Daily Papers

Intraoperative anesthesia requires systems to interpret evolving multimodal evidence, recommend timely management, and revise decisions as patient states change, yet existing benchmarks usually isolate perception or single-point reasoning. We introduce AnesTRACE, an evaluation suite comprising AnesTRACE-Bench and AnesTRACE-Eval. Built from public perioperative datasets with anesthesiologist annotation, AnesTRACE-Bench evaluates Intraoperative Perception, Single-point Anesthesia Decision-Making, and Multi-step Anesthesia Decision-Making. AnesTRACE-Eval assesses open-ended responses through anesthesiologist-defined criteria for Clinical Correctness, Evidence Grounding, Task Completeness, and Safety, with Temporal Consistency for multi-step decisions; its domain-specific evaluator is trained by supervised fine-tuning and preference alignment on expert-reviewed judgments. Across more than 30 models, fine-grained visual grounding and intervention selection remain difficult: the leading model reaches only 32.2 mIoU for TEE visual grounding and retains a 17.5\% Major/Critical Safety Error Rate in multi-step management. Evaluator alignment with anesthesiologists improves across both training stages, while the best decision quality is accompanied by a 74.3-second P95 Latency. These results show that aggregate performance alone does not establish safe, timely longitudinal decision-making. We release our code at https://zjudbxai.github.io/AnesTRACE/.

End-to-end automation of realistic healthcare operations stresses three capabilities underrepresented in current benchmarks: policy density, decisions must be grounded in a large library of medical, insurance, and operational rules; Multi-role composition: a single task requires the agent to play multiple roles with handoffs; and multilateral interaction: intermediate workflow steps are multi-turn dialogs, such as peer-to-peer review and patient outreach. We introduce χ-Bench, a benchmark of long-horizon healthcare workflows across three domains: provider prior authorization, payer utilization management, and care management. Each task hands the agent a clinical case in a high-fidelity simulator of 20 healthcare apps exposed via 87 MCP tools, which it must drive to a terminal status through tool calls and writing the role's artifacts, guided by a 1,290+ document managed-care operations handbook skill. Across 30 agent harness/models configurations, the best agent resolves only 28.0% of tasks, no agent clears 20% on strict pass^3, and executing all tasks in a single session slumps the performance to 3.8%. These results raise the hypothesis that similar gaps are likely to surface in other policy-dense, role-composed, irreversible enterprise domains.

The application of large language models (LLMs) in the medical field has gained significant attention, yet their reasoning capabilities in more specialized domains like anesthesiology remain underexplored. In this paper, we systematically evaluate the reasoning capabilities of LLMs in anesthesiology and analyze key factors influencing their performance. To this end, we introduce AnesBench, a cross-lingual benchmark designed to assess anesthesiology-related reasoning across three levels: factual retrieval (System 1), hybrid reasoning (System 1.x), and complex decision-making (System 2). Through extensive experiments, we first explore how model characteristics, including model scale, Chain of Thought (CoT) length, and language transferability, affect reasoning performance. Then, we further evaluate the effectiveness of different training strategies, leveraging our curated anesthesiology-related dataset, including continuous pre-training (CPT) and supervised fine-tuning (SFT). Additionally, we also investigate how the test-time reasoning techniques, such as Best-of-N sampling and beam search, influence reasoning performance, and assess the impact of reasoning-enhanced model distillation, specifically DeepSeek-R1. We will publicly release AnesBench, along with our CPT and SFT training datasets and evaluation code at https://github.com/MiliLab/AnesBench.

Acute poly-substance intoxication requires rapid, life-saving decisions under substantial uncertainty, as clinicians must rely on incomplete ingestion details and nonspecific symptoms. Effective diagnostic reasoning in this chaotic environment requires fusing unstructured, non-medical narratives (e.g. paramedic scene descriptions and unreliable patient self-reports or known histories), with structured medical data like vital signs. While Large Language Models (LLMs) show potential for processing such heterogeneous inputs, they struggle in this setting, often underperforming simple baselines that rely solely on patient histories. To address this, we present DeToxR (Decision-support for Toxicology with Reasoning), the first adaptation of Reinforcement Learning (RL) to emergency toxicology. We design a robust data-fusion engine for multi-label prediction across 14 substance classes based on an LLM finetuned with Group Relative Policy Optimization (GRPO). We optimize the model's reasoning directly using a clinical performance reward. By formulating a multi-label agreement metric as the reward signal, the model is explicitly penalized for missing co-ingested substances and hallucinating absent poisons. Our model significantly outperforms its unadapted base LLM counterpart and supervised baselines. Furthermore, in a clinical validation study, the model indicates a clinical advantage by outperforming an expert toxicologist in identifying the correct poisons (Micro-F1: 0.644 vs. 0.473). These results demonstrate the potential of RL-aligned LLMs to synthesize unstructured pre-clinical narratives and structured medical data for decision support in high-stakes environments.

Effective evaluation is critical for driving advancements in MLLM research. The surgical action planning (SAP) task, which aims to generate future action sequences from visual inputs, demands precise and sophisticated analytical capabilities. Unlike mathematical reasoning, surgical decision-making operates in life-critical domains and requires meticulous, verifiable processes to ensure reliability and patient safety. This task demands the ability to distinguish between atomic visual actions and coordinate complex, long-horizon procedures, capabilities that are inadequately evaluated by current benchmarks. To address this gap, we introduce SAP-Bench, a large-scale, high-quality dataset designed to enable multimodal large language models (MLLMs) to perform interpretable surgical action planning. Our SAP-Bench benchmark, derived from the cholecystectomy procedures context with the mean duration of 1137.5s, and introduces temporally-grounded surgical action annotations, comprising the 1,226 clinically validated action clips (mean duration: 68.7s) capturing five fundamental surgical actions across 74 procedures. The dataset provides 1,152 strategically sampled current frames, each paired with the corresponding next action as multimodal analysis anchors. We propose the MLLM-SAP framework that leverages MLLMs to generate next action recommendations from the current surgical scene and natural language instructions, enhanced with injected surgical domain knowledge. To assess our dataset's effectiveness and the broader capabilities of current models, we evaluate seven state-of-the-art MLLMs (e.g., OpenAI-o1, GPT-4o, QwenVL2.5-72B, Claude-3.5-Sonnet, GeminiPro2.5, Step-1o, and GLM-4v) and reveal critical gaps in next action prediction performance.

Clinical decision-making is inherently complex, often influenced by cognitive biases, incomplete information, and case ambiguity. Large Language Models (LLMs) have shown promise as tools for supporting clinical decision-making, yet their typical one-shot or limited-interaction usage may overlook the complexities of real-world medical practice. In this work, we propose a hybrid human-AI framework, MedSyn, where physicians and LLMs engage in multi-step, interactive dialogues to refine diagnoses and treatment decisions. Unlike static decision-support tools, MedSyn enables dynamic exchanges, allowing physicians to challenge LLM suggestions while the LLM highlights alternative perspectives. Through simulated physician-LLM interactions, we assess the potential of open-source LLMs as physician assistants. Results show open-source LLMs are promising as physician assistants in the real world. Future work will involve real physician interactions to further validate MedSyn's usefulness in diagnostic accuracy and patient outcomes.

In medical education, physicians convert academic knowledge into clinical expertise through residency: years of training across thousands of encounters, with diverse sources of feedback and progressively greater autonomy. Much of clinical reasoning relies on the patient encounter, a dialogue in which a clinician elicits history, refines diagnostic hypotheses, and decides management under uncertainty. While large language models (LLMs) excel on static medical benchmarks, methods to optimize the full sequence of clinical decisions remain underdeveloped. We present ResidencyRL, a reinforcement learning (RL) method for training clinical artificial intelligence (AI) agents through simulated multi-turn clinical encounters (up to 60 dialogue turns and 8 tool calls per trajectory). ResidencyRL pairs the policy agent with LLM simulators capable of complex, adversarial behaviors, training against a structured reward aligned to diagnostic accuracy, management quality, communication, documentation, and safety. On held-out evaluations, the ResidencyRL agent improves diagnostic accuracy by 7.0% under adversarial conditions (88.0% vs. 81.0%) and reduces missed red flag rates by 31%, demonstrating rigorous mitigation of premature closure. Blinded expert clinicians validated these gains, preferring the trained agent in 87.6% of side-by-side comparisons. The procedural competencies transfer to unseen benchmarks: the agent outperforms the base model across all six clinical axes of the AMIE multi-visit benchmark, and shows consistent directional improvements on AgentClinic and CRAFT-MD. Our findings demonstrate that sequential clinical decision-making can be effectively learned through multi-turn RL in simulation, yielding robust, generalizable capabilities, paving the way towards clinical mastery. Prospective validation with real-world workflows remains necessary to establish clinical utility.

Ethical decision-making is a critical aspect of human judgment, and the growing use of LLMs in decision-support systems necessitates a rigorous evaluation of their moral reasoning capabilities. However, existing assessments primarily rely on single-step evaluations, failing to capture how models adapt to evolving ethical challenges. Addressing this gap, we introduce the Multi-step Moral Dilemmas (MMDs), the first dataset specifically constructed to evaluate the evolving moral judgments of LLMs across 3,302 five-stage dilemmas. This framework enables a fine-grained, dynamic analysis of how LLMs adjust their moral reasoning across escalating dilemmas. Our evaluation of nine widely used LLMs reveals that their value preferences shift significantly as dilemmas progress, indicating that models recalibrate moral judgments based on scenario complexity. Furthermore, pairwise value comparisons demonstrate that while LLMs often prioritize the value of care, this value can sometimes be superseded by fairness in certain contexts, highlighting the dynamic and context-dependent nature of LLM ethical reasoning. Our findings call for a shift toward dynamic, context-aware evaluation paradigms, paving the way for more human-aligned and value-sensitive development of LLMs.

Clinical reasoning demands multi-step interactions -- gathering patient history, ordering tests, interpreting results, and making safe treatment decisions -- yet a unified training environment provides the breadth of clinical domains and specialized tools to train generalizable medical AI agents through reinforcement learning remains elusive. We present a comprehensive empirical study of multi-turn agentic RL for medical AI, built on , a gymnasium-compatible environment spanning 10 clinical domains with 3.6K+ tasks, 135 domain-specific tools, and a knowledge base of 828K medical passages. Our analysis reveals that agentic multi-turn structure degrades into verbose single-turn monologues, characterized by monotonic length explosion and a simultaneous erosion of tool-use frequency. We characterize how this collapse, alongside distillation instability, stems from the misalignment of sparse terminal rewards with sequential clinical trajectories. We find that vanilla GRPO achieves strong final accuracy on some benchmarks but suffers from training instability, evidenced by significant oscillations in response length and prolonged convergence periods. To improve training efficiency and stability, we propose Turn-level Truncated On-Policy Distillation (TT-OPD), a self-distillation framework where a gradient-free EMA teacher leverages outcome-privileged information to provide dense, outcome-aware KL regularization at every conversation turn. TT-OPD achieves the best performance on 10 of 18 benchmarks with an average +3.9~pp improvement over the non-RL baseline with faster early convergence, controlled response length, and sustained multi-turn tool use.

Research on autonomous surgery has largely focused on simple task automation in controlled environments. However, real-world surgical applications demand dexterous manipulation over extended durations and generalization to the inherent variability of human tissue. These challenges remain difficult to address using existing logic-based or conventional end-to-end learning approaches. To address this gap, we propose a hierarchical framework for performing dexterous, long-horizon surgical steps. Our approach utilizes a high-level policy for task planning and a low-level policy for generating robot trajectories. The high-level planner plans in language space, generating task-level or corrective instructions that guide the robot through the long-horizon steps and correct for the low-level policy's errors. We validate our framework through ex vivo experiments on cholecystectomy, a commonly-practiced minimally invasive procedure, and conduct ablation studies to evaluate key components of the system. Our method achieves a 100\% success rate across eight unseen ex vivo gallbladders, operating fully autonomously without human intervention. This work demonstrates step-level autonomy in a surgical procedure, marking a milestone toward clinical deployment of autonomous surgical systems.

