Chen Chen, Mohsen Nayebi Kerdabadi, Dongjie Wang +2cs.LG cs.AI
Longitudinal prediction from electronic health records (EHRs) is limited by the sparsity and irregularity in patient trajectories, and knowledge augmentation with external knowledge graphs (KGs) offers a promising way to alleviate these issues. However, most existing methods perform fixed, context-agnostic topology augmentation by adding the same KG nodes and edges regardless of a patient's evolving state. We propose ReTA, a Reinforcement learning-based dynamic Topology Augmentation framework that casts KG import as a per-visit, budget-aware policy. ReTA first constructs an offline refined pool of KG-grounded templates, then learns a policy to select one augment action per visit from three options: Soft Import, which enriches node features without modifying graph topology, Hard Import, which grafts a compact KG subgraph onto the visit graph to create message-passing shortcuts, and Skip, which leaves the visit unaugmented when the base encoder is already confident. To stabilize learning, ReTA employs a decoupled encoder that processes semantic and structural signals in separate channels and fuses them via adaptive gating. Experiments on MIMIC-III and MIMIC-IV across diagnosis prediction, mortality, and readmission show that ReTA consistently outperforms strong baselines while remaining efficient, transfers across datasets and knowledge graphs, and yields interpretable augmentation patterns. The robust gains under sparse supervision highlight the advantage of ReTA's dynamic decision to import knowledge, boosting accuracy while curbing costs.
When medical AI systems hallucinate clinical reasoning, the consequences extend beyond incorrect answers: fabricated justifications that superficially reference retrieved evidence can mislead clinicians into unsafe treatment decisions. Medical reasoning agents must therefore produce not only correct answers but also faithful justifications that clinicians can verify against cited evidence. We identify a systematic failure mode in RL-trained retrieval agents: outcome-only rewards improve accuracy while degrading faithfulness, a phenomenon we term confident hallucination. The agent learns to answer from parametric memory and backfill plausible but unsupported justifications; citation fabrication rates rise from 16.5% to 31.8% even as accuracy improves by 5 points over the supervised baseline. We address this with a faithfulness-gated reward design: accuracy credit is conditioned on evidence grounding via a hard gate, complemented by retrieval validity and conciseness signals that close exploitation paths unique to agentic retrieval. The resulting system, MedAgent-R1, reduces citation fabrication from 31.8% to 4.7% and raises evidence completeness from 58.7 to 82.6 while maintaining 75.1% accuracy, with 13.2-point gains on HealthBench Safety. Under the same agentic retrieval setup, MedAgent-R1 outscores GPT-4o on faithfulness-specific dimensions (Factual Support 4.55 vs. 4.25; Overclaiming 4.40 vs. 4.15) while remaining below GPT-4o in overall accuracy, suggesting that explicit faithfulness training yields evidence-grounding gains not achieved by scaling alone.
Automated fact-checking is essential for ensuring the reliability of public health information, yet the biomedical domain poses unique challenges. Validating biomedical claims requires rigorous interpretation of scientific literature, assessment of retrieved evidence, and comprehensive justification toward the conclusion. Although Large Language Models (LLMs) enhanced by Retrieval-Augmented Generation (RAG) and agentic search perform automated fact-checking in a retrieve-then-verify paradigm, current methods still output isolated prediction labels, lacking explanatory depth and offers limited utility for human understanding. To bridge this gap, we introduce an LLM-based agent named BioCheck Agent that generates structured biomedical fact-checking reports with agentic search. Rather than merely outputting supported or refuted labels, our agent synthesizes final conclusions with retrieved evidence and rigorous analysis. To ensure domain-specific accuracy, BioCheck Agent exclusively searches high-quality scientific literature in PubMed, utilizing advanced Boolean search operators. Recognizing that direct prompting often results in hallucinations and low-quality reports, especially for lightweight open-source models, we further propose the Evidence-Grounded Group Relative Policy Optimization (EG-GRPO) to perform reinforcement learning on BioCheck Agent with a task-specific reward that incentivizes advanced search behavior and high-quality evidence retrieval while penalizing hallucinations. Our experimental results show that compared to the base model Qwen3.5-4B, BioCheck Agent with EG-GRPO improves label prediction accuracy on SciFact by 9.95%. Furthermore, it achieves a 3.7% higher evidence quality score and a 19.63% lower evidence hallucination rate, demonstrating its ability to generate biomedical fact-checking reports with improved accuracy and quality.
