Clinical Reasoning

Large language models (LLMs) excel on multiple-choice clinical diagnosis benchmarks, yet it is unclear how much of this performance reflects underlying probabilistic reasoning. We study this through questions from MedQA that ask for the most likely diagnosis. We introduce Frequency-Based Probabilistic Ranker (FBPR), a lightweight method that scores options with a smoothed Naive Bayes over concept-diagnosis co-occurrence statistics from a large corpus. When co-occurrence statistics are sourced from Dolma, the pretraining corpus for OLMo, and RedPajama, an open reproduction of the LLaMA pretraining-data recipe, FBPR achieves comparable performance to the corresponding LLMs. Furthermore, direct LLM inference and FBPR exhibit complementary strengths, correctly answering largely different subsets of questions with overlap barely above chance. Combining them with a simple hybrid method yields a notable gain over either method alone. These findings show that explicit probabilistic baselines can account for a substantial portion of the benchmark performance on diagnosis questions, while serving as historically grounded reference points and complementary signals for hybridization.

There is growing interest in using machine learning (ML) to support clinical diagnosis, but most approaches rely on static, fully observed datasets and fail to reflect the sequential, resource-aware reasoning clinicians use in practice. Diagnosis remains complex and error prone, especially in high-pressure or resource-limited settings, underscoring the need for frameworks that help clinicians make timely and cost-effective decisions. We propose ACTMED (Adaptive Clinical Test selection via Model-based Experimental Design), a diagnostic framework that integrates Bayesian Experimental Design (BED) with large language models (LLMs) to better emulate real-world diagnostic reasoning. At each step, ACTMED selects the test expected to yield the greatest reduction in diagnostic uncertainty for a given patient. LLMs act as flexible simulators, generating plausible patient state distributions and supporting belief updates without requiring structured, task-specific training data. Clinicians can remain in the loop; reviewing test suggestions, interpreting intermediate outputs, and applying clinical judgment throughout. We evaluate ACTMED on real-world datasets and show it can optimize test selection to improve diagnostic accuracy, interpretability, and resource use. This represents a step toward transparent, adaptive, and clinician-aligned diagnostic systems that generalize across settings with reduced reliance on domain-specific data.

Medical question answering requires advanced reasoning that integrates domain knowledge with logical inference. However, existing large language models (LLMs) often generate reasoning chains that lack factual accuracy and clinical reliability. We propose Ranked Preference Reinforcement Optimization (RPRO), a novel framework that combines reinforcement learning with preference-driven reasoning refinement to enhance clinical chain-of-thought (CoT) performance. RPRO distinguishes itself from prior approaches by employing task-adaptive reasoning templates and a probabilistic evaluation mechanism that aligns model outputs with established clinical workflows, while automatically identifying and correcting low-quality reasoning chains. Unlike traditional pairwise preference methods, RPRO introduces a groupwise ranking optimization based on the Bradley--Terry model and incorporates KL-divergence regularization for stable training. Experiments on PubMedQA, MedQA-USMLE, and a real-world clinical dataset from Far Eastern Memorial Hospital (FEMH) demonstrate consistent improvements over strong baselines. Remarkably, our 2B-parameter model outperforms much larger 7B--20B models, including medical-specialized variants. These findings demonstrate that combining preference optimization with quality-driven refinement provides a scalable and clinically grounded approach to building more reliable medical LLMs.

Endoscopic diagnosis is an iterative process in which clinicians acquire, compare, and verify local visual evidence before reaching a conclusion. Current AI systems do not adequately support this process because fine-grained evidence acquisition and multi-step reasoning remain weakly coupled, complicating reconciliation of image-derived findings with their textual interpretations. This gives rise to two failure modes, hallucinated evidence and uncorrected error accumulation, that undermine diagnostic reliability. We propose EndoCogniAgent, a closed-loop agentic framework that formulates endoscopic diagnosis as a controlled state update process for integrating complementary visual and textual evidence. At each reasoning round, a central planner selects an evidence acquisition action, specialized expert tools extract spatial and semantic observations as structured textual evidence, and a self-consistency validation mechanism examines this evidence along two dimensions, knowledge consistency against the input image and temporal consistency with prior validated findings, before updating the diagnostic state. Validated observations are admitted into the evolving state to condition subsequent planning, while insufficiently supported or conflicting findings are retained with corrective feedback that redirects the planner toward additional verification. We further introduce EndoAgentBench, a workflow-oriented benchmark comprising 6,132 question-answer pairs from 11 endoscopic datasets, to evaluate diagnostic agents across a comprehensive diagnostic chain, from fine-grained visual perception to high-level diagnostic reasoning. EndoCogniAgent achieves 85.23% overall accuracy on perception tasks and 71.13% clinical acceptance rate on reasoning tasks. Blinded clinician evaluation further shows consistent improvements in diagnostic response quality over the evaluated baselines.