Medical image segmentation is evolving from task-specific models toward generalizable frameworks. Recent research leverages Multi-modal Large Language Models (MLLMs) as autonomous agents, employing reinforcement learning with verifiable reward (RLVR) to orchestrate specialized tools like the Segment Anything Model (SAM). However, these approaches often rely on single-turn, rigid interaction strategies and lack process-level supervision during training, which hinders their ability to fully exploit the dynamic potential of interactive tools and leads to redundant actions. To bridge this gap, we propose MedSAM-Agent, a framework that reformulates interactive segmentation as a multi-step autonomous decision-making process. First, we introduce a hybrid prompting strategy for expert-curated trajectory generation, enabling the model to internalize human-like decision heuristics and adaptive refinement strategies. Furthermore, we develop a two-stage training pipeline that integrates multi-turn, end-to-end outcome verification with a clinical-fidelity process reward design to promote interaction parsimony and decision efficiency. Extensive experiments across 6 medical modalities and 21 datasets demonstrate that MedSAM-Agent achieves state-of-the-art performance, effectively unifying autonomous medical reasoning with robust, iterative optimization. Code is available https://github.com/CUHK-AIM-Group/MedSAM-Agent{here}.

Quantification of real-time informal feedback delivered by an experienced surgeon to a trainee during surgery is important for skill improvements in surgical training. Such feedback in the live operating room is inherently multimodal, consisting of verbal conversations (e.g., questions and answers) as well as non-verbal elements (e.g., through visual cues like pointing to anatomic elements). In this work, we leverage a clinically-validated five-category classification of surgical feedback: "Anatomic", "Technical", "Procedural", "Praise" and "Visual Aid". We then develop a multi-label machine learning model to classify these five categories of surgical feedback from inputs of text, audio, and video modalities. The ultimate goal of our work is to help automate the annotation of real-time contextual surgical feedback at scale. Our automated classification of surgical feedback achieves AUCs ranging from 71.5 to 77.6 with the fusion improving performance by 3.1%. We also show that high-quality manual transcriptions of feedback audio from experts improve AUCs to between 76.5 and 96.2, which demonstrates a clear path toward future improvements. Empirically, we find that the Staged training strategy, with first pre-training each modality separately and then training them jointly, is more effective than training different modalities altogether. We also present intuitive findings on the importance of modalities for different feedback categories. This work offers an important first look at the feasibility of automated classification of real-world live surgical feedback based on text, audio, and video modalities.

Sequential decision-making problems with multiple objectives arise naturally in practice and pose unique challenges for research in decision-theoretic planning and learning, which has largely focused on single-objective settings. This article surveys algorithms designed for sequential decision-making problems with multiple objectives. Though there is a growing body of literature on this subject, little of it makes explicit under what circumstances special methods are needed to solve multi-objective problems. Therefore, we identify three distinct scenarios in which converting such a problem to a single-objective one is impossible, infeasible, or undesirable. Furthermore, we propose a taxonomy that classifies multi-objective methods according to the applicable scenario, the nature of the scalarization function (which projects multi-objective values to scalar ones), and the type of policies considered. We show how these factors determine the nature of an optimal solution, which can be a single policy, a convex hull, or a Pareto front. Using this taxonomy, we survey the literature on multi-objective methods for planning and learning. Finally, we discuss key applications of such methods and outline opportunities for future work.

Decisions about managing patients on the heart transplant waitlist are currently made by committees of doctors who consider multiple factors, but the process remains largely ad-hoc. With the growing volume of longitudinal patient, donor, and organ data collected by the United Network for Organ Sharing (UNOS) since 2018, there is increasing interest in analytical approaches to support clinical decision-making at the time of organ availability. In this study, we benchmark machine learning models that leverage longitudinal waitlist history data for time-dependent, time-to-event modeling of waitlist mortality. We train on 23,807 patient records with 77 variables and evaluate both survival prediction and discrimination at a 1-year horizon. Our best model achieves a C-Index of 0.94 and AUROC of 0.89, significantly outperforming previous models. Key predictors align with known risk factors while also revealing novel associations. Our findings can support urgency assessment and policy refinement in heart transplant decision making.

As artificial intelligence (AI) systems play an increasingly prominent role in human decision-making, challenges surface in the realm of human-AI interactions. One challenge arises from the suboptimal AI policies due to the inadequate consideration of humans disregarding AI recommendations, as well as the need for AI to provide advice selectively when it is most pertinent. This paper presents a sequential decision-making model that (i) takes into account the human's adherence level (the probability that the human follows/rejects machine advice) and (ii) incorporates a defer option so that the machine can temporarily refrain from making advice. We provide learning algorithms that learn the optimal advice policy and make advice only at critical time stamps. Compared to problem-agnostic reinforcement learning algorithms, our specialized learning algorithms not only enjoy better theoretical convergence properties but also show strong empirical performance.

Providing effective treatment and making informed clinical decisions are essential goals of modern medicine and clinical care. We are interested in simulating disease dynamics for clinical decision-making, leveraging recent advances in large generative models. To this end, we introduce the Medical World Model (MeWM), the first world model in medicine that visually predicts future disease states based on clinical decisions. MeWM comprises (i) vision-language models to serve as policy models, and (ii) tumor generative models as dynamics models. The policy model generates action plans, such as clinical treatments, while the dynamics model simulates tumor progression or regression under given treatment conditions. Building on this, we propose the inverse dynamics model that applies survival analysis to the simulated post-treatment tumor, enabling the evaluation of treatment efficacy and the selection of the optimal clinical action plan. As a result, the proposed MeWM simulates disease dynamics by synthesizing post-treatment tumors, with state-of-the-art specificity in Turing tests evaluated by radiologists. Simultaneously, its inverse dynamics model outperforms medical-specialized GPTs in optimizing individualized treatment protocols across all metrics. Notably, MeWM improves clinical decision-making for interventional physicians, boosting F1-score in selecting the optimal TACE protocol by 13%, paving the way for future integration of medical world models as the second readers.

Much of the success of multi-agent debates depends on carefully choosing the right parameters. The decision-making protocol stands out as it can highly impact final model answers, depending on how decisions are reached. Systematic comparison of decision protocols is difficult because many studies alter multiple discussion parameters beyond the protocol. So far, it has been largely unknown how decision-making influences different tasks. This work systematically evaluates the impact of seven decision protocols (e.g., majority voting, unanimity consensus). We change only one variable at a time - the decision protocol - to analyze how different methods affect the collaboration between agents and measure differences in knowledge and reasoning tasks. Our results show that voting protocols improve performance by 13.2% in reasoning tasks and consensus protocols by 2.8% in knowledge tasks compared to other decision protocols. Increasing the number of agents improves performance, while more discussion rounds before voting reduce it. To improve decision-making by increasing answer diversity, we propose two new methods, All-Agents Drafting (AAD) and Collective Improvement (CI). Our methods improve task performance by up to 3.3% with AAD and up to 7.4% with CI. This work demonstrates the importance of decision-making in multi-agent debates beyond scaling.

Interactive agents repeatedly choose among a finite set of actions, labels, or ordinal outcomes. Generating a free-form response for each choice adds latency and complicates the interface between a model and its environment. We present Intern-Decision, a family of 0.8B, 2B, and 4B multimodal decision models that return structured choices and candidate probabilities from text and optional images. Our autoregressive masked language modeling objective places one decision placeholder per field in a complete assistant JSON skeleton. Ground-truth symbols appear only in supervision, while all fields are evaluated in a single causal forward pass using the backbone's native language-model head. The 4B model achieves a 90.02% unweighted average accuracy across seven evaluation suites, compared with 88.74% for Jev v1.13.0. For a fixed 289-token request with three fields on one RTX 4090, mean latency is 44.16 ms for the 4B model and approximately 33--34 ms for the smaller models. On a separate 96-case known-distribution pilot, temperature scaling reduces expected multiclass Brier from 0.628 to 0.550 and expected calibration error from 0.213 to 0.089. A confidence-based handoff study on 111 public Jevbench-Hard items improves accuracy from 82/111 (73.87%) to 97/111 (87.39%) by routing 42 items to Atria-Dawn-Preview. We also describe qualitative game, visual interface, and browser demonstrations. These results support compact decision models as a practical component of larger agent systems.

Chain-of-thought (CoT) reasoning has advanced medical visual question answering (VQA), yet most existing CoT rationales are free-form and fail to capture the structured reasoning process clinicians actually follow. This work asks: Can traceable, multi-step reasoning supervision improve reasoning accuracy and the interpretability of Medical VQA? To this end, we introduce Step-CoT, a large-scale medical reasoning dataset with expert-curated, structured multi-step CoT aligned to clinical diagnostic workflows, implicitly grounding the model's reasoning in radiographic evidence. Step-CoT comprises more than 10K real clinical cases and 70K VQA pairs organized around diagnostic workflows, providing supervised intermediate steps that guide models to follow valid reasoning trajectories. To effectively learn from Step-CoT, we further introduce a teacher-student framework with a dynamic graph-structured focusing mechanism that prioritizes diagnostically informative steps while filtering out less relevant contexts. Our experiments show that using Step-CoT can improve reasoning accuracy and interpretability. Benchmark: github.com/hahaha111111/Step-CoT. Dataset Card: huggingface.co/datasets/fl-15o/Step-CoT

Following clinical decision pathways (CDPs) defined by clinical practice guidelines is essential for safe and reliable medical decision-making. However, existing medical large language model (LLM) benchmarks mainly evaluate final-answer accuracy, providing limited evaluation of models' ability to adhere to guidelines. To address this gap, we introduce MEGA-CDP, a benchmark for evaluating whether medical LLMs can generate guideline-adherent CDPs using provided guidelines as references. MEGA-CDP is constructed from 2,274 English and Chinese clinical practice guidelines through a guideline-to-case pipeline, yielding 42,353 clinical cases with explicit reference CDPs. It supports both single-turn vignette and multi-turn interactive settings, and introduces a CDP-oriented evaluation framework for measuring pathway consistency. Experiments on 16 representative LLMs show that reliable clinical decision support remains challenging for current models, demonstrating the need for CDP-oriented evaluation and the value of MEGA-CDP for advancing guideline adherence in medical LLMs.

The professionalism of a human doctor in outpatient service depends on two core abilities: the ability to make accurate medical decisions and the medical consultation skill to conduct strategic, empathetic patient inquiry. Existing Large Language Models (LLMs) have achieved remarkable accuracy on medical decision-making benchmarks. However, they often lack the ability to conduct the strategic and empathetic consultation, which is essential for real-world clinical scenarios. To address this gap, we propose Doctor-R1, an AI doctor agent trained to master both of the capabilities by ask high-yield questions and conduct strategic multi-turn inquiry to guide decision-making. Our framework introduces three key components: a multi-agent interactive environment, a two-tiered reward architecture that separately optimizes clinical decision-making and communicative inquiry skills, and an experience repository to ground policy learning in high-quality prior trajectories. We evaluate Doctor-R1 on OpenAI's HealthBench and MAQuE, assessed across multi-facet metrics, such as communication quality, user experience, and task accuracy. Remarkably, Doctor-R1 surpasses state-of-the-art open-source specialized LLMs by a substantial margin with higher parameter efficiency and outperforms powerful proprietary models. Furthermore, the human evaluations show a strong preference for Doctor-R1 to generate human-preferred clinical dialogue, demonstrating the effectiveness of the framework.