Large Language Model (LLM)-based counseling agents can generate fluent and supportive responses, but they often lack the structured, goal-directed progression required to conduct a coherent therapeutic session. We present DeepSAGE (Strategic AI Guidance Engine), a hybrid LLM--Deep Reinforcement Learning (DRL) framework for stage-aware counseling dialogue grounded in the first session of Cognitive Behavioral Therapy (CBT). DeepSAGE represents the session as eleven stages with explicit therapeutic objectives, with an external controller determines stage completion and the DRL model selects therapeutic intentions that guide LLM response generation. We evaluate DeepSAGE against six retrieval-, prompting-, stage-, and policy-based alternatives. DeepSAGE elicits higher simulated client engagement and openness and achieves the strongest balance of stage-goal completion and dialogue efficiency among stage-structured systems. Domain expert review further indicates that the generated conversations exhibit broadly plausible emotional trajectories and recognizable CBT processes. Because the evaluation relies primarily on simulated clients and model-based metrics, these findings demonstrate comparative dialogue-control improvements rather than clinical effectiveness. These results suggest that combining stage-structured dialogue with learned strategy selection is a promising approach for AI counseling, though clinical effectiveness, safety, and real-world utility require further human evaluation.
Radiologists generate diagnostic reports through iterative and selective revisiting of suspicious regions to refine their interpretations. Recent multimodal large language models (MLLMs) for radiology report generation (RRG) have shifted from text-only reasoning toward a ``Thinking-with-Images'' paradigm, incorporating visual evidence into the reasoning process. However, existing methods provide static visual evidence without a dynamic revisit mechanism during reasoning, neglecting how radiologists re-examine uncertain observations. To this end, we propose an Uncertainty-aware Revisit Reasoning MLLM (UR$^{2}$-MLLM) framework that dynamically revisits uncertain regions during reasoning for RRG. UR$^{2}$-MLLM is first equipped with uncertainty perception by training on an uncertainty-aware dataset. We then construct a multimodal reasoning trajectory dataset together with a detect-and-copy mechanism, which guides when and where to revisit. Finally, a visual grounding reward refines this behavior through reinforcement learning, aligning the revisited regions with corresponding anatomical structures. Experiments on MIMIC-CXR and IU-Xray show that UR$^{2}$-MLLM achieves state-of-the-art performance, highlighting the value of uncertainty-aware visual revisit reasoning for reliable and clinically aligned report generation.
The current progress of Clinical Vision Large Language Models (C-VLLMs) has substantially improved digital diagnostics, still these frameworks often endure lesion noises, modality misalignment, hallucination, and missed contextual grounding in complex clinical cases. Moreover, prevailing agent systems usually depend on static and non-adaptable pipelines and lack the versatility necessary for complex medical reasoning. To resolve these difficulties, we present BioMed-Agent-RL, a unified medical agent that incorporates adaptive orchestration, policy, and reward-based reinforcement learning (RL) models for biomedical applications. To ensure reliability, it invokes clinical context-aware preference optimization (CPO), direct preference optimization (DPO), and group relative policy optimization (GRPO) with dynamic entropy regulation. This pipeline utilizes a multimodal meta-learning approach that operates as a field-specific expert and human judgment synthesizer. The agent adaptively utilizes a set of model-level expertise, such as clinical grounding and reasoner, lesion segmenter, and field-specific synthesizer, across various clinical modalities (e.g., X-ray) by utilizing an iterative and adaptive RL approach. The agent learns to seriously synthesize misleading, conflicting vision cues and trust in inherent reasoning, while specialist advice is faulty. An intensive ablation study is conducted across multiple benchmarks, and the agent significantly outperforms existing state of the art models, such as GPT-5, attaining up to ~73% accuracy (gain of ~5%) over contemporary baselines. As a result, the framework suggests a new standard for building factual, reliable, robust, and expert-like intelligent agent systems for independent clinical reasoning.
Personalized interpretation of medical reports has emerged as an increasingly important need among patients. Addressing this need requires both evidence-grounded medical factuality and context-dependent patient communication, yet existing medical vision-language tasks do not adequately capture these dual requirements. To bridge this gap, we introduce Patient-oriented Medical Report Interpretation (PMRI), a novel open-ended multimodal generation task that requires models to explain medical reports in accurate and accessible language based on a user's query and dialogue history. These two objectives differ fundamentally in their verifiability, yet remain tightly coupled, making them difficult to optimize jointly under conventional supervised fine-tuning and holistic reinforcement learning paradigms. To address this challenge, we propose G-CARL, a grounded, checklist-aligned reinforcement learning framework that combines multi-source retrieval for atomic claim verification with context-aware, instance-specific weighted checklists for response coverage, providing structured supervision for factuality, user-demand satisfaction, and expression quality without constraining response diversity. We further construct MMedReport, a real-world PMRI benchmark, along with a clinician-designed three-dimensional evaluation protocol. Extensive experiments demonstrate that G-CARL consistently outperforms existing post-training baselines in overall quality, claim-level precision, and checklist recall. Pairwise preference evaluation by clinicians further confirms that G-CARL produces interpretations that are more accurate and better aligned with patient needs.
