Introduction

Biostatisticians, informaticists, and other data scientists are at the forefront of leveraging advanced computational tools in scientific research. These scientists collaborate closely with clinical domain specialists to design studies, manage and house data, perform data analysis, present results, and interpret findings. Their work involves understanding the clinical problem, navigating complicated analytical and data generation processes, conducting literature reviews, writing and debugging code, interpreting results, and translating statistical concepts for non-technical collaborators.

Large language models (LLMs) are advanced artificial intelligence (AI) systems trained on vast amounts of text data, capable of understanding and generating human-like text that can help data scientists transform their approach to scientific research and collaboration. Data scientists are uniquely positioned to capitalize on emerging LLM technologies to overcome numerous challenges, including the demand for their skill sets in an increasingly data-intensive research environment. Integrating LLMs into data science workflows offers innovative solutions to address these challenges and augment human expertise. Dell’Acqua et al. [Reference Dell’Acqua, McFowland and Mollick1] and Peng et al. [Reference Peng, Kalliamvakou, Cihon and Demirer2] demonstrated that these tools can streamline research processes, enhance productivity, and allow experts to focus on higher-level analytical tasks. However, their integration is complex, requiring careful navigation of multiple challenges: potential errors and hallucinations that necessitate robust verification strategies, ethical considerations around data privacy and bias mitigation, and ensuring transparency while balancing AI capabilities with human expertise [Reference Cheong3].

Recent publications have explored LLM applications in clinical research and biostatistics, highlighting their potential to enhance research workflows. These studies highlight LLMs’ capabilities in generating scientific text, guiding clinical trial design, optimizing code, synthesizing medical literature, and facilitating communication of technical findings [Reference Zhou, Liu and Gu4–Reference Hernandez and Lindsell7]. Guidelines and practical strategies have been proposed to ensure ethical implementation and maintain scientific rigor [Reference Perlis and Fihn8–Reference Pencina and Klotman10]. However, specialty-specific guidance is still needed for integrating these tools into workflows.

To address this need, we conducted a cross-sectional survey in September and October 2024 among three biostatistics units at Duke University School of Medicine and Stanford University School of Medicine to assess LLM usage, barriers to use, and training needs. This timeframe represents a specific moment in LLM development and adoption, when consumer-grade LLMs were becoming available to biostatisticians but before the widespread integration of these tools into operating systems and development environments. While the survey focused on biostatisticians, its insights apply broadly to data scientists in healthcare research. By analyzing patterns of LLM usage, practical applications, challenges, and training needs, we propose a set of key principles to provide guidance for effectively incorporating LLMs into biostatistical practice.

Methods

Results

Survey participant characteristics and LLM usage

Among 208 eligible biostatisticians (162 staff, 46 faculty) across three academic units, 69 (33.2%) responded to the survey. Of these, 68 reported their institutional affiliation: 29 (42.6%) were affiliated with DCRI Biostatistics, 25 (36.8%) with Stanford QSU, and 14 (20.6%) with Duke BERD. Among the 69 respondents, 56 (81.2%) held staff positions, and 57 (82.6%) identified as biostatisticians.

More than half of respondents (44/69, 63.8%) reported using LLMs in their work. Among those who answered the frequency question (43/69), 20 (46.5%) reported using them daily and 16 (37.2%) weekly. OpenAI ChatGPT (33/44, 75.0%) and Microsoft Copilot (22/44, 50.0%) were the most widely used tools, with many users employing multiple LLMs for different tasks. Institutional access to Microsoft Copilot varies by version and licensing model. While both institutions provide access to Copilot, full Microsoft 365 Copilot is not universally deployed and typically requires additional licensing by individual users or departments. ChatGPT and Copilot remained the primary tools across all competency domains, with ChatGPT usage ranging from 60 to 62% and Copilot usage from 26 to 38% depending on the domain. While 34 out of 69 (49.3%) reported receiving encouragement to use LLMs, fewer had access to formal guidelines (13, 18.8%) or training (13, 18.8%). See Table 1 for complete participant and LLM usage characteristics.

