Improving Heart-Focused Medical Question Answering in LLMs via Variance-Aware Rubric Rewards with GRPO

Reinforcement learning with verifiable rewards has been especially effective in mathematics and coding, where answers can be checked automatically. Many open-ended medical questions lack comparably cheap outcome verifiers: responses may be partly correct, incomplete, or contain clinically consequential errors. Rubrics written or validated by physicians offer strong clinical grounding, but involving experts in every instance is costly. Model-generated rubrics make this supervision scalable. We introduce ConRub-Med to preserve useful distinctions as rubric feedback moves from construction to policy optimization. For each prompt, three heterogeneous language models propose atomic criteria independently; a separate model reviews them, retaining only criteria with semantic support from all three generators. Three-State scoring distinguishes correct coverage, missing information, and incorrect claims. Errors receive negative rather than zero credit. When every response in a complete Group Relative Policy Optimization (GRPO) group receives the same final reward, a pairwise judge provides sequence advantages only if both candidate orders agree, without changing the scalar rewards. Groups without ties use vanilla GRPO. In a blinded study matched by question, two medical experts rate panels from the full pipeline as more clinically relevant than panels produced by one generator. Across the evaluated open models, ConRub-Med ranks first on six of nine benchmarks and achieves the highest medical and generalization averages. Using the resulting rubric dataset of 5,166 prompts, it scores $38.98 \pm 1.04$ (mean $\pm$ SD) on HealthBench-Hard, compared with InfiMed-ORBIT's 33.60 with 8,000 samples and 37.30 with 28,000.

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.

Reinforcement learning against rubrics, lists of criteria graded by an LLM judge, has become a standard way to post-train language models on tasks with no deterministic answer. The rubric, however, is a fixed proxy for quality, never a complete description of it, and a policy trained against it long enough will learn to exploit the difference. We measure this directly. Training Qwen3-8B with Group Relative Policy Optimization (GRPO) on medical and science rubrics and grading out-of-distribution (OOD) benchmarks with both the training judge and a stronger gold judge, we find that the two scores diverge during training. The training judge's score keeps climbing while the gold judge's score peaks and then falls, by 3 points on HealthBench-Hard and by 22 points on ResearchQA. A judge with a fixed bias would shift the gold curve by a constant, not send it down while the training score rises, so the divergence is reward hacking, not judge noise. We propose Rubric Dropout, a one-line fix borrowed from neuron dropout. At every step, we randomly drop a subset of the rubric's criteria before computing the reward, so the policy never optimizes the same rubric twice. The dropped subset is shared across each rollout group, so GRPO's group-relative advantages stay comparable, and evaluation always uses the full rubric. Comparing no dropout against dropout at 30% and 50% on both benchmark pairs, dropout raises the OOD gold score at every matched checkpoint (+1 to +2 points on HealthBench-Hard, +6 to +7 points on ResearchQA), lowers the two hacking measures we track, and costs nothing in domain. Sweeping the dropout fraction shows a broad 30-50% sweet spot, while the natural alternative, reweighting criteria by how useful they are to training, performs worse than no intervention at all in our setting.