SIM-UT: A User Simulation based Evaluation Framework for Medical Triage Chatbots

Abstract

LLM-based chat agents are increasingly used for complex, multi-turn, multilingual medical triage in low- and middle-income countries (LMICs), yet evaluation methods focus on single-turn, English-only benchmarks that primarily test the chatbots' knowledge. In practice, users are often confused, overwhelmed, or emotionally vulnerable, giving unclear, misspelled single-word answers or long messages in regional dialects, and the context of a conversation can shift rapidly. We propose SIM-UT (Simulation of User Behaviour for Triage), a multi-turn, simulation-based evaluation method that identifies ecologically valid, contextually relevant failure modes of LLM-based triage chat agents. Using SIM-UT, we evaluated three real-world WhatsApp-based health chatbots: a respiratory screening programme in India, a hearing health support programme in South Africa, and a diabetes and lifestyle coaching agent in Kenya. We compared a medically fine-tuned open model (MedGemma) against general-purpose frontier models (ChatGPT and Claude) across 5,000+ multilingual simulated conversation turns grounded in the personas, constraints, and communication patterns of the real user populations, over 2-4 iterative rounds. A key failure mode emerged in both model families: de-escalation risk. The agents initially identified medical emergencies correctly, but when the user minimised the symptoms without introducing new clinical information, they de-escalated, exhibiting clinically dangerous sycophancy, for example agreeing that vaginal bleeding in pregnancy was "not a problem" or that decreased fetal movements at 32 weeks "can be normal". We recommend user simulation-based behavioural evaluation, grounded in real user context and covering adversarial and edge cases, as standard practice for triage chatbots in production, so that safeguards can be added before deployment or in subsequent iterations.