a physical examination or lab measurements, which can be challenging in such health systems due to limited accessibility. Here we investigated the potential to use photoplethysmography (PPG), a sensing technology available on most smartphones that can potentially enable large-scale screening at low cost, for CVD risk prediction. We developed a deep learning PPG-based CVD risk score (DLS) to predict the probability of having major adverse cardiovascular events (MACE: non-fatal myocardial infarction, stroke, and cardiovascular death) within ten years, given only age, sex, smoking status and PPG as predictors. We compared the DLS with the office-based refit-WHO score, which adopts the shared predictors from WHO and Globorisk scores (age, sex, smoking status, height, weight and systolic blood pressure) but refitted on the UK Biobank (UKB) cohort. In UKB cohort, DLS's C-statistic (71.1%, 95% CI 69.9-72.4) was non-inferior to office-based refit-WHO score (70.9%, 95% CI 69.7-72.2; non-inferiority margin of 2.5%, p<0.01). The calibration of the DLS was satisfactory, with a 1.8% mean absolute calibration error. Adding DLS features to the office-based score increased the C-statistic by 1.0% (95% CI 0.6-1.4). DLS predicts ten-year MACE risk comparable with the office-based refit-WHO score. It provides a proof-of-concept and suggests the potential of a PPG-based approach strategies for community-based primary prevention in resource-limited regions., Comment: main: 24 pages (3 tables, 2 figures, 42 references), supplementary: 25 pages (9 tables, 4 figures, 11 references)

Text-driven image and video diffusion models have recently achieved unprecedented generation realism. While diffusion models have been successfully applied for image editing, very few works have done so for video editing. We present the first diffusion-based method that is able to perform text-based motion and appearance editing of general videos. Our approach uses a video diffusion model to combine, at inference time, the low-resolution spatio-temporal information from the original video with new, high resolution information that it synthesized to align with the guiding text prompt. As obtaining high-fidelity to the original video requires retaining some of its high-resolution information, we add a preliminary stage of finetuning the model on the original video, significantly boosting fidelity. We propose to improve motion editability by a new, mixed objective that jointly finetunes with full temporal attention and with temporal attention masking. We further introduce a new framework for image animation. We first transform the image into a coarse video by simple image processing operations such as replication and perspective geometric projections, and then use our general video editor to animate it. As a further application, we can use our method for subject-driven video generation. Extensive qualitative and numerical experiments showcase the remarkable editing ability of our method and establish its superior performance compared to baseline methods.

Large language models (LLMs) have demonstrated impressive capabilities in natural language understanding and generation, but the quality bar for medical and clinical applications is high. Today, attempts to assess models' clinical knowledge typically rely on automated evaluations on limited benchmarks. There is no standard to evaluate model predictions and reasoning across a breadth of tasks. To address this, we present MultiMedQA, a benchmark combining six existing open question answering datasets spanning professional medical exams, research, and consumer queries; and HealthSearchQA, a new free-response dataset of medical questions searched online. We propose a framework for human evaluation of model answers along multiple axes including factuality, precision, possible harm, and bias. In addition, we evaluate PaLM (a 540-billion parameter LLM) and its instruction-tuned variant, Flan-PaLM, on MultiMedQA. Using a combination of prompting strategies, Flan-PaLM achieves state-of-the-art accuracy on every MultiMedQA multiple-choice dataset (MedQA, MedMCQA, PubMedQA, MMLU clinical topics), including 67.6% accuracy on MedQA (US Medical License Exam questions), surpassing prior state-of-the-art by over 17%. However, human evaluation reveals key gaps in Flan-PaLM responses. To resolve this we introduce instruction prompt tuning, a parameter-efficient approach for aligning LLMs to new domains using a few exemplars. The resulting model, Med-PaLM, performs encouragingly, but remains inferior to clinicians. We show that comprehension, recall of knowledge, and medical reasoning improve with model scale and instruction prompt tuning, suggesting the potential utility of LLMs in medicine. Our human evaluations reveal important limitations of today's models, reinforcing the importance of both evaluation frameworks and method development in creating safe, helpful LLM models for clinical applications.

Inference from large autoregressive models like Transformers is slow - decoding K tokens takes K serial runs of the model. In this work we introduce speculative decoding - an algorithm to sample from autoregressive models faster without any changes to the outputs, by computing several tokens in parallel. At the heart of our approach lie the observations that (1) hard language-modeling tasks often include easier subtasks that can be approximated well by more efficient models, and (2) using speculative execution and a novel sampling method, we can make exact decoding from the large models faster, by running them in parallel on the outputs of the approximation models, potentially generating several tokens concurrently, and without changing the distribution. Our method can accelerate existing off-the-shelf models without retraining or architecture changes. We demonstrate it on T5-XXL and show a 2X-3X acceleration compared to the standard T5X implementation, with identical outputs., Comment: ICML 2023 Oral

