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.
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.
Large language models perform strongly on medical knowledge benchmarks, but reliable clinical deployment requires agents to conduct defensible investigations over heterogeneous, longitudinal records: determining what evidence is needed, retrieving and reconciling structured and free-text data, grounding conclusions in verifiable evidence, and deferring cases that cannot be resolved reliably. We introduce CliniCARE-Bench (Clinical Calibrated Audit of Medical Reasoning in EHR), a benchmark for retrospective clinical audit: 25 clinician-validated scenarios instantiated as 750 patient-specific cases over real-patient-derived MIMIC-IV data. Systems investigate each case through a governed, logged tool environment for record retrieval, computation, and policy access, and return one of four verdicts---Yes, No, Indeterminate: Lack of Data, or Indeterminate: Medically Ambiguous---the last two separating missing evidence from residual medical ambiguity. Beyond verdict accuracy, we score patient-evidence and policy grounding, process adherence, calibrated abstention, reliability, and efficiency against case-level reference verdicts produced by independent multi-model adjudication and calibrated against Clinical Board review. Every retrieval, computation, and report is replayable, so the investigation trace is inspectable and scorable. To our knowledge, CliniCARE-Bench is the first deployment-oriented clinical-agent benchmark to jointly evaluate real longitudinal EHR investigation, claim-level evidence grounding, governing-policy use, process adherence, and calibrated abstention within a common patient-level adjudication framework. Across 16 agentic systems, four-way accuracy spans 65.3-76.1%, but raw accuracy overstates investigation quality. Defect-free accuracy, which credits a verdict only when correct and free of prohibited shortcuts, is 4.8-14.8 points lower and reorders the leaderboard.
Large language models (LLMs) have emerged as important tools in healthcare, showing growing potential for clinical reasoning and patient care. This survey examines recent progress in medical LLMs, focusing on reasoning applications and requirements. We present a dual-view approach that connects clinical practice with computational methods. On the clinical side, we establish a five-level competency scheme following Miller's Pyramid, progressing from knowledge recall to dynamic case management. On the computational side, we link deductive, inductive, and abductive reasoning patterns to common medical goals and tasks. We also introduce a benchmark dataset spanning five levels of medical reasoning capability and report results on 18 state-of-the-art models, revealing that medical specialist models excel in diagnosis-centric tasks while general models lead in decision support and dialogue. We conclude by discussing current progress and open challenges, including data limitations, hallucination, and grounding issues, and outline directions toward safer, more reliable, and workflow-ready systems.
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.
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.
Chest X-ray visual question answering (CXR VQA) requires models not only to predict correct answers, but also to produce reliable medical reasoning. However, existing reinforcement-learning-based training typically relies on answer-level rewards, which are often too coarse to improve chain-of-thought (CoT) quality and can become ineffective when group-level advantages collapse to zero. We propose \textbf{Teach-to-Reason (T2R)}, a framework that introduces comparison-based supervision into CoT optimization through a self-improving \emph{Teacher} and a competition-guided \emph{Reasoner}. As the Teacher is iteratively strengthened via self-competition, the Reasoner is optimized against progressively stronger Teacher-generated references. We further introduce a case-wise reward design that preserves the original reward-induced positive/negative partition when it is informative, and restores supervision from competition scores when the original reward signal degenerates. Experiments on multiple CXR open-ended VQA benchmarks show that T2R consistently outperforms strong baselines, indicating that comparison-based supervision, when integrated in a controlled and principled manner, provides a more effective training signal for reasoning optimization.
Hallucinations and opaque reasoning remain unacceptable failure modes for clinical LLMs. We present a production-grade GraphRAG stack that constrains answers to verifiable graph chain-of-thought paths in a heterogeneous, ~700K-node medical knowledge graph powering a fertility assistant. The core idea is targeted navigation: a directed Pruned Landmark Labeling (PLL) oracle provides exact distances for sub-millisecond feasibility checks and simple-path enumeration, while a lightweight AStarNet heuristic operates strictly within the PLL corridor to prioritize clinically plausible expansions. We score and pack a small, diverse set of paths (CUI/semantic-type overlap, length prior, provenance priors) to condition generation, yielding compact prompts and improved Time to First Token (TTFT). On fertility-focused queries, the hybrid (PLL+AStarNet) establishes a better latency/recall Pareto frontier than text-only RAG and single-component baselines, lowers TTFT, and reduces clinician-audited hallucinations while preserving explanation clarity. The result is a practical recipe for explainable, low-hallucination multi-hop medical reasoning ready for real-world deployment.