Yunseo Lee, Hyun Jun Kim, Heeseung Shin +1cs.CV cs.CL
Medical image captioning is a technique that accelerates early-stage diagnostic workflows and enhances the interpretability of medical diagnostic AI systems. However, unlike general image captioning, clinically reliable captioning remains challenging due to grayscale-based modalities, subtle anatomical cues, specialized medical phrasing, and variations in data quality. Despite recent advances in large vision-language models, fluent outputs do not necessarily guarantee sufficient alignment with clinical concept spaces or evaluation criteria. To address this issue, we propose a framework that strengthens clinical alignment by separating and enhancing training-time alignment and inference-time alignment. We build a medical image captioning pipeline that integrates single/dual vision encoders based on BioMedCLIP and SigLIP2, a Q-Former, and a LLaMA-based decoder, and examine the contribution of auxiliary learning for UMLS concept/type prediction. At inference, we apply single-embedding-based reranking to select the best caption among candidates, while at training we introduce MedPAIR-SCST, which combines clinically relevant rewards to shift the generative distribution toward improved clinical alignment. Our experiments show that complementary visual representations with a multi-encoder design and concept-level auxiliary learning help preserve clinically meaningful information. Furthermore, inference-time reranking provides a practical way to improve semantic and clinical alignment without additional training, whereas MedPAIR-SCST goes beyond selection by directly improving the model's distribution to generate more consistent and clinically grounded captions. These findings suggest that jointly leveraging selection-based alignment and reinforcement-learning-based alignment can promote more trustworthy medical image captioning even in data-constrained settings.
Falls among older adults represent a major public health challenge driven by complex, time-varying interactions across multiple risk domains. Effective fall risk factor identification requires learning from heterogeneous longitudinal data while accounting for sparse and delayed fall-related outcome events. However, existing approaches are largely static and fail to adaptively model evolving, individualized risk factors across modalities and time. We propose PAFIR, a Personalized and Adaptive Feature selection framework for fall risk Identification and pRevention, which formulates adaptive feature selection as a reinforcement learning problem over longitudinal multimodal health data. PAFIR jointly models structural dependencies among correlated assessment variables and temporal dynamics in wearable-derived physical activity data, and learns adaptive selection policies across repeated study visits using reward signals derived from sparse fall incidence outcomes. We apply PAFIR to data from the Physio fEedback Exercise pRogram (PEER) cluster-randomized trial. Experimental results demonstrate that PAFIR more effectively captures longitudinal and structural patterns of feature relevance than state-of-the-art baselines, and enables dynamic, subject-specific feature selection. By adapting selected features over time, PAFIR supports more timely and personalized fall prevention strategies.
Mohamad Mohamad, Francesco Ponzio, Maxime Gassier +2cs.CV
Whole-slide image (WSI) analysis remains computationally challenging due to the extremely large spatial resolution of slides and the sparse distribution of tumour regions. We propose an end-to-end reinforcement learning framework for sequential tumour segmentation directly on WSIs. Instead of treating the slide as a predefined collection of candidate patches, we formulate the WSI itself as a hierarchical multi-resolution environment through which an agent navigates using movement, zooming, and tumour selection actions. The agent jointly processes local observations and a global thumbnail representation within an actor-critic architecture trained using proximal policy optimization (PPO). Experiments on pulmonary adenocarcinoma WSIs demonstrate the feasibility of direct sequential tumour segmentation on full slides, achieving comparable coarse segmentation quality relative to patch-based approaches operating at similar magnification levels, while reducing inference time to a few seconds per slide. We further analyse the impact of environment design and action-space granularity. Our results suggest that modelling WSIs as interactive environments provides a promising direction for RL-based computational pathology
Medical visual agents can use tools to inspect images and retrieve external knowledge, but indiscriminate tool use may introduce noisy or misleading evidence. Reliable diagnosis therefore requires not only acquiring additional observations, but also verifying whether tool actions are necessary and whether the resulting evidence supports the current hypothesis. We introduce MIRA (Medical Image Reflection for Agentic Diagnosis), a medical visual diagnostic framework for autonomous evidence search and reflective verification. MIRA dynamically invokes image-processing operations, including zooming, grounding, pointing, rotation, and measurement, as well as web search, while evaluating the relevance and consistency of the acquired evidence. We develop MIRA through a two-stage training strategy. First, a tool-augmented Monte Carlo Tree Search