More Reasoning Is Not Always Better: Executing Clinical Guidelines with LLMs and Rules

Large language models (LLMs) have shown considerable promise in clinical decision support. However, existing approaches often rely on multi-step reasoning or multi-agent collaboration to execute clinical guidelines, introducing substantial computational overhead without reliably preventing decision errors. To address these limitations, we propose a framework for Medical Decision Execution (MedDEx) that integrates structured patient states with deterministic rule execution to support guideline-based treatment planning. MedDEx separates clinical record interpretation from guideline execution, leveraging LLMs to extract patient information and generate treatment plans while assigning guideline-defined decision logic to a rule executor. Experiments across multiple clinical guideline benchmarks demonstrate that MedDEx improves decision accuracy while reducing inference costs. Further analyses highlight the critical roles of structured patient representations and deterministic rule execution, suggesting that additional LLM reasoning does not necessarily translate into better guideline adherence.