Intensive care units (ICU) generate long, dense and evolving streams of clinical information, where physicians must repeatedly reassess patient states under time pressure, underscoring a clear need for reliable AI decision support. Existing ICU benchmarks typically treat historical clinician actions as ground truth. However, these actions are made under incomplete information and limited temporal context of the underlying patient state, and may therefore be suboptimal, making it difficult to assess the true reasoning capabilities of AI systems. We introduce RealICU, a hindsight-annotated benchmark for evaluating large language models (LLMs) under realistic ICU conditions, where labels are created after senior physicians review the full patient trajectory. We formulate four physician-motivated tasks: assess Patient Status, Acute Problems, Recommended Actions, and Red Flag actions that risk unsafe outcomes. We partition each trajectory with 30-min windows and release two datasets: RealICU-Gold with 930-window annotations from 94 MIMIC-IV patients, and RealICU-Scale with 11,862 windows extended by Oracle, a physician-validated LLM hindsight labeler. Existing LLMs including memory-augmented ones performed poorly on RealICU, exposing two failure modes: a recall-safety tradeoff for clinical recommendations, and an anchoring bias to early interpretations of the patient. We further introduce ICU-Evo to study structured-memory agents that improves long-horizon reasoning but does not fully eliminate safety failures. Together, RealICU provides a clinically grounded testbed for measuring and improving AI sequential decision-support in high-stakes care. Project page: https://chengzhi-leo.github.io/RealICU-Bench/

Machine learning has successfully framed many sequential decision making problems as either supervised prediction, or optimal decision-making policy identification via reinforcement learning. In data-constrained offline settings, both approaches may fail as they assume fully optimal behavior or rely on exploring alternatives that may not exist. We introduce an inherently different approach that identifies possible "dead-ends" of a state space. We focus on the condition of patients in the intensive care unit, where a "medical dead-end" indicates that a patient will expire, regardless of all potential future treatment sequences. We postulate "treatment security" as avoiding treatments with probability proportional to their chance of leading to dead-ends, present a formal proof, and frame discovery as an RL problem. We then train three independent deep neural models for automated state construction, dead-end discovery and confirmation. Our empirical results discover that dead-ends exist in real clinical data among septic patients, and further reveal gaps between secure treatments and those that were administered.

Operating rooms (ORs) demand precise coordination among surgeons, nurses, and equipment in a fast-paced, occlusion-heavy environment, necessitating advanced perception models to enhance safety and efficiency. Existing datasets either provide partial egocentric views or sparse exocentric multi-view context, but do not explore the comprehensive combination of both. We introduce EgoExOR, the first OR dataset and accompanying benchmark to fuse first-person and third-person perspectives. Spanning 94 minutes (84,553 frames at 15 FPS) of two emulated spine procedures, Ultrasound-Guided Needle Insertion and Minimally Invasive Spine Surgery, EgoExOR integrates egocentric data (RGB, gaze, hand tracking, audio) from wearable glasses, exocentric RGB and depth from RGB-D cameras, and ultrasound imagery. Its detailed scene graph annotations, covering 36 entities and 22 relations (568,235 triplets), enable robust modeling of clinical interactions, supporting tasks like action recognition and human-centric perception. We evaluate the surgical scene graph generation performance of two adapted state-of-the-art models and offer a new baseline that explicitly leverages EgoExOR's multimodal and multi-perspective signals. This new dataset and benchmark set a new foundation for OR perception, offering a rich, multimodal resource for next-generation clinical perception.

Medical vision-language model (VLM) evaluation is sensitive to workflow design, prompting strategy, and benchmark construction, yet most studies treat these factors in isolation. We introduce a reliability stress test for chest X-ray interpretation built on two balanced datasets (a private report-backed set and a curated MIMIC subset). Three medical VLMs (CheXagent, MedGemma-4B, and MedGemma-27B) are evaluated across three prompt styles and two workflows (single-VLM and multi-agent), producing 36 configurations. We show that exact-match accuracy alone can overstate the effectiveness of conservative models that default to "Normal" predictions. Diagnostic reliability also depends heavily on model family and scale: multi-agent reasoning helps some configurations but hurts others. Building on these observations, we propose a decision-time routing framework that selectively escalates to multi-agent inference only when beneficial, improving the cost-quality trade-off over fixed workflows. Our results highlight the need for evaluation protocols that jointly consider prompt sensitivity, failure-mode diversity, and workflow choice before clinical deployment.

Intra-operative recognition of surgical phases holds significant potential for enhancing real-time contextual awareness in the operating room. However, we argue that online recognition, while beneficial, primarily lends itself to post-operative video analysis due to its limited direct impact on the actual surgical decisions and actions during ongoing procedures. In contrast, we contend that the prediction and anticipation of surgical phases are inherently more valuable for intra-operative assistance, as they can meaningfully influence a surgeon's immediate and long-term planning by providing foresight into future steps. To address this gap, we propose a dual approach that simultaneously recognises the current surgical phase and predicts upcoming ones, thus offering comprehensive intra-operative assistance and guidance on the expected remaining workflow. Our novel method, Surgical Phase Recognition and Anticipation (SuPRA), leverages past and current information for accurate intra-operative phase recognition while using future segments for phase prediction. This unified approach challenges conventional frameworks that treat these objectives separately. We have validated SuPRA on two reputed datasets, Cholec80 and AutoLaparo21, where it demonstrated state-of-the-art performance with recognition accuracies of 91.8% and 79.3%, respectively. Additionally, we introduce and evaluate our model using new segment-level evaluation metrics, namely Edit and F1 Overlap scores, for a more temporal assessment of segment classification. In conclusion, SuPRA presents a new multi-task approach that paves the way for improved intra-operative assistance through surgical phase recognition and prediction of future events.

Persona conditioning can be viewed as a behavioral prior for large language models (LLMs) and is often assumed to confer expertise and improve safety in a monotonic manner. However, its effects on high-stakes clinical decision-making remain poorly characterized. We systematically evaluate persona-based control in clinical LLMs, examining how professional roles (e.g., Emergency Department physician, nurse) and interaction styles (bold vs.\ cautious) influence behavior across models and medical tasks. We assess performance on clinical triage and patient-safety tasks using multidimensional evaluations that capture task accuracy, calibration, and safety-relevant risk behavior. We find systematic, context-dependent, and non-monotonic effects: Medical personas improve performance in critical care tasks, yielding gains of up to sim+20% in accuracy and calibration, but degrade performance in primary-care settings by comparable margins. Interaction style modulates risk propensity and sensitivity, but it's highly model-dependent. While aggregated LLM-judge rankings favor medical over non-medical personas in safety-critical cases, we found that human clinicians show moderate agreement on safety compliance (average Cohen's κ= 0.43) but indicate a low confidence in 95.9\% of their responses on reasoning quality. Our work shows that personas function as behavioral priors that introduce context-dependent trade-offs rather than guarantees of safety or expertise. The code is available at https://github.com/rsinghlab/Persona\_Paradox.

Background: AI-driven prediction algorithms have the potential to enhance emergency medicine by enabling rapid and accurate decision-making regarding patient status and potential deterioration. However, the integration of multimodal data, including raw waveform signals, remains underexplored in clinical decision support. Methods: We present a dataset and benchmarking protocol designed to advance multimodal decision support in emergency care. Our models utilize demographics, biometrics, vital signs, laboratory values, and electrocardiogram (ECG) waveforms as inputs to predict both discharge diagnoses and patient deterioration. Results: The diagnostic model achieves area under the receiver operating curve (AUROC) scores above 0.8 for 609 out of 1,428 conditions, covering both cardiac (e.g., myocardial infarction) and non-cardiac (e.g., renal disease, diabetes) diagnoses. The deterioration model attains AUROC scores above 0.8 for 14 out of 15 targets, accurately predicting critical events such as cardiac arrest, mechanical ventilation, ICU admission, and mortality. Conclusions: Our study highlights the positive impact of incorporating raw waveform data into decision support models, improving predictive performance. By introducing a unique, publicly available dataset and baseline models, we provide a foundation for measurable progress in AI-driven decision support for emergency care.

Medical models are judged not only on correctness, but on whether reported confidence matches actual accuracy. Generalist multimodal medical models have expanded what a single model can perceive, yet they still express bounded decisions such as diagnoses, findings or cell counts as generated text, so the reported probability reflects the next token rather than the decision itself. Motivated by decision-native interfaces such as Jev, we introduce OmniMed-Jev, which represents each medical decision as a Choice, Noul or Score decision over a runtime-supplied candidate set and returns a full distribution over that set: mutually exclusive classes, binary presence of a finding, or a bounded ordered value. The design is omni in three respects: it accepts diverse imaging modalities, covers different prediction tasks, and expresses them through one candidate-conditioned probability model, so heterogeneous outputs become comparable probabilities rather than task-specific strings. In an interface-controlled comparison against a generative baseline trained on the same backbone, data and schedule, OmniMed-Jev's reported probabilities track observed correctness far more closely, reducing calibration error by up to an order of magnitude and reliability error by up to two, while point-prediction performance remains comparable; counting is the one family where the generative baseline stays ahead. Making the decision distribution the model's output is not a format change but what turns reported numbers into probabilities that mean what they say. These results support explicit decision modeling as a way to make reported confidence meaningful within the evaluated tasks, and they are not evidence of clinical readiness: the comparison cannot separate the interface from associated training differences, which we state alongside the results. Code is available at github.com/lytang63/OmniMed-Jev.

As models increasingly leverage multi-step reasoning strategies to solve complex problems, supervising the logical validity of these intermediate steps has become a critical research challenge. Process reward models address this by providing step-by-step feedback, but current approaches have two major drawbacks: they typically function as classifiers without providing explanations, and their reliance on supervised fine-tuning with static datasets limits generalization. Inspired by recent advances, we reframe stepwise reward modeling from a classification task to a reasoning task itself. We thus propose a generative judge that reasons about the policy model's reasoning steps (i.e., meta-reasons), outputting thinking tokens before delivering a final verdict. Our model, StepWiser, is trained by reinforcement learning using relative outcomes of rollouts. We show it provides (i) better judgment accuracy on intermediate steps than existing methods; (ii) can be used to improve the policy model at training time; and (iii) improves inference-time search.

The emergence of advanced reasoning capabilities in Large Language Models (LLMs) marks a transformative development in healthcare applications. Beyond merely expanding functional capabilities, these reasoning mechanisms enhance decision transparency and explainability-critical requirements in medical contexts. This survey examines the transformation of medical LLMs from basic information retrieval tools to sophisticated clinical reasoning systems capable of supporting complex healthcare decisions. We provide a thorough analysis of the enabling technological foundations, with a particular focus on specialized prompting techniques like Chain-of-Thought and recent breakthroughs in Reinforcement Learning exemplified by DeepSeek-R1. Our investigation evaluates purpose-built medical frameworks while also examining emerging paradigms such as multi-agent collaborative systems and innovative prompting architectures. The survey critically assesses current evaluation methodologies for medical validation and addresses persistent challenges in field interpretation limitations, bias mitigation strategies, patient safety frameworks, and integration of multimodal clinical data. Through this survey, we seek to establish a roadmap for developing reliable LLMs that can serve as effective partners in clinical practice and medical research.

Real-world clinical diagnosis is a complex process in which the doctor is required to obtain information from both interaction with the patient and conducting medical exams. Additionally, the doctor needs to adapt to different patient personas, as well as noisy and incomplete information that can happen at any time during the process. However, existing benchmarks for medical LLMs and methods for automatic diagnosis largely simplify this process by reducing it to single-turn question answering, noise-free conversations, or sequential exam making, etc., ignoring the interactive and uncertain nature of clinical diagnosis. In this paper, we aim to address this gap by formalizing clinical diagnosis as a Partially Observable Markov Decision Process (POMDP) with three action types: questioning the patient, ordering medical exams as tool calls, and issuing a diagnosis. We also introduce a systematic noise model comprising seven patient noise types and three exam noise types. Using our proposed environment, we train an effective diagnosis agent, MedExAgent, through a two-stage pipeline that first performs supervised finetuning on synthetic conversations structured after the Calgary-Cambridge model for clinical interviews, and then applies DAPO to optimize a composite reward capturing diagnostic accuracy, tool call quality, and exam cost including financial cost and patient discomfort. Through extensive experiments and ablation studies, we demonstrate that MedExAgent achieves diagnostic performance comparable to larger models while maintaining cost-efficient examination strategies.