data engine explores diverse diagnostic hypotheses and jointly verifies visual grounding accuracy and semantic consistency to construct supervised fine-tuning trajectories. Second, reinforcement learning further improves decision-making through online reflective principle evolution: failure cases are distilled into candidate principles, and only principles that improve held-out rollout rewards are retained. Across nine medical visual reasoning benchmarks, MIRA achieves an average score of 64.73, improving its Qwen3-VL-8B backbone by 7.44 points. It also increases useful tool-use judgments from 56.2% to 73.8% and reduces harmful judgments from 8.9% to 1.6%. Qualitative analyses show that MIRA can re-examine evidence, correct premature conclusions, and adapt its tool-use strategy. Project page: https://MIRA-VL.github.io/
In Reinforcement Learning with Verifiable Rewards (RLVR) frameworks for mathematical reasoning tasks, floating-point results are typically evaluated using a tolerance-based reward. However, this strategy suffers from challenges such as difficulty in threshold calibration, unstable training dynamics, and limited accuracy, especially in clinical scenarios. To address these limitations, we propose a knowledge-guided hybrid reward framework (\textsc{MedCalc-R1}). Specifically, we introduce a knowledge verification reward mechanism that enforces explicit generation of computational formulas, which are further validated by an external verifier to enhance interpretability and reasoning reliability. Furthermore, we design a hybrid soft-hard reward scheme combining a hard constraint based on clinical safety thresholds with a soft, precision-sensitive reward that progressively guides learning within the acceptable range. Experimental results demonstrate that our method significantly outperforms existing baselines in both reasoning accuracy and generalization capability, validating the effectiveness and applicability in safety-critical domains.
Causal diagnostic models must explain how conclusions follow from evidence because diagnoses guide repairs and treatments. Yet serious cases are scarce, records rarely contain reasoning paths, and data transfer poorly across configurations, complicating local deployment. We present DiagLoop, a counterfactual data flywheel that converts codified physical relations or clinical guidelines, authored once per mechanism family, into training supervision beyond recorded cases. A training-only teacher proposes counterfactual worlds by varying causes, contexts, and observations, while an independent hybrid checker admits only valid worlds. The student reasons through symptom abstraction, causal-chain construction, and root-cause attribution. Stage-specific criteria identify its earliest failure. For nonterminal failures, a bounded repair probes downstream competence, and the resulting weakness profile guides subsequent data generation. Stage-localized reinforcement learning updates only the model-generated continuation, while replay and preservation reduce forgetting. The same criteria govern admission, attribution, reward, and regeneration through checks separate from the proposer. Using only synthesized scenarios and no case-level expert reasoning annotations, the resulting 8B model improves strict path correctness over the strongest conventional baseline. Gains are 11.6 points across eight industrial systems and 5.5 points across ten disease categories. Gains over a deranged-routing control are 3.9 and 2.3 points, respectively. The model also exceeds the evaluated proprietary references in both domains, even when they receive few-shot examples or the specification in context.
Ofir Ben Shoham, Oriel Perets, Nir Grinberg +1cs.CL cs.AI
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.
Pathological diagnosis is inherently multi-scale, requiring the integration of global tissue architecture at low magnification with cellular morphology at higher magnification. However, existing pathology benchmarks and vision-language models (VLMs) are still largely developed under single-scale settings, limiting their ability to learn clinically meaningful multi-magnification reasoning. Moreover, naively constructed visual question answering (VQA) tasks may be susceptible to text-only or superficial visual shortcuts, leading to unreliable assessments of visual understanding. To address these limitations, we introduce a benchmark and training framework for shortcut-resistant cross-scale pathology reasoning. We design an Adversarial Text-only Screening strategy for semantic reasoning questions and a Structure-controlled Distractor Sampling strategy for visual grounding questions, encouraging models to rely on cross-scale visual evidence. Based on this pipeline, we construct PathScale-VQA, a high-quality cross-scale pathology VQA benchmark with 10,373 multiple-choice questions grounded in 1,368 diagnostic paths across multiple magnification levels. Building on the semantic reasoning set, PathScale-R1 is optimized through Difficulty-driven Reasoning Distillation supervised fine-tuning followed by reinforcement learning with a Scale-aware Reasoning Structure reward, which encourages the use of evidence across magnifications. Extensive experiments demonstrate state-of-the-art performance of PathScale-R1 on cross-scale reasoning tasks and effective transfer to conventional single-scale pathology VQA. Our code is available at https://github.com/iMVR-PL/PathScale-R1.