Table 1. Participant demographics and large language model (LLM) Usage characteristics

LLM = large language model; DCRI = Duke Clinical Research Institute; QSU = Quantitative Sciences Unit; BERD = Biostatistics, Epidemiology, and Research Design; n = number of respondents; % = percentage of respondents. * Multiple-select question; percentages may exceed 100%. ^† Organizational support question was implemented as single-select though intended as multiple-select. ^‡ Institutional access to listed LLM tools varies. Some tools, such as Microsoft Copilot, may be available through enterprise agreements, but full feature access may require additional individual or departmental licensing.

Key principles for responsible LLM use in biostatistical workflows

In addition to workforce training for LLM use, clear processes for implementing best practices with these tools are needed. Based on our survey analysis, literature review, and professional experience using LLMs, we propose eight core principles for effective LLM use in biostatistical workflows (Figure 1). These principles, grounded in respondents’ experiences with verification strategies, usage barriers, and general observations, represent an initial framework for responsible LLM usage in biostatistical practice – one that will evolve with continued use and technological advancement.

Figure 1. Eight guiding principles for responsible large language model (LLM) use in biostatistical workflows. These principles were developed as a synthesis of findings from our survey – particularly reported usage barriers, verification strategies, and ethical concerns – alongside a review of responsible AI literature and our professional experience as early adopters in academic biostatistics. This framework is not a direct representation of survey frequencies but is instead intended to offer early guidance on best practices. Issues such as federal grant policy restrictions and risks of intellectual property exposure through public application programming interfaces (APIs) fall within the scope of principles such as ethical considerations, transparency, and multiple tool integration.

These principles reflect key challenges and opportunities identified by survey respondents and draw from broader discussions on responsible LLM practices and verification strategies:

1. 1. Critical Evaluation: Use personal judgment, domain expertise, and trusted sources to independently assess LLM outputs before integrating them into biostatistical work.

2. 2. Collaborative Verification: Engage colleagues or supervisors to review LLM outputs, offering complementary perspectives that help identify errors or misinterpretations.

3. 3. Multiple Tool Integration: Combine resources and approaches to ensure comprehensive verification.

4. 4. Continuous Learning: Use LLMs to augment existing biostatistical knowledge while ensuring users possess the domain expertise necessary to critically evaluate and verify outputs.

5. 5. Ethical Considerations: Ensure alignment with institutional guidelines and regulatory requirements, particularly regarding data privacy, security, and bias. Where possible, consider using enterprise-grade systems that safeguard confidential or sensitive information.

6. 6. Transparency: Maintain clear documentation of LLM use and verification processes.

7. 7. Experimentation and Creative Prompting: Embrace creative experimentation in LLM interactions, recognizing that different approaches to framing prompts can yield significantly different results. This includes using LLMs to draft potential approaches or propose code, as well as to reflect on or refine work already in progress.

8. 8. Stay Informed: Given rapid technological advancement, regularly monitor LLM developments and emerging best practices, particularly new models optimized for code generation.

Discussion

Among 208 eligible biostatisticians at two major academic medical centers, our survey achieved a 33.2% response rate (69/208). More than half of respondents (44, 63.8%) reported using LLMs in their work; of the 43 who answered the frequency question, 20 (46.5%) used them daily and 16 (37.2%) weekly. Given the typical lag between study design, data analysis, and publication, our findings likely reflect AI practices that will shape clinical and translational research studies appearing in the literature over the next several years. Moreover, understanding current biostatistical workflows provides an important context for interpreting clinical and translational research publications emerging today, many of which reflect practices from the same period captured in our survey.

LLM use was highest for “writing, debugging, or documenting code (e.g., R, Python, SAS)” (31/40, 77.5%), followed by “editing and improving writing quality” (29/38, 76.3%) and “composing emails or other messages” (27/38, 71.1%). Most respondents found LLMs valuable for their tasks, with the highest perceived usefulness in communication (23/37, 62.2% rated “very useful”) and quantitative expertise (17/38, 44.7% rated “very useful”), while 15/34 (44.1%) rated clinical and domain knowledge applications as “very useful.”

As organizations formalize policies, training, and infrastructure around LLMs, broader adoption may extend beyond early users. Institutional agreements likely influence tool selection, as evidenced by the high prevalence of Microsoft Copilot usage among respondents. This suggests that adoption is influenced not only by user preference but also by enterprise partnerships, licensing structures, and ongoing institutional caution and integration.