Surgical future prediction, driven by real-time AI analysis of surgical video, is critical for operating room safety and efficiency. It provides actionable insights into upcoming events, their timing, and risks-enabling better resource allocation, timely instrument readiness, and early warnings for complications (e.g., bleeding, bile duct injury). Despite this need, current surgical AI research focuses on understanding what is happening rather than predicting future events. Existing methods target specific tasks in isolation, lacking unified approaches that span both short-term (action triplets, events) and long-term horizons (remaining surgery duration, phase transitions). These methods rely on coarse-grained supervision while fine-grained surgical action triplets and steps remain underexplored. Furthermore, methods based only on future feature prediction struggle to generalize across different surgical contexts and procedures. We address these limits by reframing surgical future prediction as state-change learning. Rather than forecasting raw observations, our approach classifies state transitions between current and future timesteps. We introduce SurgFUTR, implementing this through a teacher-student architecture. Video clips are compressed into state representations via Sinkhorn-Knopp clustering; the teacher network learns from both current and future clips, while the student network predicts future states from current videos alone, guided by our Action Dynamics (ActDyn) module. We establish SFPBench with five prediction tasks spanning short-term (triplets, events) and long-term (remaining surgery duration, phase and step transitions) horizons. Experiments across four datasets and three procedures show consistent improvements. Cross-procedure transfer validates generalizability.

Large language models (LLMs) are increasingly used across society, including in domains like business, engineering, and medicine. These fields often grapple with decision-making under uncertainty, a critical yet challenging task. In this paper, we show that directly prompting LLMs on these types of decision-making problems yields poor results, especially as the problem complexity increases. To overcome this limitation, we propose DeLLMa (Decision-making Large Language Model assistant), a framework designed to enhance decision-making accuracy in uncertain environments. DeLLMa involves a multi-step scaffolding procedure, drawing upon principles from decision theory and utility theory, to provide an optimal and human-auditable decision-making process. We validate our framework on decision-making environments involving real agriculture and finance data. Our results show that DeLLMa can significantly improve LLM decision-making performance, achieving up to a 40% increase in accuracy over competing methods.

Current approaches for training Process Reward Models (PRMs) often involve breaking down responses into multiple reasoning steps using rule-based techniques, such as using predefined placeholder tokens or setting the reasoning step's length into a fixed size. These approaches overlook the fact that specific words do not typically mark true decision points in a text. To address this, we propose AdaptiveStep, a method that divides reasoning steps based on the model's confidence in predicting the next word. This division method provides more decision-making information at each step, enhancing downstream tasks, such as reward model learning. Moreover, our method does not require manual annotation. We demonstrate its effectiveness through experiments with AdaptiveStep-trained PRMs in mathematical reasoning and code generation tasks. Experimental results indicate that the outcome PRM achieves state-of-the-art Best-of-N performance, surpassing greedy search strategy with token-level value-guided decoding, while also reducing construction costs by over 30% compared to existing open-source PRMs. In addition, we provide a thorough analysis and case study on the PRM's performance, transferability, and generalization capabilities.

Large language models have enabled agents of all kinds to interact with users through natural conversation. Consequently, agents now have two jobs: conversing and planning/reasoning. Their conversational responses must be informed by all available information, and their actions must help to achieve goals. This dichotomy between conversing with the user and doing multi-step reasoning and planning can be seen as analogous to the human systems of "thinking fast and slow" as introduced by Kahneman. Our approach is comprised of a "Talker" agent (System 1) that is fast and intuitive, and tasked with synthesizing the conversational response; and a "Reasoner" agent (System 2) that is slower, more deliberative, and more logical, and is tasked with multi-step reasoning and planning, calling tools, performing actions in the world, and thereby producing the new agent state. We describe the new Talker-Reasoner architecture and discuss its advantages, including modularity and decreased latency. We ground the discussion in the context of a sleep coaching agent, in order to demonstrate real-world relevance.

Operating rooms (ORs) are complex, high-stakes environments requiring precise understanding of interactions among medical staff, tools, and equipment for enhancing surgical assistance, situational awareness, and patient safety. Current datasets fall short in scale, realism and do not capture the multimodal nature of OR scenes, limiting progress in OR modeling. To this end, we introduce MM-OR, a realistic and large-scale multimodal spatiotemporal OR dataset, and the first dataset to enable multimodal scene graph generation. MM-OR captures comprehensive OR scenes containing RGB-D data, detail views, audio, speech transcripts, robotic logs, and tracking data and is annotated with panoptic segmentations, semantic scene graphs, and downstream task labels. Further, we propose MM2SG, the first multimodal large vision-language model for scene graph generation, and through extensive experiments, demonstrate its ability to effectively leverage multimodal inputs. Together, MM-OR and MM2SG establish a new benchmark for holistic OR understanding, and open the path towards multimodal scene analysis in complex, high-stakes environments. Our code, and data is available at https://github.com/egeozsoy/MM-OR.

The recent adoption of artificial intelligence in socio-technical systems raises concerns about the black-box nature of the resulting decisions in fields such as hiring, finance, admissions, etc. If data subjects -- such as job applicants, loan applicants, and students -- receive an unfavorable outcome, they may be interested in algorithmic recourse, which involves updating certain features to yield a more favorable result when re-evaluated by algorithmic decision-making. Unfortunately, when individuals do not fully understand the incremental steps needed to change their circumstances, they risk following misguided paths that can lead to significant, long-term adverse consequences. Existing recourse approaches focus exclusively on the final recourse goal but neglect the possible incremental steps to reach the goal with real-life constraints, user preferences, and model artifacts. To address this gap, we formulate a visual analytic workflow for incremental recourse planning in collaboration with AI/ML experts and contribute an interactive visualization interface that helps data subjects efficiently navigate the recourse alternatives and make an informed decision. We present a usage scenario and subjective feedback from observational studies with twelve graduate students using a real-world dataset, which demonstrates that our approach can be instrumental for data subjects in choosing a suitable recourse path.

The field of computer vision applied to videos of minimally invasive surgery is ever-growing. Workflow recognition pertains to the automated recognition of various aspects of a surgery: including which surgical steps are performed; and which surgical instruments are used. This information can later be used to assist clinicians when learning the surgery; during live surgery; and when writing operation notes. The Pituitary Vision (PitVis) 2023 Challenge tasks the community to step and instrument recognition in videos of endoscopic pituitary surgery. This is a unique task when compared to other minimally invasive surgeries due to the smaller working space, which limits and distorts vision; and higher frequency of instrument and step switching, which requires more precise model predictions. Participants were provided with 25-videos, with results presented at the MICCAI-2023 conference as part of the Endoscopic Vision 2023 Challenge in Vancouver, Canada, on 08-Oct-2023. There were 18-submissions from 9-teams across 6-countries, using a variety of deep learning models. A commonality between the top performing models was incorporating spatio-temporal and multi-task methods, with greater than 50% and 10% macro-F1-score improvement over purely spacial single-task models in step and instrument recognition respectively. The PitVis-2023 Challenge therefore demonstrates state-of-the-art computer vision models in minimally invasive surgery are transferable to a new dataset, with surgery specific techniques used to enhance performance, progressing the field further. Benchmark results are provided in the paper, and the dataset is publicly available at: https://doi.org/10.5522/04/26531686.

Recent advances in medical multi-modal models focus on specialized image analysis like dermatology, pathology, or radiology. However, they do not fully capture the complexity of real-world clinical diagnostics, which involve heterogeneous inputs and require ongoing contextual understanding during patient-physician interactions. To bridge this gap, we introduce PulseMind, a new family of multi-modal diagnostic models that integrates a systematically curated dataset, a comprehensive evaluation benchmark, and a tailored training framework. Specifically, we first construct a diagnostic dataset, MediScope, which comprises 98,000 real-world multi-turn consultations and 601,500 medical images, spanning over 10 major clinical departments and more than 200 sub-specialties. Then, to better reflect the requirements of real-world clinical diagnosis, we develop the PulseMind Benchmark, a multi-turn diagnostic consultation benchmark with a four-dimensional evaluation protocol comprising proactiveness, accuracy, usefulness, and language quality. Finally, we design a training framework tailored for multi-modal clinical diagnostics, centered around a core component named Comparison-based Reinforcement Policy Optimization (CRPO). Compared to absolute score rewards, CRPO uses relative preference signals from multi-dimensional com-parisons to provide stable and human-aligned training guidance. Extensive experiments demonstrate that PulseMind achieves competitive performance on both the diagnostic consultation benchmark and public medical benchmarks.

A robust decision-making process must take into account uncertainty, especially when the choice involves inherent risks. Because artificial intelligence (AI) systems are increasingly integrated into decision-making workflows, managing uncertainty relies more and more on the metacognitive capabilities of these systems; i.e, their ability to assess the reliability of and regulate their own decisions. Hence, it is crucial to employ robust methods to measure the metacognitive abilities of AI. This paper is primarily a methodological contribution arguing for the adoption of the meta-d' framework as the gold standard for assessing the metacognitive sensitivity of AIs--the ability to generate confidence ratings that distinguish correct from incorrect responses. Moreover, we propose to leverage signal detection theory (SDT) to measure the ability of AIs to spontaneously regulate their decisions based on uncertainty and risk. To demonstrate the practical utility of these psychophysical frameworks, we conduct two series of experiments on three large language models (LLMs)--GPT-5, DeepSeek-V3.2-Exp, and Mistral-Medium-2508.

Recent Artificial Intelligence (AI) models have matched or exceeded human experts in several benchmarks of biomedical task performance, but have lagged behind on surgical image-analysis benchmarks. Since surgery requires integrating disparate tasks -- including multimodal data integration, human interaction, and physical effects -- generally-capable AI models could be particularly attractive as a collaborative tool if performance could be improved. On the one hand, the canonical approach of scaling architecture size and training data is attractive, especially since there are millions of hours of surgical video data generated per year. On the other hand, preparing surgical data for AI training requires significantly higher levels of professional expertise, and training on that data requires expensive computational resources. These trade-offs paint an uncertain picture of whether and to-what-extent modern AI could aid surgical practice. In this paper, we explore this question through a case study of surgical tool detection using state-of-the-art AI methods available in 2026. We demonstrate that even with multi-billion parameter models and extensive training, current Vision Language Models fall short in the seemingly simple task of tool detection in neurosurgery. Additionally, we show scaling experiments indicating that increasing model size and training time only leads to diminishing improvements in relevant performance metrics. Thus, our experiments suggest that current models could still face significant obstacles in surgical use cases. Moreover, some obstacles cannot be simply ``scaled away'' with additional compute and persist across diverse model architectures, raising the question of whether data and label availability are the only limiting factors. We discuss the main contributors to these constraints and advance potential solutions.

The growing ability of large language models and vision language models to jointly interpret and reason over images and text is reshaping medical agents, moving them from task specific predictors toward autonomous systems that perceive, reason, plan, remember, and act in clinical environments. This work departs from the capability first perspective of existing literature and instead begins from clinical deployment, asking what tasks, contamination resistant benchmarks, and interactive training environments are required before medical agents can be trusted in practice. Medical agents are formalized as sequential decision making systems under partial observability, together with a three level autonomy taxonomy spanning assisted, cooperative, and fully autonomous operation. The field is organized along a unified scaling spine consisting of framework scaling, capability scaling, and environment scaling. Within this framework, clinical environment scaling, the integration of tools, data, and clinical gyms, is identified as the most actionable yet underexplored direction for agents operating in PACS, EHR, and FHIR ecosystems. Clinical self evolution, where agents improve through interaction with their environments rather than parameter scaling alone, is further positioned as a key research frontier, drawing insights from self improving agents, agent gyms, and test time compute scaling. Applications across radiology, pathology, ophthalmology, and hospital workflows are examined together with deployment challenges including hallucination, cascading failures, and fairness. By consolidating more than 300 references, with particular emphasis on advances from 2025 to 2026, this work provides a roadmap toward trustworthy, self improving medical imaging systems for real clinical practice.