This paper describes TalTech's submissions to the Beyond Transcription Challenge (BeTraC), which requires generating SOAP notes directly from long doctor-patient conversation recordings, without intermediate transcription. After screening open-weight speech LLMs for long-audio robustness, we adapted Voxtral Mini (lightweight track) and Voxtral Small (heavyweight track) with LoRA supervised fine-tuning followed by DAPO reinforcement learning that uses the challenge metric, Open Medical Concept F1, as its reward. Our systems ranked first in both tracks, and an independent LLM-as-a-judge evaluation showed the lowest hallucination rate among all submissions, indicating that reinforcement learning against a concept-matching metric need not compromise factual reliability. We also find that fine-tuning on text transcripts transfers well to speech input and appears to improve robustness on out-of-domain real recordings.
Bladder cancer treatment requires personalized and adaptive decision-making, particularly for recurrent disease, where treatment effectiveness changes across successive clinical episodes. Conventional clinical decision support systems typically rely on static treatment guidelines or single-step predictive models, limiting their ability to capture disease progression over time. This paper presents a recurrent patient state-transition simulation framework for bladder cancer treatment planning that integrates predictive state-transition modeling with a Markov Decision Process (MDP) and a Deep Q-Network (DQN) reinforcement learning environment. The predictive module estimates changes in tumor characteristics following treatment, while the reinforcement learning agent sequentially optimizes treatment decisions by interacting with simulated patient trajectories. This framework enables dynamic, patient-specific treatment planning by continuously adapting recommendations to evolving clinical states. It also generates interpretable treatment trajectories and detailed simulation logs to improve transparency and support clinical decision-making. The proposed framework was evaluated against existing reinforcement learning-based treatment planning approaches. It achieved a cumulative reward of 63,918.87, an average training loss per episode of 0.0056, and a policy improvement score of 6.62%, demonstrating effective sequential learning and robust treatment optimization in a simulated recurrent treatment environment. These findings highlight the potential of recurrent patient state-transition simulation with reinforcement learning as a flexible decision-support framework for personalized bladder cancer treatment planning and AI-assisted precision oncology.
Emergency department (ED) boarding occurs when admitted patients remain in the ED while awaiting inpatient beds. Boarding is a major driver of ED crowding and has been associated with poor patient outcomes. We propose a framework to help EDs reduce boarding time and length of stay by using information about current patients and bed availability to proactively request inpatient beds before admission decisions are finalized. We formulate the problem as a Markov decision process in which predictions of each patient's admission probability and time to disposition are aggregated to guide early inpatient bed requests. This formulation leads to three data-driven policies based on approximate dynamic programming, reinforcement learning, and a newsvendor-type approach. Using a simulation model based on data from a large ED, we evaluate these policies across a wide range of settings. The simulation study shows that proactive aggregate bed requests can reduce average boarding times for admitted patients by 30-70\% and average length of stay for all ED patients by 6-15\%, while creating only modest idle time for prepared inpatient beds. The newsvendor heuristic provides the most attractive tradeoff between ED performance and inpatient bed idle time, whereas the reinforcement learning heuristic produces smoother bed-request patterns when stability in downstream hospital processes is especially important. Our work shows how EDs can use prediction tools to make proactive bed-request decisions that improve ED operations while helping managers balance reductions in ED delays against inpatient bed idle time. Our findings also illustrate the value of evaluating both simple myopic heuristics and more sophisticated reinforcement learning-based approaches, since each can offer distinct advantages depending on the performance measures and implementation constraints most important to managers.
3D geometric tooth alignment planning, which determines sequential trajectories from initial malocclusion to the final target alignment, is a cornerstone of modern digital orthodontics. This paper presents a novel deep reinforcement learning (DRL) framework to automate the generation of these alignment paths. We formulate the planning process as a Markov Decision Process (MDP) to capture its sequential decision-making nature, focusing on optimizing geometric trajectories while integrating essential spatial constraints, such as inter-dental collision avoidance and path efficiency. The proposed method leverages the Deep Deterministic Policy Gradient (DDPG) algorithm, enhanced by three key innovations: (1) a Transformer-based agent to model complex spatial interactions between teeth and manage high-dimensional state-action spaces; (2) a dynamic masking scheme that restricts movement to a sparse subset of teeth per step, better reflecting the clinical logic of sequential alignment; and (3) a two-stage curriculum learning strategy that gradually increases task difficulty to ensure training stability and efficient path discovery. We evaluate our approach on a dataset of 10K expert-designed treatment plans based on clinical data. Experimental results demonstrate that our method outperforms existing baselines in terms of path safety and geometric efficiency, providing a robust and automated solution for 3D geometric orthodontic alignment planning.
