Medical RAG needs evidence-grounded claims, so plugging a claim-level NLI checker into retrieval-augmented RL is intuitive. \textbf{We find that the checker's \emph{output distribution} during training, not its held-out accuracy, decides whether it provides trainable gradient.} We compare four NLI checker back-ends as process rewards inside a GRPO-trained medical RAG agent (Qwen2.5-7B, replicated on Qwen3-4B and Llama-3.1-8B) across four held-out medical QA benchmarks. Three diagnostic findings emerge. \textbf{(i)} Signal collapse is log-prob-specific: LLM log-probability scoring labels over 97% of claims neutral -- collapsing the RL gradient to zero -- while a calibrated MedNLI classifier scores the same pairs non-degenerately. \textbf{(ii)} Moderate signal beats strong signal on answer quality: a strong proprietary checker triggers a three-step reward-hacking cascade -- ultra-short answers, search avoidance, language collapse -- so a moderate-signal local classifier trains a higher-quality model (\textbf{+12% BERTScore over zero-shot, no GPT dependency}). \textbf{(iii)} Signal strength is policy-dependent: the same checker registers as moderate on one policy but strong on another without triggering the cascade end-state. We frame these as boundary conditions for verifier-as-reward systems.
In medical multiple-choice question answering (MCQA), Retrieval-Augmented Generation (RAG) can supplement the domain knowledge of language models (LMs). However, since vanilla RAG indiscriminately utilizes retrieved documents, it can degrade LM performance. To address this, we propose MedJudgeRAG. Our framework represents retrieved documents as a dynamic knowledge graph (KG) composed of entities and relations. For each option, the model judges an evidence verdict from the retrieved documents and the KG. Based on the verdict combination, the model determines a knowledge utilization strategy to reason toward the final answer. These capabilities are trained via supervised fine-tuning using structured reasoning traces generated by a teacher LM. The training employs a weighted cross-entropy loss that differentially weights the KG and reasoning segments. Experiments on two medical MCQA benchmarks demonstrate that MedJudgeRAG consistently outperforms both vanilla RAG and parametric baselines. Furthermore, ablation analysis reveals that the dynamic KG is more effective as graph-conditioned supervision at training time than as an explicit output at inference time. Our code is available at https://github.com/hyu-amllab/medjudgerag, and the generated reasoning traces are released at https://huggingface.co/datasets/youarethewon/medjudgerag.
Medical question answering is a high-stakes setting where factual errors can have serious consequences. Retrieval-augmented generation (RAG) is widely viewed as a promising solution, and prior work has reported substantial gains for large medical QA models. We revisit this assumption across a broad range of open-weight instruction-tuned models spanning 7B to 72B parameters. Across five models, ten biomedical QA datasets, four retrieval methods, and four retrieval corpora, we find that retrieval yields only small and inconsistent improvements over a no-retrieval baseline, typically within 1-2 points. In contrast, the choice of backbone model has a much larger effect than the choice of retriever or corpus, and expert and layman retrieval sources perform similarly in most settings. These results suggest that the main bottleneck is not retrieval quality alone, but the model's limited ability to use retrieved evidence effectively.
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.