Generative artificial intelligence in clinical reasoning and differential diagnosis in internal medicine

Clinical reasoning and differential diagnosis are core competencies in medicine. Large language models (LLMs) have generated considerable interest as potential tools to support these skills. This article presents a narrative review of the available evidence, organized around five key questions: the effect of LLMs on diagnostic reasoning, the optimal design of clinician-LLM interaction, the appropriate timing of consultation during the clinical encounter, the safest models of clinical-AI integration, and the main risks associated with their use. The evidence shows that LLMs improve differential diagnosis when used by trained professionals within structured workflows. However, passive use generates biases, and clinician-AI collaboration may not consistently outperform autonomous LLMs. A practical framework stratified by degree of diagnostic uncertainty is proposed, with operational and educational recommendations oriented toward "physician-in-the-loop" models, in which LLMs amplify, challenge, and make explicit the diagnostic reasoning process under critical human oversight.