When labeled data are scarce, off-the-shelf diffusion models can augment training sets for few-shot medical image classification, but not all generated samples are equally useful for the downstream task. Existing approaches largely improve synthetic data by increasing realism, diversity, or domain adaptation, while overlooking a more fundamental question: how should sample usefulness for classification be measured and optimized? We address this with Class-Contrastive Influence (C2I), a criterion that quantifies a sample's usefulness through its gradient-based influence on the classifier. We find that effective samples exhibit a strong C2I gap: their loss gradients align with validation gradients from the same class and oppose those from other classes. Our analysis further suggests that such high-C2I samples are hard, boundary-proximal examples that help refine the decision boundary and improve robustness. Building on this insight, we fine-tune diffusion models with reinforcement learning using a C2I-based reward to steer generation toward class-informative samples. Across several few-shot medical imaging benchmarks, C2I-guided generation improves downstream accuracy and robustness over diffusion-based augmentation baselines, showing that synthetic augmentation is most effective when guided by task usefulness rather than image quality alone.
Deep learning for EEG-based seizure detection faces critical challenges: severe annotation scarcity and extreme class imbalance, where ictal events comprise less than 10\% of clinical recordings. We present DiffEEG, a 9.6M-parameter self-supervised foundation model that addresses both limitations through denoising diffusion pre-training and reinforcement learning (RL)-based fine-tuning. Pre-trained on 1.3M unlabeled segments from the Temple University Hospital Seizure Corpus (TUHSZ), DiffEEG learns generic neural representations via a 1D U-Net with multi-head self-attention. For downstream adaptation, a reinforced decision layer employs policy gradient optimization to directly maximize F1-score, prioritizing sensitivity to rare seizure events over overall accuracy. Under strict patient-wise evaluation (279 patients, Leave-One-Fold-Out), DiffEEG achieves 61\% accuracy and 59\% F1 for 4-class seizure subtyping, and 81\% accuracy with 85\% weighted F1 for binary detection, maintaining clinically viable seizure recall (59\%) despite extreme imbalance (6.7\% prevalence). Segment-level evaluation establishes an upper bound of 97.6\% accuracy, confirming strong architectural capacity. DiffEEG demonstrates that diffusion-based pre-training combined with metric-aware reinforcement learning enables clinically deployable seizure monitoring with minimal labeled data requirements.
Automated chest X-ray report generation has recently benefited from reinforcement learning (RL) and large language models. However, RL training often suffers from instability or limited exploration due to fixed Kullback-Leibler (KL) regularization and a static reference policy that accumulates KL pressure over time. We propose Response-Weighted and Validation-Anchored Policy Optimization (REVA-PO), a RL framework that stabilizes long-term training via Response-Weighted Regularization (RER) and Validation-Anchored Policy Reset (VAPR). RER dynamically adjusts per-response KL weights based on advantage and reference-policy entropy, relaxing constraints for high-quality responses while tightening them for low-quality ones. Complementarily, VAPR periodically synchronizes the reference and current policies to the best validation checkpoint, resetting accumulated regularization pressure to expand the viable exploration space. To ensure a robust starting point, we employ a three-stage pipeline consisting of warm-up training, classifier-guided supervised fine-tuning, and RL. Extensive evaluations on MIMIC-CXR and IU-Xray demonstrate that REVA-PO sets new state-of-the-art benchmarks in both linguistic quality and clinical accuracy. Notably, BLEU-4 improves by 5.1% on MIMIC-CXR and 3.6% on IU-Xray, while CheXpert F1 and RadGraph F1 scores increase by 4.5% and 12.8%, respectively, over prior leading methods. The code is publicly available at https://github.com/LiGuo12/REVA_PO/.