Purpose. Patients with advanced cancer may undergo multiple lines of treatment, switching therapies as their disease progresses. Motivated by a study of metastatic prostate cancer, we develop a microsimulation framework to study therapy sequence. Methods. We propose a discrete-time state transition model to study two lines of anti-cancer therapy. Based on digitized published progression-free survival (PFS) and overall survival (OS) curves, we infer event types (progression or death), and estimate transition probabilities using cumulative incidence functions with competing risks. Our model incorporates within-patient dependence over time, such that response to first-line therapy informs subsequent event probabilities. Parameters governing the degree of within-patient dependence can be used to calibrate the model-based results to those of a target trial. We demonstrate these methods in a study of two therapy sequences for metastatic prostate cancer, where Docetaxel (DCT) and Abiraterone Acetate (AA) are both appropriate for use in either first or second line treatment. We assess costs, Quality-Adjusted Life Years (QALYs) and Incremental Cost Effectiveness Ratio (ICER) for two treatment strategies: DCT then AA vs AA then DCT. Results. Using digitized survival curves from relevant clinical trials, we identified 8.6-13.9% of PFS times that should be categorized as deaths, allowing for estimation of cumulative incidence functions. Models assuming within-patient independence overestimated OS time, corrected with our calibration approach. Correction resulted in meaningful changes in the difference in QALYs between treatment strategies (0.07 vs 0.15) and the ICER (-\76,836/QALY vs -21,030/QALY). Conclusions. Microsimulation models can be successfully used to study cost-effectiveness of therapy sequences, taking care to account correctly for within-patient dependence.

We introduce StartLux-Decision, decision models from 0.8B to 27B parameters that combine efficient single-pass prediction with adaptive, confidence-guided reasoning. The Instant models use bidirectional attention in full-attention layers to improve decision accuracy while keeping single-pass inference. The AutoThink models invoke explicit reasoning for uncertain decisions and answer confident cases directly. A three-stage training pipeline establishes shared decision capabilities, specializes the two variants, and equips AutoThink with reasoning through reasoning supervision and reinforcement learning. We introduce Reinforcement Learning for Calibrated Deliberative Decisions (RLCD^2), which uses a frozen model and proper scoring rules to reward improvements in decision probability quality and applies a soft penalty to overlong reasoning traces. RLCD^2 raises the share of reasoning traces that terminate within the generation limit by up to 48 percentage points and cuts average reasoning length by up to 65%, while largely preserving decision accuracy. On the public subset of Decision Index 0.3, the Instant models outperform the strongest evaluated comparable-scale open-weight decision models by 7.4-16.9 points, and the 27B AutoThink model reaches 73.4. We also introduce DecisionPivot, a programmatically verifiable benchmark of computational decisions built from contrast pairs that differ in a single answer-changing detail. On DecisionPivot, AutoThink outperforms its Instant counterparts by 11.5-18.4 points in pair accuracy and leads among evaluated systems. The models run on vLLM, llama.cpp and MLX, with quantized variants for lower memory use.

Multi-step learning applies lookahead over multiple time steps and has proved valuable in policy evaluation settings. However, in the optimal control case, the impact of multi-step learning has been relatively limited despite a number of prior efforts. Fundamentally, this might be because multi-step policy improvements require operations that cannot be approximated by stochastic samples, hence hindering the widespread adoption of such methods in practice. To address such limitations, we introduce doubly multi-step off-policy VI (DoMo-VI), a novel oracle algorithm that combines multi-step policy improvements and policy evaluations. DoMo-VI enjoys guaranteed convergence speed-up to the optimal policy and is applicable in general off-policy learning settings. We then propose doubly multi-step off-policy actor-critic (DoMo-AC), a practical instantiation of the DoMo-VI algorithm. DoMo-AC introduces a bias-variance trade-off that ensures improved policy gradient estimates. When combined with the IMPALA architecture, DoMo-AC has showed improvements over the baseline algorithm on Atari-57 game benchmarks.

Clinical early warning systems built on irregularly sampled medical time series (ISMTS) from electronic health records must deliver continuous risk scores for patient triage as well as interpretable rationales that clinicians can verify. Large language models (LLMs) are uniquely positioned for both, deriving risk from their output probabilities and rationales from their medical knowledge. However, we find that conventional LLM reasoning collapses graded risk into overconfident predictions and thereby undermines the cross-patient comparability on which triage depends. We refer to this failure mode as risk polarization and identify two underlying behaviors: early commitment to a single outcome, and one-sided reasoning that focuses only on the evidence for that outcome. To address this, we propose TRIAGE, a framework that trains an LLM to reason dialectically over competing clinical outcomes by eliciting outcome-specific rationales. This dialectical formulation mitigates risk polarization, enabling a single LLM to jointly provide explicit clinical rationales and risk scores comparable across patients. Across five ISMTS benchmarks, TRIAGE improves mean AUPRC by 17.0% and reduces mean calibration error by 82.8% relative to the competitive LLM-based baseline, while surpassing the strongest ISMTS baseline by 3.5% in mean AUPRC.

Integration of Vision-Language Models (VLMs) in surgical intelligence is hindered by hallucinations, domain knowledge gaps, and limited understanding of task interdependencies within surgical scenes, undermining clinical reliability. While recent VLMs demonstrate strong general reasoning and thinking capabilities, they still lack the domain expertise and task-awareness required for precise surgical scene interpretation. Although Chain-of-Thought (CoT) can structure reasoning more effectively, current approaches rely on self-generated CoT steps, which often exacerbate inherent domain gaps and hallucinations. To overcome this, we present SurgRAW, a CoT-driven multi-agent framework that delivers transparent, interpretable insights for most tasks in robotic-assisted surgery. By employing specialized CoT prompts across five tasks: instrument recognition, action recognition, action prediction, patient data extraction, and outcome assessment, SurgRAW mitigates hallucinations through structured, domain-aware reasoning. Retrieval-Augmented Generation (RAG) is also integrated to external medical knowledge to bridge domain gaps and improve response reliability. Most importantly, a hierarchical agentic system ensures that CoT-embedded VLM agents collaborate effectively while understanding task interdependencies, with a panel discussion mechanism promotes logical consistency. To evaluate our method, we introduce SurgCoTBench, the first reasoning-based dataset with structured frame-level annotations. With comprehensive experiments, we demonstrate the effectiveness of proposed SurgRAW with 29.32% accuracy improvement over baseline VLMs on 12 robotic procedures, achieving the state-of-the-art performance and advancing explainable, trustworthy, and autonomous surgical assistance.

We present Multi-expert Prompting, a novel enhancement of ExpertPrompting (Xu et al., 2023), designed to improve the large language model (LLM) generation. Specifically, it guides an LLM to fulfill an input instruction by simulating multiple experts, aggregating their responses, and selecting the best among individual and aggregated responses. This process is performed in a single chain of thoughts through our seven carefully designed subtasks derived from the Nominal Group Technique (Ven and Delbecq, 1974), a well-established decision-making framework. Our evaluations demonstrate that Multi-expert Prompting significantly outperforms ExpertPrompting and comparable baselines in enhancing the truthfulness, factuality, informativeness, and usefulness of responses while reducing toxicity and hurtfulness. It further achieves state-of-the-art truthfulness by outperforming the best baseline by 8.69% with ChatGPT. Multi-expert Prompting is efficient, explainable, and highly adaptable to diverse scenarios, eliminating the need for manual prompt construction.

Applying a valid medication-safety rule when its patient-specific conditions are not met can produce an incorrect decision. Existing medical evaluations largely use isolated and fixed scenarios. A model may therefore answer correctly by recalling a drug-risk association without showing that it used patient information to decide whether the rule applies. To address this gap, we introduce MedPIC-Bench, a benchmark of source-verifiable recommendations and expert-validated questions for patient-specific medication-safety reasoning. It combines guideline-following questions with paired counterfactual questions in which a controlled change in patient information changes whether a rule applies. The benchmark contains 467 questions annotated along six clinical and reasoning dimensions. Across 28 medical-specific, general, and proprietary LLMs, every model performs worse on counterfactual questions, with mean accuracy falling from 63.6\% to 45.1\%. Models perform well when an explicit patient attribute directly signals a familiar contraindication, but struggle when patient information must narrow or withdraw a safety warning. Model rationales often acknowledge the changed patient information, yet the final answers retain the previous safety judgment. This vulnerability persists among medical-specific LLMs, whose average CF performance trails that of general LLMs. MedPIC-Bench therefore makes conditional rule application measurable and highlights the limitations of static medication-safety accuracy for assessing patient-specific reliability.

Restless multi-armed bandits (RMAB) have demonstrated success in optimizing resource allocation for large beneficiary populations in public health settings. Unfortunately, RMAB models lack flexibility to adapt to evolving public health policy priorities. Concurrently, Large Language Models (LLMs) have emerged as adept automated planners across domains of robotic control and navigation. In this paper, we propose a Decision Language Model (DLM) for RMABs, enabling dynamic fine-tuning of RMAB policies in public health settings using human-language commands. We propose using LLMs as automated planners to (1) interpret human policy preference prompts, (2) propose reward functions as code for a multi-agent RMAB environment, and (3) iterate on the generated reward functions using feedback from grounded RMAB simulations. We illustrate the application of DLM in collaboration with ARMMAN, an India-based non-profit promoting preventative care for pregnant mothers, that currently relies on RMAB policies to optimally allocate health worker calls to low-resource populations. We conduct a technology demonstration in simulation using the Gemini Pro model, showing DLM can dynamically shape policy outcomes using only human prompts as input.

Foundation Models that are capable of processing and generating multi-modal data have transformed AI's role in medicine. However, a key limitation of their reliability is hallucination, where inaccurate or fabricated information can impact clinical decisions and patient safety. We define medical hallucination as any instance in which a model generates misleading medical content. This paper examines the unique characteristics, causes, and implications of medical hallucinations, with a particular focus on how these errors manifest themselves in real-world clinical scenarios. Our contributions include (1) a taxonomy for understanding and addressing medical hallucinations, (2) benchmarking models using medical hallucination dataset and physician-annotated LLM responses to real medical cases, providing direct insight into the clinical impact of hallucinations, and (3) a multi-national clinician survey on their experiences with medical hallucinations. Our results reveal that inference techniques such as Chain-of-Thought (CoT) and Search Augmented Generation can effectively reduce hallucination rates. However, despite these improvements, non-trivial levels of hallucination persist. These findings underscore the ethical and practical imperative for robust detection and mitigation strategies, establishing a foundation for regulatory policies that prioritize patient safety and maintain clinical integrity as AI becomes more integrated into healthcare. The feedback from clinicians highlights the urgent need for not only technical advances but also for clearer ethical and regulatory guidelines to ensure patient safety. A repository organizing the paper resources, summaries, and additional information is available at https://github.com/mitmedialab/medical hallucination.

Medical care follows complex clinical pathways that extend beyond isolated physician-patient encounters, emphasizing decision-making and transitions between different stages. Current benchmarks focusing on static exams or isolated dialogues inadequately evaluate large language models (LLMs) in dynamic clinical scenarios. We introduce CP-Env, a controllable agentic hospital environment designed to evaluate LLMs across end-to-end clinical pathways. CP-Env simulates a hospital ecosystem with patient and physician agents, constructing scenarios ranging from triage and specialist consultation to diagnostic testing and multidisciplinary team meetings for agent interaction. Following real hospital adaptive flow of healthcare, it enables branching, long-horizon task execution. We propose a three-tiered evaluation framework encompassing Clinical Efficacy, Process Competency, and Professional Ethics. Results reveal that most models struggle with pathway complexity, exhibiting hallucinations and losing critical diagnostic details. Interestingly, excessive reasoning steps can sometimes prove counterproductive, while top models tend to exhibit reduced tool dependency through internalized knowledge. CP-Env advances medical AI agents development through comprehensive end-to-end clinical evaluation. We provide the benchmark and evaluation tools for further research and development at https://github.com/SPIRAL-MED/CP_ENV.

Off-policy learning from multistep returns is crucial for sample-efficient reinforcement learning, but counteracting off-policy bias without exacerbating variance is challenging. Classically, off-policy bias is corrected in a per-decision manner: past temporal-difference errors are re-weighted by the instantaneous Importance Sampling (IS) ratio after each action via eligibility traces. Many off-policy algorithms rely on this mechanism, along with differing protocols for cutting the IS ratios to combat the variance of the IS estimator. Unfortunately, once a trace has been fully cut, the effect cannot be reversed. This has led to the development of credit-assignment strategies that account for multiple past experiences at a time. These trajectory-aware methods have not been extensively analyzed, and their theoretical justification remains uncertain. In this paper, we propose a multistep operator that can express both per-decision and trajectory-aware methods. We prove convergence conditions for our operator in the tabular setting, establishing the first guarantees for several existing methods as well as many new ones. Finally, we introduce Recency-Bounded Importance Sampling (RBIS), which leverages trajectory awareness to perform robustly across lambda-values in an off-policy control task.

