MedUPS: Towards Diagnostic Assistance in Uncommon Medical Cases with Large Language Models

Uncommon and off-guideline cases are difficult for clinical decision support, because physicians must make a series of management decisions under diagnostic uncertainty and rarely see the full case at once. Most large language model (LLM) benchmarks for medicine score only the final diagnosis, yet much of clinical care turns on the next appropriate action: the next test to order, the imaging study to obtain, the specialist to involve, or the differential to pursue. We introduce MedUPSQA, a dataset of 21,874 mid-stream clinical decision points built from 5,535 real case reports, and MedUPS, an alignment framework that supervises models on these intermediate decisions as they unfold along a patient's trajectory. We segment free-text case presentations into chronologically ordered, accumulating clinical chunks and align models to predict the next step with reinforcement learning (GRPO), using an external LLM-as-a-Judge reward. This objective mirrors how clinicians actually meet patients, reasoning forward from accumulating evidence toward the next decision, rather than committing to a final label. Across three backbones, mid-stream alignment raises next-step accuracy from 55.2 to 66.7 for Qwen3.6-27B, from 47.2 to 57.8 for Qwen3.5-9B, and from 37.8 to 44.4 for HuatuoGPT-3-8B, with 95% CI. In several model scales we test the objective improves accuracy more than scale, with smaller models surpassing larger, frontier models we evaluate. We further train supervised fine-tuning (SFT) baselines on the mid-stream task, SFT improves all backbones above base, indicating the target framwork carries signal independently of the optimizer. We release the dataset, code, and aligned checkpoints.

TD-DPO: Difference-Aware Preference Optimization for Mitigating Sycophancy in Clinical Autism Intervention Dialogue

The sycophancy of large language models can increase the safety risk in intervention dialogue for autistic children. Supervised fine-tuning can somewhat reduce sycophancy, but relying solely on positive examples is often insufficient to identify and correct failure patterns. We observe that sycophancy behaviors can often be localized to a limited span within the model response. In this regime, sequence-level preference optimization can over-update preference-irrelevant tokens and degrade intervention ability. To address this, we propose the \textbf{M}inimal \textbf{E}dit \textbf{D}ata \textbf{A}ugmentation (MEDA) strategy to construct controlled, stable, minimal edit preference pairs and \textbf{T}oken-level \textbf{D}ifference \textbf{D}irect \textbf{P}reference \textbf{O}ptimization (TD-DPO), which upweights difference tokens between chosen and rejected responses while downweighting shared tokens to suppress background drift. Extensive experiments across multiple backbones and evaluators show that TD-DPO achieves a better trade-off between sycophancy mitigation and intervention ability retention in our offline settings, highlighting its potential as a practical alignment approach for autism intervention.