Clinical protocol-execution tasks -- checking a lab value, applying a threshold, placing a correctly structured FHIR order -- are natural candidates for RL from world feedback: once clinical SMEs encode decision logic into a verifier, that verifier grades unlimited rollouts without per-episode annotation. But applying RL requires a sound feedback channel and sufficient base capability. We audit MedAgentBench v1/v2, find a 41.7\% silent-finish ceiling that makes inaction the RL dominant strategy, and construct \textbf{MedAgentBench-v3 (MAB-v3)} (508 tasks, 8.9\% ceiling). Training Qwen3-8B exposes two structural barriers: a \emph{capability ceiling} (10/20 task types have 0\% base performance, zero gradient) and a \emph{format-knowledge barrier} (3/20 types require exact clinical codes undiscoverable by exploration). Pure RL reaches 18.2\% pass@1 vs.\ 34.1\% for rule-based SFT; the 15.9~pp gap is attributable entirely to these barriers. A decision/format-knowledge/lookup taxonomy predicts RL learnability and prescribes the fix: SFT to inject codes, RL to learn conditionals.
Faithful reasoning is essential in medicine, where clinical decisions require transparent justification grounded in reliable evidence. Current medical LLMs either lack active access to evidence or use retrieved evidence without supervising how it should be appraised and applied during reasoning. To address this, we formalize evidence-based medicine principles as process-level criteria and introduce FaithMed, a framework that combines clinician-designed, automatically refined rubrics with reinforcement learning using step-level process reward assignment and advantage grouping. Across seven medical benchmarks, FaithMed improves over agentic-search baselines (+9% on average) and outcome-only RL (+5.8%), while raising average evidence-based medicine rubric scores over agentic-search Qwen3 baselines (+15.5%). This work demonstrates that explicit step-level supervision can improve both task success and the faithfulness of the reasoning process. Code is available at https://github.com/cxcscmu/FaithMed.
Rare disease differential diagnosis is a critical yet arduous clinical task, requiring physicians to identify precise phenotypes from complex, unstructured patient symptoms and execute intricate reasoning within a vast search space. However, existing AI approaches typically rely on pipeline-based phenotype extraction or retrieval-augmented generation, which suffer from critical information loss due to predefined ontologies, retrieval bottlenecks, and a lack of diagnostic logic. To address these challenges, we introduce RareDxR1, an end-to-end reasoning-centric large language model designed for open-domain rare disease diagnosis directly from unstructured clinical notes. We design a progressive end-to-end training framework by synergizing knowledge internalization with autonomous evolutionary learning, thereby bypassing reliance on structured phenotypes and closed-set decision-making. To overcome the limitations of RAG and phenotype restriction, we enabled the deep internalization of fragmented rare-disease knowledge directly into the model's parameters. Moreover, to bridge the gap between model generation and expert reasoning, we propose Reflection-Enhanced Reasoning Sampling (RERS), a strategy that synthesizes expert-level diagnostic trajectories by learning from failures without human annotation. Additionally, we propose a dual-level curriculum reinforcement learning approach for gradually mastering rare disease diagnosis. Experimental results demonstrate that RareDxR1 achieves state-of-the-art accuracy across different benchmarks, marking a significant breakthrough in open-domain rare disease diagnosis. Our code and dataset will be publicly available.
Vision-language models (VLMs) combining reinforcement learning (RL) ignite remarkable progress in multimodal reasoning, yet still struggle with medical images, which typically exhibit extremely sparse visual evidence to inform clinical decision-making. We recognize that pruning visual tokens outside the grounding region greatly enhances medical reasoning. However, a united RL framework for active visual token pruning (VTP) and medical multimodal reasoning remains unestablished. Here, we propose a dual-stream RL framework, ViToS, to fulfill token pruning and question answering. ViToS trains one policy model with two task branches, where one focuses on grounding while the other conducts token-sparse reasoning after VTP. Furthermore, we solve the coupled policy learning problem by introducing the cross-feedback sequential optimization, avoiding gradient conflict and facilitating convergence of the shared policy model. Evaluated on seven medical benchmarks, our method reduces visual tokens to 77% of the original sequence length while achieving a 108.27% relative performance on Lingshu-7B and 104.16% relative performance on HuatuoGPT-Vision-7B. Overall, ViToS delivers superior performance and inference speedup, establishing an efficient paradigm for medical multimodal reasoning.
Yucheng Zhou, Peng Luo, Qianning Wang +2cs.CL cs.CV
Large Language Models (LLMs) have shown strong potential for medical reasoning, yet the scarcity and cost of expert-annotated data constrain their progress. While reinforcement learning offers a scalable alternative, standard outcome-based methods in medicine often suffer from autoregressive credit assignment failure and gradient variance explosion. This leads to the "Right Answer, Wrong Reason" trap, where models inadvertently reinforce spurious correlations and dataset shortcuts rather than valid clinical deduction. In this work, we propose Causally-Aligned Reasoning Exploration (CARE), a theoretically grounded framework for intrinsic experience curation. CARE is built upon two rigorous conditions for high-quality training trajectories: Causal Sufficiency, which utilizes an agreement-based self-verification mechanism to mimic $do$-calculus interventions and effectively debias gradients; and Proximal Learnability, which employs dynamic entropy bounds to select experiences within the model's zone of proximal development for variance-bounded optimization. These rigorously filtered experiences are optimized via a dual-stream objective that combines on-policy group-relative exploration with difficulty-weighted experience replay. Extensive experiments on diverse medical multimodal and text-only benchmarks demonstrate that CARE consistently outperforms other strong competitors, substantially reducing correct-but-inconsistent reasoning and improving training stability.