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.

Medical calculators are fundamental to quantitative, evidence-based clinical practice. However, their real-world use is an adaptive, multi-stage process, requiring proactive EHR data acquisition, scenario-dependent calculator selection, and multi-step computation, whereas current benchmarks focus only on static single-step calculations with explicit instructions. To address these limitations, we introduce MedMCP-Calc, the first benchmark for evaluating LLMs in realistic medical calculator scenarios through Model Context Protocol (MCP) integration. MedMCP-Calc comprises 118 scenario tasks across 4 clinical domains, featuring fuzzy task descriptions mimicking natural queries, structured EHR database interaction, external reference retrieval, and process-level evaluation. Our evaluation of 23 leading models reveals critical limitations: even top performers like Claude Opus 4.5 exhibit substantial gaps, including difficulty selecting appropriate calculators for end-to-end workflows given fuzzy queries, poor performance in iterative SQL-based database interactions, and marked reluctance to leverage external tools for numerical computation. Performance also varies considerably across clinical domains. Building on these findings, we develop CalcMate, a fine-tuned model incorporating scenario planning and tool augmentation, achieving state-of-the-art performance among open-source models. Benchmark and Codes are available in https://github.com/SPIRAL-MED/MedMCP-Calc.

Clinical image interpretation is inherently multi-step and tool-centric: clinicians iteratively combine visual evidence with patient context, quantify findings, and refine their decisions through a sequence of specialized procedures. While LLM-based agents promise to orchestrate such heterogeneous medical tools, existing systems treat tool sets and invocation strategies as static after deployment. This design is brittle under real-world domain shifts, across tasks, and evolving diagnostic requirements, where predefined tool chains frequently degrade and demand costly manual re-design. We propose MACRO, a self-evolving, experience-augmented medical agent that shifts from static tool composition to experience-driven tool discovery. From verified execution trajectories, the agent autonomously identifies recurring effective multi-step tool sequences, synthesizes them into reusable composite tools, and registers these as new high-level primitives that continuously expand its behavioral repertoire. A lightweight image-feature memory grounds tool selection in a visual-clinical context, while a GRPO-like training loop reinforces reliable invocation of discovered composites, enabling closed-loop self-improvement with minimal supervision. Extensive experiments across diverse medical imaging datasets and tasks demonstrate that autonomous composite tool discovery consistently improves multi-step orchestration accuracy and cross-domain generalization over strong baselines and recent state-of-the-art agentic methods, bridging the gap between brittle static tool use and adaptive, context-aware clinical AI assistance. Code will be available upon acceptance.

Large language model agents can plan, invoke tools, and modify external states, yet most systems still take an explicit user instruction as a fixed starting point. Proactive service moves the decision upstream: an agent must infer service opportunities from incomplete environmental and user signals, choose among remaining silent, asking, assisting, and acting, and account for interruption, misunderstanding, overreach, and privacy costs. This survey gives an operational definition centered on initiative and formulates the problem as a partially observable sequential decision process constrained by authorization and risk. The formulation represents timing, content, and delivery within one structured action, while making explicit the option value of waiting, the decision value of questions, and feedback-induced state changes. On this basis, we organize existing methods along one decision pipeline (state and need estimation, intervention gating, action construction, and feedback adaptation) and describe prescribed, predictive, model based, and return optimizing mechanisms as nonexclusive policy-construction components. We further normalize decision units and three-axis evidence descriptors across streaming dialogue, screen, video, software-engineering, and human-agent collaboration resources, and formalize metrics for triggering, timing, calibration, user burden, safety, and policy value. The synthesis shows why offline classification performance alone does not predict deployment benefit and why long-term memory is not a defining condition of proactivity. Reliable proactive service instead requires calibrated incremental intervention value, verifiable authorization, recoverable execution, and counterfactual evidence.

This paper studies the problem of performing a sequence of optimal interventions in a causal dynamical system where both the target variable of interest and the inputs evolve over time. This problem arises in a variety of domains e.g. system biology and operational research. Dynamic Causal Bayesian Optimization (DCBO) brings together ideas from sequential decision making, causal inference and Gaussian process (GP) emulation. DCBO is useful in scenarios where all causal effects in a graph are changing over time. At every time step DCBO identifies a local optimal intervention by integrating both observational and past interventional data collected from the system. We give theoretical results detailing how one can transfer interventional information across time steps and define a dynamic causal GP model which can be used to quantify uncertainty and find optimal interventions in practice. We demonstrate how DCBO identifies optimal interventions faster than competing approaches in multiple settings and applications.

AI explanations are often mentioned as a way to improve human-AI decision-making, but empirical studies have not found consistent evidence of explanations' effectiveness and, on the contrary, suggest that they can increase overreliance when the AI system is wrong. While many factors may affect reliance on AI support, one important factor is how decision-makers reconcile their own intuition -- beliefs or heuristics, based on prior knowledge, experience, or pattern recognition, used to make judgments -- with the information provided by the AI system to determine when to override AI predictions. We conduct a think-aloud, mixed-methods study with two explanation types (feature- and example-based) for two prediction tasks to explore how decision-makers' intuition affects their use of AI predictions and explanations, and ultimately their choice of when to rely on AI. Our results identify three types of intuition involved in reasoning about AI predictions and explanations: intuition about the task outcome, features, and AI limitations. Building on these, we summarize three observed pathways for decision-makers to apply their own intuition and override AI predictions. We use these pathways to explain why (1) the feature-based explanations we used did not improve participants' decision outcomes and increased their overreliance on AI, and (2) the example-based explanations we used improved decision-makers' performance over feature-based explanations and helped achieve complementary human-AI performance. Overall, our work identifies directions for further development of AI decision-support systems and explanation methods that help decision-makers effectively apply their intuition to achieve appropriate reliance on AI.

Surgical tool segmentation and action recognition are fundamental building blocks in many computer-assisted intervention applications, ranging from surgical skills assessment to decision support systems. Nowadays, learning-based action recognition and segmentation approaches outperform classical methods, relying, however, on large, annotated datasets. Furthermore, action recognition and tool segmentation algorithms are often trained and make predictions in isolation from each other, without exploiting potential cross-task relationships. With the EndoVis 2022 SAR-RARP50 challenge, we release the first multimodal, publicly available, in-vivo, dataset for surgical action recognition and semantic instrumentation segmentation, containing 50 suturing video segments of Robotic Assisted Radical Prostatectomy (RARP). The aim of the challenge is twofold. First, to enable researchers to leverage the scale of the provided dataset and develop robust and highly accurate single-task action recognition and tool segmentation approaches in the surgical domain. Second, to further explore the potential of multitask-based learning approaches and determine their comparative advantage against their single-task counterparts. A total of 12 teams participated in the challenge, contributing 7 action recognition methods, 9 instrument segmentation techniques, and 4 multitask approaches that integrated both action recognition and instrument segmentation. The complete SAR-RARP50 dataset is available at: https://rdr.ucl.ac.uk/projects/SARRARP50_Segmentation_of_surgical_instrumentation_and_Action_Recognition_on_Robot-Assisted_Radical_Prostatectomy_Challenge/191091

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.

Recent progress in multimodal large language models (MLLMs) has demonstrated promising performance on medical benchmarks and in preliminary trials as clinical assistants. Yet, our pilot audit of diagnostic cases uncovers a critical failure mode: instability in early evidence interpretation precedes hallucination, creating branching reasoning trajectories that cascade into globally inconsistent conclusions. This highlights the need for clinical reasoning agents that constrain stochasticity and hallucination while producing auditable decision flows. We introduce MedMMV, a controllable multimodal multi-agent framework for reliable and verifiable clinical reasoning. MedMMV stabilizes reasoning through diversified short rollouts, grounds intermediate steps in a structured evidence graph under the supervision of a Hallucination Detector, and aggregates candidate paths with a Combined Uncertainty scorer. On six medical benchmarks, MedMMV improves accuracy by up to 12.7% and, more critically, demonstrates superior reliability. Blind physician evaluations confirm that MedMMV substantially increases reasoning truthfulness without sacrificing informational content. By controlling instability through a verifiable, multi-agent process, our framework provides a robust path toward deploying trustworthy AI systems in high-stakes domains like clinical decision support.

Clinical decision-making in emergency medicine demands rapid, accurate diagnoses under uncertainty. Despite benchmark progress, evidence for LLMs as interactive aids in live physician workflows remains sparse. MedSyn lets physicians iteratively query an LLM provided with the full clinical record while initially viewing only the chief complaint. Seven physicians (three seniors, four residents) completed baseline and AI-assisted sessions across 52 MIMIC-IV cases stratified by difficulty. Blinded evaluation showed residents' Hard-case correctness rose from 0.589 to 0.734; difficulty-standardised completely-correct rates confirmed a medium effect (Δ = 0.092; p = 0.071; d = 0.47). Automated metrics corroborated these gains: standardised any-match accuracy improved by 0.156 (p < 0.0001), and residents showed the largest F1 gain (Δ = 0.138; p < 0.0001). Dialogue analysis revealed expertise-dependent strategies (seniors asked targeted, hypothesis-driven questions; residents relied on broader queries) and cross-expertise concordance increased (Δ = 0.145; p < 0.0001). Interactive LLM support meaningfully enhances diagnostic reasoning.

Decision-making is a dynamic process requiring perception, memory, and reasoning to make choices and find optimal policies. Traditional approaches to decision-making suffer from sample efficiency and generalization, while large-scale self-supervised pretraining has enabled fast adaptation with fine-tuning or few-shot learning in language and vision. We thus argue to integrate knowledge acquired from generic large-scale self-supervised pretraining into downstream decision-making problems. We propose Pretrain-Then-Adapt pipeline and survey recent work on data collection, pretraining objectives and adaptation strategies for decision-making pretraining and downstream inference. Finally, we identify critical challenges and future directions for developing decision foundation model with the help of generic and flexible self-supervised pretraining.

Two common approaches to sequential decision-making are AI planning (AIP) and reinforcement learning (RL). Each has strengths and weaknesses. AIP is interpretable, easy to integrate with symbolic knowledge, and often efficient, but requires an up-front logical domain specification and is sensitive to noise; RL only requires specification of rewards and is robust to noise but is sample inefficient and not easily supplied with external knowledge. We propose an integrative approach that combines high-level planning with RL, retaining interpretability, transfer, and efficiency, while allowing for robust learning of the lower-level plan actions. Our approach defines options in hierarchical reinforcement learning (HRL) from AIP operators by establishing a correspondence between the state transition model of AI planning problem and the abstract state transition system of a Markov Decision Process (MDP). Options are learned by adding intrinsic rewards to encourage consistency between the MDP and AIP transition models. We demonstrate the benefit of our integrated approach by comparing the performance of RL and HRL algorithms in both MiniGrid and N-rooms environments, showing the advantage of our method over the existing ones.

Clinical diagnosis is critical in medical practice, typically requiring a continuous and evolving process that includes primary diagnosis, differential diagnosis, and final diagnosis. However, most existing clinical diagnostic tasks are single-step processes, which does not align with the complex multi-step diagnostic procedures found in real-world clinical settings. In this paper, we propose a multi-step diagnostic task and annotate a clinical diagnostic dataset (MSDiagnosis). This dataset includes primary diagnosis, differential diagnosis, and final diagnosis questions. Additionally, we propose a novel and effective framework. This framework combines forward inference, backward inference, reflection, and refinement, enabling the LLM to self-evaluate and adjust its diagnostic results. To assess the effectiveness of our proposed method, we design and conduct extensive experiments. The experimental results demonstrate the effectiveness of the proposed method. We also provide a comprehensive experimental analysis and suggest future research directions for this task.

Achieving mission objectives in a realistic simulation of aerial combat is highly challenging due to imperfect situational awareness and nonlinear flight dynamics. In this work, we introduce a novel 3D multi-agent air combat environment and a Hierarchical Multi-Agent Reinforcement Learning framework to tackle these challenges. Our approach combines heterogeneous agent dynamics, curriculum learning, league-play, and a newly adapted training algorithm. To this end, the decision-making process is organized into two abstraction levels: low-level policies learn precise control maneuvers, while high-level policies issue tactical commands based on mission objectives. Empirical results show that our hierarchical approach improves both learning efficiency and combat performance in complex dogfight scenarios.

