MedLLM: An Open Medical Language Model at the Sub-Billion Scale

Practitioners deploying small open-weight large language models (LLMs) for medical question answering face a recurring design choice: invest in a domain-fine-tuned model, or keep a general-purpose model and inject domain knowledge at inference time via retrieval-augmented generation (RAG). We isolate this trade-off by holding model size, prompt template, decoding temperature, retrieval pipeline, and evaluation protocol fixed, and varying only (i) whether the model has been domain-adapted (Gemma 3 4B vs. MedGemma 4B, both 4-bit quantized and served via Ollama) and (ii) whether retrieved passages from a medical knowledge corpus are inserted into the prompt. We evaluate all four cells of this 2x2 design on the full MedQA-USMLE 4-option test split (1,273 questions) with three repetitions per question (15,276 LLM calls). Domain fine-tuning yields a +6.8 percentage-point gain in majority-vote accuracy over the general 4B baseline (53.3% vs. 46.4%, McNemar p < 10^-4). RAG over MedMCQA explanations does not produce a statistically significant gain in either model, and in the domain-tuned model the point estimate is slightly negative (-1.9 pp, p = 0.16). At this scale and on this benchmark, domain knowledge encoded in weights dominates domain knowledge supplied in context. We release the full experiment code and JSONL traces to support replication.

Large Language Models (LLMs) with reasoning capabilities have recently demonstrated strong potential in medical Question Answering (QA). Existing approaches are largely English-focused and primarily rely on distillation from general-purpose LLMs, raising concerns about the reliability of their medical knowledge. In this work, we present a method to generate multilingual reasoning traces based on medical knowledge extracted from Wikipedia. We produce 500k traces in English, Italian, and Spanish, using a retrieval-augmented generation approach over medical information from Wikipedia. The traces are generated to solve medical questions drawn from MedQA and MedMCQA, which we extend to Italian and Spanish. We test our pipeline in both in-domain and out-of-domain settings across Medical QA benchmarks, and demonstrate that our reasoning traces improve performance both when utilized via in-context learning (few-shot) and supervised fine-tuning, yielding state-of-the-art results among 8B-parameter LLMs. We believe that these resources can support the development of more transparent clinical decision-support tools in multilingual settings. We release the full suite of resources: reasoning traces, translated QA datasets, Medical-Wikipedia, and fine-tuned models.

Evaluating large language models (LLMs) for medical applications remains challenging due to benchmark saturation, limited data accessibility, and insufficient coverage of relevant tasks. Existing suites have either saturated, heavily depend on restricted datasets, or lack comprehensive model coverage. We introduce Medmarks, a fully open-source evaluation suite with 30 benchmarks spanning question answering, information extraction, medical calculations, and open-ended clinical reasoning. We perform a systematic evaluation of 61 models across 71 configurations using verifiable metrics and LLM-as-a-Judge. Our results show that frontier reasoning models (Gemini 3 Pro Preview, GPT-5.1, & GPT-5.2) achieve the highest performance across both benchmarks, most frontier proprietary models are significantly more token efficient than open-weight alternatives, medically fine-tuned models outperform their generalist counterparts, and that models are susceptible to answer-order bias (particularly smaller models and Grok 4). A subset of our evals (Medmarks-T) can be directly used as reinforcement learning environments to post-train LLMs for medical reasoning. Code is available at https://github.com/MedARC-AI/Medmarks