Clinical diagnosis is a step-by-step, cost-aware process: a physician orders examinations one at a time, observes the results, and updates the diagnosis before reaching a final conclusion. Most medical language models instead treat diagnosis as a one-pass classification task and ignore the trade-off between a test's value and its cost. We model diagnosis as a cost-aware sequential decision process and train the policy with reinforcement learning. The main difficulty is credit assignment: the only reliable signal comes once at the end of a long trajectory, so it scores a wasteful workup the same as an efficient one. We propose CDPR (Counterfactual Diagnostic Process Reward), which needs no expert labels and no learned critic. CDPR first finds the states where the policy hesitates, using the uncertainty of its action distribution, and then scores the chosen action by its advantage over the alternatives the policy itself would consider, estimated with short rollouts under a utility that balances correctness against test count, cost, and infeasible requests. A rollout cache reuses within-batch trajectories to keep the cost low. We integrate CDPR into GRPO and test it on one in-domain (MIMIC-IV) and two out-of-domain (ClinicalBench and a private hospital dataset) benchmarks. CDPR improves diagnostic accuracy while clearly reducing the number and cost of examinations.
Treatment reasoning underpins every therapeutic decision, integrating disease context, comorbidities, medications, contraindications, and evolving biomedical knowledge to select an appropriate therapy. It is inherently iterative: candidates are weighed against many constraints, revised as evidence emerges, and grounded in verifiable sources. Here we introduce ATHENA-R1, an AI agent for treatment reasoning across all FDA approved drugs since 1939, trained by reinforcement learning over a universe of 212 biomedical tools. At each step it identifies missing information, selects and runs relevant tools, and incorporates the evidence. To train it without human-annotated traces, we build a two-level self-learning framework: multi-agent systems construct the tools, tasks, and reasoning trajectories for supervised fine-tuning, then reinforcement learning with scientific feedback rewards reasoning quality (evidence gathering, grounded tool use, logical non-redundancy). Across five benchmarks of 3,168 drug reasoning tasks and 456 patient treatment cases, ATHENA-R1 outperforms language models and tool-use systems, reaching 94.7% accuracy on open-ended drug reasoning and 82.9% on treatment reasoning, 17.8 and 10.7 points above GPT-5. In blinded evaluations by experts from 28 rare disease organizations, it is preferred over reference models on all criteria, and physicians rated it favorably on complex hospitalized cardiovascular and infectious-disease cases. Adverse-event hypotheses it generated, tested in electronic health records from 5.4 million patients, reached adjusted odds ratios of 1.48-1.84, with no elevation among negative controls. Because it requires knowing what evidence to seek before concluding, treatment reasoning has long been hard for AI; we show it can be reframed as a learnable process of iterative evidence gathering that reinforcement learning can train AI to perform.
Binh Nguyen, Colleen Josephson, Mircea Teodorescu +2cs.NE cs.AI cs.LG eess.SY
Neuromorphic and edge computing research has focused on reducing the inference cost of neural network controllers, yet in physical closed-loop systems the actuator can rival or exceed an efficient controller in energy. An efficient controller is therefore necessary but not sufficient, because the actuator becomes the cost worth reducing once inference no longer dominates it. Here, we introduce energy-aware learning, an approach that incorporates actuator energy directly into the reinforcement learning reward, and demonstrate it in closed-loop deep brain stimulation (DBS) for Parkinson's disease. A deep spiking Q-network, trained in a biophysical cortico-basal ganglia-thalamic circuit model, learns to suppress pathological alpha-beta oscillations by 45.2% while reducing stimulation charge by 80.0% relative to continuous DBS. Sparsity-constrained knowledge distillation compresses the policy onto the SynSense XyloAudio 3 neuromorphic processor at 0.52 mW inference power, yielding 28.1x lower energy per inference than an equivalent artificial neural network on conventional edge hardware. By co-optimizing stimulation energy and inference efficiency, the framework addresses both major power demands in implantable neuromodulation.