Organizations: National Engineering Research Center of Software Engineering, Peking University, China · School of Computing and Data Science, The University of Hong Kong · School of Computer Science, Peking University, Beijing, China · Key Laboratory of High Confidence Software Technologies, Ministry of Education · Peking University Information Technology Institute, Tianjin Binhai, China
Interactive medical questioning is essential in clinical consultations, where physicians must actively gather necessary patient information. Yet existing medical Large Language Models (LLMs) predominantly follow a reactive paradigm, risking diagnostic errors by answering before seeking sufficient details. To bridge this gap, we propose ProMed, a reinforcement learning framework that transitions LLMs toward a proactive paradigm, enabling them to ask clinically valuable questions before decision-making. Central to ProMed is the Shapley Information Gain (SIG) reward, which quantifies a question's clinical utility as the amount of newly acquired information, while considering its contextual importance via Shapley values. We integrate SIG into a two-stage training pipeline: (1) SIG-Guided Model Initialization uses Monte Carlo Tree Search to construct high-reward interaction trajectories for supervision, and (2) SIG-Augmented Policy Optimization, with a novel SIG-guided Reward Distribution Mechanism that prioritizes informative questions for fine-grained optimization. Experiments on partial-information medical benchmarks show that ProMed significantly outperforms state-of-the-art methods by 6.29% on average and delivers a 54.45% gain over the reactive paradigm, and generalizes robustly to out-of-domain cases. Our codes are available at https://github.com/hxxding/ProMed.
Deploying Large Language Models (LLMs) in healthcare requires robust performance across two complementary dimensions - diagnostic reasoning: the convergent, evidence-driven task of inferring a patient's condition from clinical data to produce a diagnosis, and clinical healthcare reasoning: the broader, navigational judgment required to communicate, plan, and adapt across multi-turn clinical interactions where a single correct answer may not exist. Recent benchmarks such as HealthBench and MedXpertQA reveal persistent weaknesses in both areas, exposing failures in complex diagnostic scenarios and limitations in contextual, patient-centered dialogue. We introduce a sequential training framework that targets these facets using synthetic data and rubric-based reinforcement learning. First, we improve diagnostic reasoning using MedBullets-derived questions with rule- and rubric-guided Reinforcement Learning (RL). We then shift to clinical reasoning by generating 5.3k synthetic multi-turn scenarios, each paired with multi-dimensional rubrics to comprehensively assess the response. This approach yields over 10% improvement on MedXpertQA, and our 30B model achieves 50.1% accuracy on HealthBench-Hard, surpassing proprietary baselines including GPT-5 (thinking). Our results show that targeted synthetic datasets and rubric-based training can systematically improve both diagnostic and interactive clinical reasoning in medical LLMs.
Recent reasoning-centric Large Language Models (LLMs) have made significant strides, yet they predominantly operate on a passive-inference pattern that assumes complete information. In contrast, real-world clinical intelligence is inherently an iterative investigative process requiring strategic evidence acquisition. To bridge this gap, we formalize medical diagnosis as an Iterative Evidence-Seeking Task. We leverage Reinforcement Learning with Verifiable Rewards (RLVR) to elicit intrinsic reasoning within a closed-loop environment, guided by a novel suite of rewards that enforce diagnostic precision and examination consistency. To facilitate this, we introduce the Retrieval-Augmented Generation-based Examination Simulator (RAGES), a high-fidelity clinical oracle that provides realistic, knowledge-grounded follow-up evidence. Empirical results across diverse datasets demonstrate that our framework enables LLMs to transition from passive responders to autonomous assistants. Notably, our model demonstrates comparable performance to larger and reasoning-enhanced baselines, while RAGES proves superior to vanilla LLMs in generating biologically plausible clinical feedback.
Test-time reinforcement learning adapts a model on its own unlabeled test set using majority-vote pseudo-labels and has shown strong results in mathematics. We show that this recipe collapses on medical multiple-choice QA: accuracy stagnates while output diversity rapidly declines. Through a controlled experiment that keeps the questions, model, and optimizer fixed while changing only the answer space, we trace this failure to answer-space structure rather than domain difficulty. In small answer spaces, incorrect rollouts often collide on the same wrong pseudo-label and reinforce it; in large answer spaces, they disperse and receive little reward. This diagnosis motivates PROSE, Process Reward Guided Self-Training, which rewards reasoning quality instead of answer agreement. PROSE scores each reasoning step with a medical process reward model, assigns the trajectory reward as the minimum score across steps, and enforces answer-format constraints. Without labels, PROSE substantially improves a general Llama model, surpassing purpose-built medical models and matching much larger systems. Because the process signal is internalized into the policy, the adapted model requires no reward model at inference and transfers its gains to unseen datasets. We further show that the minimum aggregation is essential: mean aggregation can be exploited, saturating the proxy reward while degrading accuracy.