Recent advances in Large Language Models (LLMs) and multi-agent systems have driven the rise of Agentic AI, showing promise for medical reasoning. However, open-ended conversational agents remain prone to two critical failure modes: premature diagnostic handoff and silent clinical hallucinations that may go undetected before reaching the patient. In this work, we propose a multi-agent framework that addresses both issues by replacing ``LLM-as-a-judge'' routing with deterministic orchestration constraints. The framework incorporates two safety mechanisms. First, a neuro-symbolic state-tracking gate enforces completeness of the OLDCARTS clinical protocol (Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, and Severity) by blocking diagnostic transitions until all required dimensions are collected. Second, an epistemic uncertainty quantification (UQ) gate computes semantic entropy (H) across K=5 independent diagnostic samples to identify and intercept divergent outputs before delivery. We evaluate the system using simulated patient agents powered by the llama-3.1-70b-instruct model on 150 test cases. The full architecture achieves 49.3% diagnostic precision, representing an absolute improvement of 11.3 percentage points over an unconstrained baseline. Additionally, we observe a statistically significant negative correlation (r = -0.181, p < 0.05) between OLDCARTS completeness (σ) and semantic entropy (H), suggesting that structured information gathering is associated with reduced diagnostic uncertainty.
Building trustworthy medical multimodal large language models (MLLMs) is critical for reliable clinical decision support. Existing medical hallucination benchmarks mainly focus on data collection, but often ignore where hallucinations originate within the reasoning process. We find that hallucination sources vary across samples: errors may arise from visual misrecognition, incorrect medical knowledge recall, or flawed reasoning integration. To enable source-level hallucination diagnosis, we introduce ClinHallu, a benchmark for stage-wise hallucination diagnosis in medical MLLM reasoning. ClinHallu contains 7,031 validated instances, where each instance is augmented with a structured reasoning trace decomposed into Visual Recognition, Knowledge Recall, and Reasoning Integration. We also use stage-replacement interventions to measure how correcting specific stages affects the final answer. Beyond evaluation, we show that trace-supervised fine-tuning reduces stage-wise hallucinations. ClinHallu provides a fine-grained hallucination testbed for diagnosing and mitigating reasoning failures in medical MLLMs. The benchmark is publicly available at https://github.com/alibaba-damo-academy/ClinHallu.
Negin Baghbanzadeh, Pritam Sarkar, Michael Colacci +6cs.CV cs.AI cs.CL cs.LG
High-stakes clinical use of large vision-language models (LVLMs) requires reasoning that is grounded in visual evidence and clinical knowledge, not just correct final answers. We introduce OpenMedReason, a large-scale, open multimodal medical reasoning corpus comprising approximately 450K image-question-answer instances whose reasoning traces are primarily derived from curated biomedical, human-authored scientific articles. OpenMedReason provides high-fidelity supervision beyond synthetic chains of thought, covering diverse medical domain vision modalities such as radiological scans, microscopic images, visible light photographs, charts, and others. We complement it with OpenMedReason-Bench, a held-out benchmark that allows fine-grained evaluation of LVLMs along three complementary axes of capability, including perception, medical knowledge, and rationale, enabling diagnostic evaluation beyond final-answer accuracy. OpenMedReason is a rich training resource that exhibits its effectiveness in both supervised fine-tuning (SFT) and reinforcement-based alignment. Training with OpenMedReason yields a 20% average improvement in VQA accuracy over the base model and achieves performance within 4.2% of the strongest comparable-scale medical LVLMs. Fine-grained performance analysis confirms that the gains are not concentrated in any single axis: OpenMedReason improves perception, medical knowledge, and rationale jointly, and its reasoning traces are preferred over those of the base model in 86.1% of pairwise comparisons. We release the code and dataset at huggingface.co/datasets/neginb/OpenMedReason.
Large language models (LLMs) have made remarkable progress in reasoning tasks, largely driven by post-training paradigms, especially reinforcement learning with verifiable rewards (RLVR). However, a critical bottleneck persists: RLVR fails on highly challenging zero-reward problems, where all sampled reasoning trajectories yield uniformly failed outcomes, providing no optimization signal to drive model improvement. Prior efforts to address this limitation, such as dense process supervision, partial reward assignment, or prefix-guided exploration, suffer from inherent task constraints or do not fully equip the policy model with the capabilities necessary to solve the original intractable problems. To address this, we propose TD-Grokking, a training-time decomposition framework for zero-reward problems. It recursively decomposes intractable root problems into self-contained, verifiable subproblems, forming hierarchical trees where solvable leaves provide non-zero rewards. Evaluations on mathematical and medical tasks show that TD-Grokking outperforms vanilla GRPO as well as all baseline approaches. Together with detailed analysis, these results confirm that training-time decomposition effectively converts zero-reward examples into usable training signals, enabling consistent performance gains. Our code and datasets are available at https://anonymous.4open.science/r/TD-Grokking-6567/.