How Robust Are Large Language Models for Clinical Numeracy? An Empirical Study on Numerical Reasoning Abilities in Clinical Contexts

Large language models (LLMs) achieve strong results on mathematical reasoning benchmarks yet remain unreliable on elementary numerical tasks, including magnitude comparison, large-integer arithmetic, fractions, and scientific notation. This survey examines basic numerical understanding as a capability distinct from high-level mathematical reasoning. We propose the Numerical Grounding Framework (NGF), which decomposes numeracy into Representational Grounding (RG), mapping numeral forms to value, magnitude, and equivalent representations, and Procedural Grounding (PG), executing arithmetic operations in accordance with their mathematical definitions. Using NGF, we organize recent diagnostic benchmarks, failure modes, structural explanations, and mitigation strategies. We review evidence concerning tokenization, positional encoding, embedding geometry, and pretraining-data distribution. We also apply NGF in a coordinated evaluation of three frontier model families across Number Cookbook, NumericBench, and GSM-Symbolic, comparing atomic, contextual, and reasoning-assisted numeracy. Architectural interventions such as digit-aware tokenization and Abacus Embeddings can improve models trained from scratch but are generally unavailable to users of pretrained systems, for whom supervised fine-tuning, reasoning scaffolds, and external tools are more practical. We conclude with deployment recommendations and research directions for more reliable numerical behavior in foundation models.

Large language models (LLMs) have achieved strong performance on medical exam-style tasks, motivating growing interest in their deployment in real-world clinical settings. However, clinical decision-making is inherently safety-critical, context-dependent, and conducted under evolving evidence. In such situations, reliable LLM performance depends not on factual recall alone, but on robust medical reasoning. In this work, we present a comprehensive review of medical reasoning with LLMs. Grounded in cognitive theories of clinical reasoning, we conceptualize medical reasoning as an iterative process of abduction, deduction, and induction, and organize existing methods into seven major technical routes spanning training-based and training-free approaches. We further conduct a unified cross-benchmark evaluation of representative medical reasoning models under a consistent experimental setting, enabling a more systematic and comparable assessment of the empirical impact of existing methods. To better assess clinically grounded reasoning, we introduce MR-Bench, a benchmark derived from real-world hospital data. Evaluations on MR-Bench expose a pronounced gap between exam-level performance and accuracy on authentic clinical decision tasks. Overall, this survey provides a unified view of existing medical reasoning methods, benchmarks, and evaluation practices, and highlights key gaps between current model performance and the requirements of real-world clinical reasoning.

Exam-style accuracy does not establish whether large language models (LLMs) reason well over clinical records. We define clinical reasoning as integrating and updating evidence across time and sources to form, revise and justify a patient's problem representation and a defensible plan. This structured narrative review maps three literatures: medical education assessment instruments, clinical LLM benchmarks published from 2023 onwards, and general-domain methods for evaluating long-form generation. We examine six dimensions: problem representation, temporal synthesis, differential and management reasoning, counterfactual reasoning, calibrated uncertainty, and reasoning faithfulness. Preprints are included and flagged. No single instrument covers all six dimensions. Problem representation and differential or management reasoning are reasonably covered, although reliability varies by instrument and setting. TIMER-Eval targets temporal synthesis, and ER-Reason assesses sequential diagnostic belief updating. Dedicated uncertainty and counterfactual evaluations are emerging, but their applicability to longitudinal free-text reasoning remains limited. Factual completeness is well theorised in general-domain evaluation, with early clinical evidence of important omissions. Faithfulness remains the weakest dimension, with one identified clinical causal-ablation study on multiple-choice questions. Existing tools should be combined through binary rubric items, separate completeness and correctness scores, case-specific importance weighting with non-compensable safety caps, temporal order-consistency checks, and chance-corrected reliability reporting. Further design work is needed for calibrated uncertainty, counterfactual reasoning and faithfulness over longitudinal free-text records. This review provides a design rationale, not a validated instrument.