Recent studies of LLM adoption in technical workflows parallel our findings while highlighting biostatistics-specific considerations. While data scientists follow similar interaction patterns, Chopra et al. [Reference Chopra, Singha and Fariha25] found that practitioners spend significant time on prompt preparation and validation, reflecting the careful verification approaches our participants described. However, our study reveals additional complexity in biostatistical applications, where concerns extend beyond code correctness to statistical validity and clinical implications.

Verification challenges appear consistently across the three professional domains assessed in our survey – communication, clinical knowledge, and quantitative expertise. Low et al. [Reference Low, Jackson and Hyde26] found that general-purpose LLMs produced relevant, evidence-based answers in only 2%–10% of clinical applications, while domain-specialized systems achieved 24%–58% – supporting our participants’ emphasis on domain-specific adaptation. Similarly, our survey found that 70.7% of respondents encountered errors that could have led to significant consequences, reinforcing the need for rigorous verification strategies. These findings highlight a broader issue in data-intensive fields, including biostatistics, where errors can propagate through analytical workflows if not properly validated. While emerging techniques such as content-grounded prompting and agentic LLM workflows show promise in addressing these challenges, they were not widely available or implemented during our study. Our analysis reflects usage patterns during the early retail-access phase when most users interacted with general-purpose tools without dedicated infrastructure for grounding or orchestration.

Building on these observations, prior research has further highlighted the importance of domain-specific validation, particularly in biostatistics and regulated environments where incorrect outputs can pose significant risks. Denecke et al. [Reference Denecke, May and Rivera Romero27] emphasized that LLM validation should be domain-specific. Komandur et al. [Reference Komandur, McDunn and Nair28] found substantial variation in LLM performance when analyzing biomedical data, demonstrating that outputs shift based on prompting strategies and model architecture. Similarly, Lee et al. [Reference Lee, Park, Shin and Cho29] highlighted inconsistencies in LLM evaluation methodologies across healthcare applications, emphasizing the lack of standardized validation frameworks and the challenge of ensuring reproducibility.

Several key limitations contextualize our findings. The relatively low response rate of 33.2% (69/208 eligible respondents) raises concerns about response bias, as individuals already using or interested in LLMs may have been more likely to participate in the survey. This is particularly relevant given that our recruitment targeted biostatisticians within our institutions. Additionally, our sample from two academic medical centers with established biostatistics groups may not represent experiences across all biostatistical practice settings. Thus, our findings may reflect early adopters rather than typical usage patterns, limiting generalizability.

Importantly, even when LLM tools are widely accessible, integration into daily biostatistical practice may lag substantially. This underscores the need for researchers to clearly document how and when LLMs are incorporated into scientific workflows, as practices vary across settings and over time. Nevertheless, this focus on early adopters provides valuable insights into emerging practices and implementation challenges that will become increasingly relevant as adoption broadens across the biostatistical community.

Our reliance on self-reported interactions rather than direct analysis of LLM use presents another limitation. While we collected examples of effective prompts, we did not systematically analyze how different LLM models varied in their responses to the same statistical queries. This limitation becomes increasingly significant as LLM technology evolves – during the study period and manuscript preparation (September 2024–February 2025), major advancements occurred across all leading companies, introducing new functionalities, model updates, and shifts in behavior. Notable releases included OpenAI’s GPT-4o, GPT-4o with Canvas, o1, and o3; Anthropic’s Claude 3.5 Sonnet and Claude Artifacts; Google’s Gemini 2.0; and DeepSeek’s open-source breakthroughs [30]. These developments introduced improved image processing, direct computer interaction, enhanced project management capabilities, and significantly improved code generation, further altering the landscape of LLM capabilities. As Bedi et al. [Reference Bedi, Liu and Orr-Ewing31] noted, many LLM evaluations focus on accuracy without addressing real-world variability, model drift, or contextual reasoning – factors that may influence reliability over time.