Specialist epilepsy expertise is scarce in resource-constrained settings, making LLM-based decision support attractive for frontline clinicians managing longitudinal treatment. Such systems must adapt to local prescribing practice and know when to defer. We study this problem in Ugandan pediatric epilepsy care, predicting anti-seizure medication regimens from longitudinal unstructured clinic notes. Standard prompting achieves non-trivial agreement with physician prescriptions, but neurologist review shows that many errors reflect distribution-miscalibrated prescribing defaults rather than failures to parse the local record. We introduce MANANA, a non-parametric prompt-learning framework that learns local prescribing guidance from a small patient-level training set. MANANA converts observed prescription errors into auditable prompt memories, instantiated in single-agent and multi-agent variants, and improves over classical ML models, direct LLM prompting, and prompt-optimization baselines across two independently collected Ugandan cohorts. We further propose Bayesian prompt averaging, which converts the learned prompt trajectory into prescription likelihoods and an uncertainty-based deferral signal. On the independently collected held-out cohort, this improves visit-level top-3 prescription accuracy by 4-8 percentage points over prompt-optimization baselines and enables selective prediction: the system can auto-handle the most confident half of cases at 95% precision, or the most confident quarter at 99% precision, while deferring lower-confidence cases for specialist review.

Sequential decision-making agents struggle with long horizon tasks, since solving them requires multi-step reasoning. Most reinforcement learning (RL) algorithms address this challenge by improved credit assignment, introducing memory capability, altering the agent's intrinsic motivation (i.e. exploration) or its worldview (i.e. knowledge representation). Many of these components could be learned from offline data. In this work, we follow the hypothesis that exploration and representation learning can be improved by separately learning two different models from a single offline dataset. We show that learning a state representation using noise-contrastive estimation and a model of auxiliary reward separately from a single collection of human demonstrations can significantly improve the sample efficiency on the challenging NetHack benchmark. We also ablate various components of our experimental setting and highlight crucial insights.

Surgical intelligence has the potential to improve the safety and consistency of surgical care, yet most existing surgical AI frameworks remain task-specific and struggle to generalize across procedures and institutions. Although multimodal foundation models, particularly multimodal large language models, have demonstrated strong cross-task capabilities across various medical domains, their advancement in surgery remains constrained by the lack of large-scale, systematically curated multimodal data. To address this challenge, we introduce SurgΣ, a spectrum of large-scale multimodal data and foundation models for surgical intelligence. At the core of this framework lies SurgΣ-DB, a large-scale multimodal data foundation designed to support diverse surgical tasks. SurgΣ-DB consolidates heterogeneous surgical data sources (including open-source datasets, curated in-house clinical collections and web-source data) into a unified schema, aiming to improve label consistency and data standardization across heterogeneous datasets. SurgΣ-DB spans 6 clinical specialties and diverse surgical types, providing rich image- and video-level annotations across 18 practical surgical tasks covering understanding, reasoning, planning, and generation, at an unprecedented scale (over 5.98M conversations). Beyond conventional multimodal conversations, SurgΣ-DB incorporates hierarchical reasoning annotations, providing richer semantic cues to support deeper contextual understanding in complex surgical scenarios. We further provide empirical evidence through recently developed surgical foundation models built upon SurgΣ-DB, illustrating the practical benefits of large-scale multimodal annotations, unified semantic design, and structured reasoning annotations for improving cross-task generalization and interpretability.

People supported by AI-powered decision support tools frequently overrely on the AI: they accept an AI's suggestion even when that suggestion is wrong. Adding explanations to the AI decisions does not appear to reduce the overreliance and some studies suggest that it might even increase it. Informed by the dual-process theory of cognition, we posit that people rarely engage analytically with each individual AI recommendation and explanation, and instead develop general heuristics about whether and when to follow the AI suggestions. Building on prior research on medical decision-making, we designed three cognitive forcing interventions to compel people to engage more thoughtfully with the AI-generated explanations. We conducted an experiment (N=199), in which we compared our three cognitive forcing designs to two simple explainable AI approaches and to a no-AI baseline. The results demonstrate that cognitive forcing significantly reduced overreliance compared to the simple explainable AI approaches. However, there was a trade-off: people assigned the least favorable subjective ratings to the designs that reduced the overreliance the most. To audit our work for intervention-generated inequalities, we investigated whether our interventions benefited equally people with different levels of Need for Cognition (i.e., motivation to engage in effortful mental activities). Our results show that, on average, cognitive forcing interventions benefited participants higher in Need for Cognition more. Our research suggests that human cognitive motivation moderates the effectiveness of explainable AI solutions.

More and more processes governing our lives use in some part an automatic decision step, where -- based on a feature vector derived from an applicant -- an algorithm has the decision power over the final outcome. Here we present a simple idea which gives some of the power back to the applicant by providing her with alternatives which would make the decision algorithm decide differently. It is based on a formalization reminiscent of methods used for evasion attacks, and consists in enumerating the subspaces where the classifiers decides the desired output. This has been implemented for the specific case of decision forests (ensemble methods based on decision trees), mapping the problem to an iterative version of enumerating k-cliques.

Equipping agents with the capacity to justify made decisions using supporting evidence represents a cornerstone of accountable decision-making. Furthermore, ensuring that justifications are in line with human expectations and societal norms is vital, especially in high-stakes situations such as healthcare. In this work, we propose the use of a debate-based reward model for reinforcement learning agents, where the outcome of a zero-sum debate game quantifies the justifiability of a decision in a particular state. This reward model is then used to train a justifiable policy, whose decisions can be more easily corroborated with supporting evidence. In the debate game, two argumentative agents take turns providing supporting evidence for two competing decisions. Given the proposed evidence, a proxy of a human judge evaluates which decision is better justified. We demonstrate the potential of our approach in learning policies for prescribing and justifying treatment decisions of septic patients. We show that augmenting the reward with the feedback signal generated by the debate-based reward model yields policies highly favored by the judge when compared to the policy obtained solely from the environment rewards, while hardly sacrificing any performance. Moreover, in terms of the overall performance and justifiability of trained policies, the debate-based feedback is comparable to the feedback obtained from an ideal judge proxy that evaluates decisions using the full information encoded in the state. This suggests that the debate game outputs key information contained in states that is most relevant for evaluating decisions, which in turn substantiates the practicality of combining our approach with human-in-the-loop evaluations. Lastly, we showcase that agents trained via multi-agent debate learn to propose evidence that is resilient to refutations and closely aligns with human preferences.

Foundation models are becoming valuable tools in medicine. Yet despite their promise, the best way to leverage Large Language Models (LLMs) in complex medical tasks remains an open question. We introduce a novel multi-agent framework, named Medical Decision-making Agents (MDAgents) that helps address this gap by automatically assigning a collaboration structure to a team of LLMs. The assigned solo or group collaboration structure is tailored to the medical task at hand, emulating real-world medical decision-making processes adapted to tasks of varying complexities. We evaluate our framework and baseline methods using state-of-the-art LLMs across a suite of real-world medical knowledge and medical diagnosis benchmarks, including a comparison of LLMs' medical complexity classification against human physicians. MDAgents achieved the best performance in seven out of ten benchmarks on tasks requiring an understanding of medical knowledge and multi-modal reasoning, showing a significant improvement of up to 4.2% (p < 0.05) compared to previous methods' best performances. Ablation studies reveal that MDAgents effectively determines medical complexity to optimize for efficiency and accuracy across diverse medical tasks. Notably, the combination of moderator review and external medical knowledge in group collaboration resulted in an average accuracy improvement of 11.8%. Our code can be found at https://github.com/mitmedialab/MDAgents.

Agentic reinforcement learning (RL) is emerging as a critical post-training paradigm for improving LLM agent capabilities. Existing RL algorithms for LLMs largely follow the token-centric paradigm as in RLHF and RLVR, where tokens serve as the basic units for modeling and optimization. However, this paradigm introduces a granularity mismatch in agentic RL, as it optimizes token-level predictions while LLM agents make step-level decisions through cycles of environmental observations and actions. To bridge this gap, we propose StepPO, a step-centric paradigm for agentic RL via step-aligned policy optimization. Specifically, we reformulate agentic RL from a token-level Markov Decision Process (MDP) into a step-level MDP, where interaction steps serve as the basic trajectory representations. We further propose step-level credit assignment to align policy optimization with the natural granularity of agent decisions. Together, StepPO optimizes agent policies at the step level for multi-turn agent-environment interaction. Experiments across multi-hop QA, academic paper search, and text-world action tasks show that StepPO consistently outperforms various RL algorithms. Further analyses provide insights into how step-centric paradigm improves agent training. We hope this step-centric paradigm offers a useful lens for understanding agent behavior and a practical path for training more capable LLM agents.

Large Language Models (LLMs) have been used to make decisions in complex scenarios, where they need models to think deeply, reason logically, and decide wisely. Many existing studies focus solely on multi-round conversations in social tasks or simulated environments, neglecting the various types of decisions and their interdependence. Current reinforcement learning methods struggle to consider the strategies of others during training. To address these issues, we first define a strategic decision-making problem that includes two types of decisions and their temporal dependencies. Furthermore, we propose **T**heory **o**f **M**ind **P**olicy **O**ptimization **(ToMPO)** algorithm to optimize the perception of other individual strategies and the game situation trends. Compared to the Group Relative Policy Optimization (GRPO) algorithm, ToMPO enhances the LLM's strategic decision-making mainly by: 1) generating rollouts based on reasoning the strategies of other individuals, 2) estimating advantages at both the graph-level and sample-level, and 3) balancing global and partial rewards. The ToMPO algorithm outperforms the GRPO method by 35% in terms of model output compliance and cooperative outcomes. Additionally, when compared to models with parameter sizes 100 times larger, it shows an 18% improvement. This demonstrates the effectiveness of the ToMPO algorithm in enhancing the model's strategic decision-making capabilities.

Lung cancer patients frequently experience breakthrough pain episodes, with up to 91% requiring timely intervention. To enable proactive pain management, we propose a hybrid machine learning and large language model pipeline that predicts pain episodes within 48 and 72 hours of hospitalization using both structured and unstructured electronic health record data. A retrospective cohort of 266 inpatients was analyzed, with features including demographics, tumor stage, vital signs, and WHO-tiered analgesic use. The machine learning module captured temporal medication trends, while the large language model interpreted ambiguous dosing records and free-text clinical notes. Integrating these modalities improved sensitivity and interpretability. Our framework achieved an accuracy of 0.874 (48h) and 0.917 (72h), with an improvement in sensitivity of 8.6% and 10.4% due to the augmentation of large language model. This hybrid approach offers a clinically interpretable and scalable tool for early pain episode forecasting, with potential to enhance treatment precision and optimize resource allocation in oncology care.

Chain-of-Thought (CoT) reasoning has proven effective in enhancing large language models by encouraging step-by-step intermediate reasoning, and recent advances have extended this paradigm to Multimodal Large Language Models (MLLMs). In the medical domain, where diagnostic decisions depend on nuanced visual cues and sequential reasoning, CoT aligns naturally with clinical thinking processes. However, Current benchmarks for medical image understanding generally focus on the final answer while ignoring the reasoning path. An opaque process lacks reliable bases for judgment, making it difficult to assist doctors in diagnosis. To address this gap, we introduce a new M3CoTBench benchmark specifically designed to evaluate the correctness, efficiency, impact, and consistency of CoT reasoning in medical image understanding. M3CoTBench features 1) a diverse, multi-level difficulty dataset covering 24 examination types, 2) 13 varying-difficulty tasks, 3) a suite of CoT-specific evaluation metrics (correctness, efficiency, impact, and consistency) tailored to clinical reasoning, and 4) a performance analysis of multiple MLLMs. M3CoTBench systematically evaluates CoT reasoning across diverse medical imaging tasks, revealing current limitations of MLLMs in generating reliable and clinically interpretable reasoning, and aims to foster the development of transparent, trustworthy, and diagnostically accurate AI systems for healthcare. Project page at https://juntaojianggavin.github.io/projects/M3CoTBench/.