Text-driven image generation methods have shown impressive results recently, allowing casual users to generate high quality images by providing textual descriptions. However, similar capabilities for editing existing images are still out of reach. Text-driven image editing methods usually need edit masks, struggle with edits that require significant visual changes and cannot easily keep specific details of the edited portion. In this paper we make the observation that image-generation models can be converted to image-editing models simply by fine-tuning them on a single image. We also show that initializing the stochastic sampler with a noised version of the base image before the sampling and interpolating relevant details from the base image after sampling further increase the quality of the edit operation. Combining these observations, we propose UniTune, a novel image editing method. UniTune gets as input an arbitrary image and a textual edit description, and carries out the edit while maintaining high fidelity to the input image. UniTune does not require additional inputs, like masks or sketches, and can perform multiple edits on the same image without retraining. We test our method using the Imagen model in a range of different use cases. We demonstrate that it is broadly applicable and can perform a surprisingly wide range of expressive editing operations, including those requiring significant visual changes that were previously impossible., Comment: SIGGRAPH 2023

Despite recent advances in natural language understanding and generation, and decades of research on the development of conversational bots, building automated agents that can carry on rich open-ended conversations with humans "in the wild" remains a formidable challenge. In this work we develop a real-time, open-ended dialogue system that uses reinforcement learning (RL) to power a bot's conversational skill at scale. Our work pairs the succinct embedding of the conversation state generated using SOTA (supervised) language models with RL techniques that are particularly suited to a dynamic action space that changes as the conversation progresses. Trained using crowd-sourced data, our novel system is able to substantially exceeds the (strong) baseline supervised model with respect to several metrics of interest in a live experiment with real users of the Google Assistant.

External eye photos were recently shown to reveal signs of diabetic retinal disease and elevated HbA1c. In this paper, we evaluate if external eye photos contain information about additional systemic medical conditions. We developed a deep learning system (DLS) that takes external eye photos as input and predicts multiple systemic parameters, such as those related to the liver (albumin, AST); kidney (eGFR estimated using the race-free 2021 CKD-EPI creatinine equation, the urine ACR); bone & mineral (calcium); thyroid (TSH); and blood count (Hgb, WBC, platelets). Development leveraged 151,237 images from 49,015 patients with diabetes undergoing diabetic eye screening in 11 sites across Los Angeles county, CA. Evaluation focused on 9 pre-specified systemic parameters and leveraged 3 validation sets (A, B, C) spanning 28,869 patients with and without diabetes undergoing eye screening in 3 independent sites in Los Angeles County, CA, and the greater Atlanta area, GA. We compared against baseline models incorporating available clinicodemographic variables (e.g. age, sex, race/ethnicity, years with diabetes). Relative to the baseline, the DLS achieved statistically significant superior performance at detecting AST>36, calcium<8.6, eGFR<60, Hgb<11, platelets<150, ACR>=300, and WBC<4 on validation set A (a patient population similar to the development sets), where the AUC of DLS exceeded that of the baseline by 5.2-19.4%. On validation sets B and C, with substantial patient population differences compared to the development sets, the DLS outperformed the baseline for ACR>=300 and Hgb<11 by 7.3-13.2%. Our findings provide further evidence that external eye photos contain important biomarkers of systemic health spanning multiple organ systems. Further work is needed to investigate whether and how these biomarkers can be translated into clinical impact.

Grounded text generation systems often generate text that contains factual inconsistencies, hindering their real-world applicability. Automatic factual consistency evaluation may help alleviate this limitation by accelerating evaluation cycles, filtering inconsistent outputs and augmenting training data. While attracting increasing attention, such evaluation metrics are usually developed and evaluated in silo for a single task or dataset, slowing their adoption. Moreover, previous meta-evaluation protocols focused on system-level correlations with human annotations, which leave the example-level accuracy of such metrics unclear. In this work, we introduce TRUE: a comprehensive survey and assessment of factual consistency metrics on a standardized collection of existing texts from diverse tasks, manually annotated for factual consistency. Our standardization enables an example-level meta-evaluation protocol that is more actionable and interpretable than previously reported correlations, yielding clearer quality measures. Across diverse state-of-the-art metrics and 11 datasets we find that large-scale NLI and question generation-and-answering-based approaches achieve strong and complementary results. We recommend those methods as a starting point for model and metric developers, and hope TRUE will foster progress towards even better evaluation methods., Comment: Accepted as a long paper to NAACL 2022 main conference