Future research should explore how model updates impact biostatistical workflows, particularly regarding the consistency of statistical interpretations. Since LLM performance is based on prompt design, computational constraints, and evolving training data, developing standardized, reproducible validation frameworks will be critical to ensuring long-term reliability in biostatistical applications. Additionally, our exclusive focus on text-based LLMs rather than broader generative AI represents another scope limitation. While multimodal applications such as image generation and audio content creation will likely become relevant to biostatistical workflows over time, they were not widely adopted by biostatisticians during our study period. Future investigations should track the integration of these expanded capabilities as the generative AI ecosystem evolves. Addressing these challenges will require structured investigations into LLM verification methods and long-term model consistency. These limitations, combined with our findings, suggest three important research priorities.

First, longitudinal and experimental evaluation studies should assess how LLM capabilities and adoption patterns evolve, incorporating objective productivity and work quality measures, such as time to task completion, error rates, satisfaction, and first-pass code accuracy, rather than relying solely on self-reported data. Research should examine individual and team-based usage patterns, particularly in relation to innovative organizational models such as dedicated prompt engineering specialists serving as internal consultants. These specialists could guide best practices, assist with prompt engineering, and support verification efforts within biostatistics teams.

Second, building on these findings and prior work demonstrating variable performance in biomedical contexts, the development and evaluation of domain-specific implementations should be a research priority. Future studies should investigate various approaches to domain adaptation in biostatistical workflows, including customized LLM interfaces, dedicated workspace environments, and knowledge-augmented architectures that can securely incorporate domain-specific content. These efforts may also benefit from emerging techniques such as content-grounded prompting and agentic architectures, which could help improve reliability and reduce hallucination by anchoring outputs in curated knowledge sources or enabling cross-verification among systems. Emerging AI agents designed to orchestrate full analytic pipelines may further enhance efficiency, although their success will depend heavily on access to high-quality, domain-specific training data and transparent orchestration frameworks.

Comparative studies evaluating these approaches could provide valuable insights into their relative effectiveness, security, and practicality. Given the substantial error rate reported by respondents, specialized verification protocols and domain-adapted solutions may offer clear advantages over general-purpose LLMs for biostatistical applications.

Third, organizational implementation strategies require systematic investigation. Our findings show limited formal support: while nearly half of respondents received encouragement to use LLMs, fewer than twenty percent had access to formal guidelines or training. Expanding training initiatives, particularly for biostatisticians without prior experience with LLMs, could further support responsible adoption. In addition to training and access, institutions may consider secure infrastructure, such as enterprise LLM environments, to protect sensitive data better and support safe implementation. Research into the effectiveness of different training models (e.g., peer mentoring, interactive tutorials, or embedded support teams) is needed to guide best practices. A consensus-building approach, such as a Delphi process involving diverse stakeholders, could refine and validate these preliminary principles as the technology and implementation patterns mature. Future research should also explore ethical implications, including bias mitigation, transparency in model outputs, and reproducibility standards to ensure that LLM-generated content aligns with rigorous scientific principles.

Given these challenges, structured guidance is needed to ensure responsible LLM integration in biostatistics. Our findings reinforce the need for clear principles that support methodological integrity, scientific rigor, and ethical responsibility. Drawing on our survey results, literature review, and professional experience, we propose eight core principles to guide biostatisticians in engaging LLMs effectively and responsibly. While not yet formally validated, these principles represent an important starting point for shaping practice. Future efforts should explore how these guidelines can be operationalized in institutional settings and refined as LLM technologies continue to evolve.

Conclusion

This survey offers early insights into LLM usage among biostatisticians in academic medical centers, highlighting productivity benefits and integration challenges. Although LLMs enhance efficiency, especially for coding, writing, and communication, their responsible use demands rigorous verification and systematic validation. Respondents expressed strong interest in educational resources, underscoring the need for structured training, formal guidelines, and institutional support.

As LLM technologies continue to evolve, standardized verification frameworks and domain-specific adaptations will be essential for maintaining statistical rigor. Our proposed core principles offer a foundational framework for structuring LLM use in biostatistical practice. Future research should focus on refining these principles, developing domain-specific adaptations, and implementing institutional strategies for training, governance, and ethical oversight, ensuring transparent, reproducible, and scientifically sound LLM-assisted workflows.