The operational flood forecasting system by Google was developed to provide accurate real-time flood warnings to agencies and the public, with a focus on riverine floods in large, gauged rivers. It became operational in 2018 and has since expanded geographically. This forecasting system consists of four subsystems: data validation, stage forecasting, inundation modeling, and alert distribution. Machine learning is used for two of the subsystems. Stage forecasting is modeled with the Long Short-Term Memory (LSTM) networks and the Linear models. Flood inundation is computed with the Thresholding and the Manifold models, where the former computes inundation extent and the latter computes both inundation extent and depth. The Manifold model, presented here for the first time, provides a machine-learning alternative to hydraulic modeling of flood inundation. When evaluated on historical data, all models achieve sufficiently high-performance metrics for operational use. The LSTM showed higher skills than the Linear model, while the Thresholding and Manifold models achieved similar performance metrics for modeling inundation extent. During the 2021 monsoon season, the flood warning system was operational in India and Bangladesh, covering flood-prone regions around rivers with a total area of 287,000 km2, home to more than 350M people. More than 100M flood alerts were sent to affected populations, to relevant authorities, and to emergency organizations. Current and future work on the system includes extending coverage to additional flood-prone locations, as well as improving modeling capabilities and accuracy., Comment: 36 pages, 10 figures, 3 tables, 1 supplementary table (9 pages)

In this paper, we introduce adversarially robust streaming algorithms for central machine learning and algorithmic tasks, such as regression and clustering, as well as their more general counterparts, subspace embedding, low-rank approximation, and coreset construction. For regression and other numerical linear algebra related tasks, we consider the row arrival streaming model. Our results are based on a simple, but powerful, observation that many importance sampling-based algorithms give rise to adversarial robustness which is in contrast to sketching based algorithms, which are very prevalent in the streaming literature but suffer from adversarial attacks. In addition, we show that the well-known merge and reduce paradigm in streaming is adversarially robust. Since the merge and reduce paradigm allows coreset constructions in the streaming setting, we thus obtain robust algorithms for $k$-means, $k$-median, $k$-center, Bregman clustering, projective clustering, principal component analysis (PCA) and non-negative matrix factorization. To the best of our knowledge, these are the first adversarially robust results for these problems yet require no new algorithmic implementations. Finally, we empirically confirm the robustness of our algorithms on various adversarial attacks and demonstrate that by contrast, some common existing algorithms are not robust. (Abstract shortened to meet arXiv limits), Comment: NeurIPS 2021

Background: Floods are the most common natural disaster in the world, affecting the lives of hundreds of millions. Flood forecasting is therefore a vitally important endeavor, typically achieved using physical water flow simulations, which rely on accurate terrain elevation maps. However, such simulations, based on solving partial differential equations, are computationally prohibitive on a large scale. This scalability issue is commonly alleviated using a coarse grid representation of the elevation map, though this representation may distort crucial terrain details, leading to significant inaccuracies in the simulation. Contributions: We train a deep neural network to perform physics-informed downsampling of the terrain map: we optimize the coarse grid representation of the terrain maps, so that the flood prediction will match the fine grid solution. For the learning process to succeed, we configure a dataset specifically for this task. We demonstrate that with this method, it is possible to achieve a significant reduction in computational cost, while maintaining an accurate solution. A reference implementation accompanies the paper as well as documentation and code for dataset reproduction.

Floods are among the most common and deadly natural disasters in the world, and flood warning systems have been shown to be effective in reducing harm. Yet the majority of the world's vulnerable population does not have access to reliable and actionable warning systems, due to core challenges in scalability, computational costs, and data availability. In this paper we present two components of flood forecasting systems which were developed over the past year, providing access to these critical systems to 75 million people who didn't have this access before., Comment: Submitted/accepted to NeurIPS HADR workshop: https://www.hadr.ai/home

A streaming algorithm is said to be adversarially robust if its accuracy guarantees are maintained even when the data stream is chosen maliciously, by an adaptive adversary. We establish a connection between adversarial robustness of streaming algorithms and the notion of differential privacy. This connection allows us to design new adversarially robust streaming algorithms that outperform the current state-of-the-art constructions for many interesting regimes of parameters.

Colonoscopy is the tool of choice for preventing Colorectal Cancer, by detecting and removing polyps before they become cancerous. However, colonoscopy is hampered by the fact that endoscopists routinely miss 22-28% of polyps. While some of these missed polyps appear in the endoscopist's field of view, others are missed simply because of substandard coverage of the procedure, i.e. not all of the colon is seen. This paper attempts to rectify the problem of substandard coverage in colonoscopy through the introduction of the C2D2 (Colonoscopy Coverage Deficiency via Depth) algorithm which detects deficient coverage, and can thereby alert the endoscopist to revisit a given area. More specifically, C2D2 consists of two separate algorithms: the first performs depth estimation of the colon given an ordinary RGB video stream; while the second computes coverage given these depth estimates. Rather than compute coverage for the entire colon, our algorithm computes coverage locally, on a segment-by-segment basis; C2D2 can then indicate in real-time whether a particular area of the colon has suffered from deficient coverage, and if so the endoscopist can return to that area. Our coverage algorithm is the first such algorithm to be evaluated in a large-scale way; while our depth estimation technique is the first calibration-free unsupervised method applied to colonoscopies. The C2D2 algorithm achieves state of the art results in the detection of deficient coverage. On synthetic sequences with ground truth, it is 2.4 times more accurate than human experts; while on real sequences, C2D2 achieves a 93.0% agreement with experts.