A world model is an AI system that simulates how an environment evolves under actions, enabling planning through imagined futures rather than reactive perception. Current world models, however, suffer from visual conflation: the mistaken assumption that high-fidelity video generation implies an understanding of physical and causal dynamics. We show that while modern models excel at predicting pixels, they frequently violate invariant constraints, fail under intervention, and break down in safety-critical decision-making. This survey argues that visual realism is an unreliable proxy for world understanding. Instead, effective world models must encode causal structure, respect domain-specific constraints, and remain stable over long horizons. We propose a reframing of world models as actionable simulators rather than visual engines, emphasizing structured 4D interfaces, constraint-aware dynamics, and closed-loop evaluation. Using medical decision-making as an epistemic stress test, where trial-and-error is impossible and errors are irreversible, we demonstrate that a world model's value is determined not by how realistic its rollouts appear, but by its ability to support counterfactual reasoning, intervention planning, and robust long-horizon foresight.

Every day, countless surgeries are performed worldwide, each within the distinct settings of operating rooms (ORs) that vary not only in their setups but also in the personnel, tools, and equipment used. This inherent diversity poses a substantial challenge for achieving a holistic understanding of the OR, as it requires models to generalize beyond their initial training datasets. To reduce this gap, we introduce ORacle, an advanced vision-language model designed for holistic OR domain modeling, which incorporates multi-view and temporal capabilities and can leverage external knowledge during inference, enabling it to adapt to previously unseen surgical scenarios. This capability is further enhanced by our novel data augmentation framework, which significantly diversifies the training dataset, ensuring ORacle's proficiency in applying the provided knowledge effectively. In rigorous testing, in scene graph generation, and downstream tasks on the 4D-OR dataset, ORacle not only demonstrates state-of-the-art performance but does so requiring less data than existing models. Furthermore, its adaptability is displayed through its ability to interpret unseen views, actions, and appearances of tools and equipment. This demonstrates ORacle's potential to significantly enhance the scalability and affordability of OR domain modeling and opens a pathway for future advancements in surgical data science. We will release our code and data upon acceptance.

Predicting how a patient's vital signs respond to an intervention is a central question in intensive care. World models can do so by learning dynamics as a function of prior actions. However, such models tend to be brittle outside of training data. Clinicians choose drug dosages based on the patient's state, so the association a model learns between dose and outcome runs opposite to the drug's effect, generalizing poorly to out-of-distribution (OOD) dosing practices. Yet, pharmacological information provides the directional effects of different drugs, which are invariant to OOD shifts. To resolve the OOD sensitivity of current ICU world models, we introduce PHYSIO WORLD, which isolates an intervention's effect by evaluating a forward pass twice: once under recorded doses, and once with those doses set to zero. The difference is projected onto pharmacologically admissible effect directions stated by 70 rules over 28 drugs, leaving the magnitude to be learned from data. Across five distribution-shift parameters over cohorts from three intensive-care databases, and against forecasters, counterfactual models, and invariance objectives, PHYSIO WORLD attains the lowest OOD RMSE in every setting, improving on the strongest external baseline by 8-12%, while matching the in-distribution error of its backbone. Reversing the pharmacological directions degrades accuracy below the backbone, and data-mined directions recover almost no gain, indicating the improvement derives from the content of the pharmacological knowledge. The construction may extend to other settings where the sign of an effect is known in advance and its magnitude is confounded by treatment assignment.

LLMs are increasingly being used for complex problems which are not necessarily resolved in a single response, but require interacting with an environment to acquire information. In these scenarios, LLMs must reason about inherent cost-uncertainty tradeoffs in when to stop exploring and commit to an answer. For instance, on a programming task, an LLM should test a generated code snippet if it is uncertain about the correctness of that code; the cost of writing a test is nonzero, but typically lower than the cost of making a mistake. In this work, we show that we can induce LLMs to explicitly reason about balancing these cost-uncertainty tradeoffs, then perform more optimal environment exploration. We formalize multiple tasks, including information retrieval and coding, as sequential decision-making problems under uncertainty. Each problem has latent environment state that can be reasoned about via a prior which is passed to the LLM agent. We introduce a framework called Calibrate-Then-Act (CTA), where we feed the LLM this additional context to enable it to act more optimally. This improvement is preserved even under RL training of both the baseline and CTA. Our results on information-seeking QA and on a simplified coding task show that making cost-benefit tradeoffs explicit with CTA can help agents discover more optimal decision-making strategies.

Recent advancements in large language models (LLMs) often rely on generating intermediate reasoning steps to enhance accuracy. However, little work has examined how reasoning utility contributes to the final answer's correctness. Due to the stochastic nature of autoregressive generation, generating more context does not guarantee increased confidence in the answer. If we could predict, during generation, whether a reasoning step will be useful, we could stop early or prune ineffective steps, avoiding distractions in the final decision. We present an oracle study on MATH dataset, using Qwen2.5-32B and GPT-4o to generate reasoning chains, and then employing a separate model (Qwen3-8B) to quantify the utility of these chains for final accuracy. Specifically, we measure the model's uncertainty on the answer span Y at each reasoning step using conditional entropy (expected negative log-likelihood over the vocabulary) with context expanding step by step. Our results show a clear pattern: conditional entropy that decreases over steps is strongly associated with correct answers, whereas flat or increasing entropy often results in wrong answers. We also corroborate that incorrect reasoning paths tend to be longer than correct ones, suggesting that longer reasoning does not necessarily yield better outcomes. These findings serve as a foundation to inspire future work on designing efficient reasoning pipelines that detect and avoid unproductive reasoning early.

As large language models (LLMs) advance in conversational and reasoning capabilities, their practical application in healthcare has become a critical research focus. However, there is a notable gap between the performance of medical LLMs on static benchmarks such as USMLE and their utility in real-world clinical decision-making. This discrepancy arises because traditional exams fail to capture the dynamic, interactive nature of medical consultations. To address this challenge, we introduce a novel dynamic verification framework that moves beyond static answer verifier, establishing a large-scale, high-fidelity interactive reinforcement learning system. Our framework comprises two key components: a Patient Simulator that creates realistic clinical environments using de-identified medical records, and a Clinical Rubrics Generator that dynamically produces multi-dimensional evaluation metrics. Building on this foundation, we develop Baichuan-M2, a 32B-parameter medical augmented reasoning model trained through a multi-stage reinforcement learning strategy with an improved Group Relative Policy Optimization (GRPO) algorithm. Evaluated on HealthBench, Baichuan-M2 outperforms all other open-source models and most advanced closed-source counterparts, achieving a score above 32 on the challenging HealthBench Hard benchmark-previously exceeded only by GPT-5. Our work demonstrates that robust dynamic verifier system is essential for aligning LLM capabilities with practical clinical applications, establishing a new Pareto front in the performance-parameter trade-off for medical AI deployment.

A central puzzle for the behavioural sciences and for human-facing artificial intelligence is the persistence of within-person variability. The same individual, presented with the same observable input, produces different outcomes on different occasions, and different individuals produce divergent outcomes that no observable covariate fully predicts. We argue that this variability belongs in the dynamic latent state of the person, and that human outcomes are controllable in a precise and operational sense through interventions that target the state and its weighting at the moment a decision is being formed. We define a state as the time-indexed weighting vector over the dimensions that govern how an individual's biology, physiology, and neuropsychology process the next event into a decision and an outcome. The relationship between state, decision, and outcome is causal rather than correlational. The weighting vector is dynamic at sub-daily timescales. The conscious channel through which outcomes are reportable is a narrow attentional bottleneck whose contents are themselves state-dependent. Taken together, these claims imply that the outcome of a given event is controllable, conditionally, on the state-trajectory at the time of intervention. We motivate the framework with six strands of established evidence (causal inference, predictive processing, allostasis, attentional bottleneck, chronobiology, computational psychiatry) and a 24-month observational base from a deployed behavioural platform spanning more than 200,000 consented users across four occupational personas (research period 2023 to 2026). We derive seven testable predictions, list six operational requirements for state-aware systems, and discuss implications for digital health, education, AI personalisation, and personal agency.

Open procedures represent the dominant form of surgery worldwide. Artificial intelligence (AI) has the potential to optimize surgical practice and improve patient outcomes, but efforts have focused primarily on minimally invasive techniques. Our work overcomes existing data limitations for training AI models by curating, from YouTube, the largest dataset of open surgical videos to date: 1997 videos from 23 surgical procedures uploaded from 50 countries. Using this dataset, we developed a multi-task AI model capable of real-time understanding of surgical behaviors, hands, and tools - the building blocks of procedural flow and surgeon skill. We show that our model generalizes across diverse surgery types and environments. Illustrating this generalizability, we directly applied our YouTube-trained model to analyze open surgeries prospectively collected at an academic medical center and identified kinematic descriptors of surgical skill related to efficiency of hand motion. Our Annotated Videos of Open Surgery (AVOS) dataset and trained model will be made available for further development of surgical AI.

Countless decisions shape our daily lives, and it is paramount to understand the how and why behind these choices. In this paper, we introduce a new LLM decision-making framework called STRUX, which enhances LLM decision-making by providing structured explanations. These include favorable and adverse facts related to the decision, along with their respective strengths. STRUX begins by distilling lengthy information into a concise table of key facts. It then employs a series of self-reflection steps to determine which of these facts are pivotal, categorizing them as either favorable or adverse in relation to a specific decision. Lastly, we fine-tune an LLM to identify and prioritize these key facts to optimize decision-making. STRUX has been evaluated on the challenging task of forecasting stock investment decisions based on earnings call transcripts and demonstrated superior performance against strong baselines. It enhances decision transparency by allowing users to understand the impact of different factors, representing a meaningful step towards practical decision-making with LLMs.

Multimodal large language models (MLLMs) hold significant potential in medical applications, including disease diagnosis and clinical decision-making. However, these tasks require highly accurate, context-sensitive, and professionally aligned responses, making reliable reward models and judges critical. Despite their importance, medical reward models (MRMs) and judges remain underexplored, with no dedicated benchmarks addressing clinical requirements. Existing benchmarks focus on general MLLM capabilities or evaluate models as solvers, neglecting essential evaluation dimensions like diagnostic accuracy and clinical relevance. To address this, we introduce Med-RewardBench, the first benchmark specifically designed to evaluate MRMs and judges in medical scenarios. Med-RewardBench features a multimodal dataset spanning 13 organ systems and 8 clinical departments, with 1,026 expert-annotated cases. A rigorous three-step process ensures high-quality evaluation data across six clinically critical dimensions. We evaluate 32 state-of-the-art MLLMs, including open-source, proprietary, and medical-specific models, revealing substantial challenges in aligning outputs with expert judgment. Additionally, we develop baseline models that demonstrate substantial performance improvements through fine-tuning.

Explanations of model behavior are commonly evaluated via proxy properties weakly tied to the purposes explanations serve in practice. We contribute a decision theoretic framework that treats explanations as information signals valued by the expected improvement they enable on a specified decision task. This approach yields three distinct estimands: 1) a theoretical benchmark that upperbounds achievable performance by any agent with the explanation, 2) a human-complementary value that quantifies the theoretically attainable value that is not already captured by a baseline human decision policy, and 3) a behavioral value representing the causal effect of providing the explanation to human decision-makers. We instantiate these definitions in a practical validation workflow, and apply them to assess explanation potential and interpret behavioral effects in human-AI decision support and mechanistic interpretability.

In this study, we propose a multicriteria group decision making (MCGDM) algorithm under uncertainty where data is collected as intervals. The proposed MCGDM algorithm aggregates the data, determines the optimal weights for criteria and ranks alternatives with no further input. The intervals give flexibility to experts in assessing alternatives against criteria and provide an opportunity to gain maximum information. We also propose a novel method to aggregate expert judgements using cloud models. We introduce an experimental approach to check the validity of the aggregation method. After that, we use the aggregation method for an MCGDM problem. Here, we find the optimal weights for each criterion by proposing a bilevel optimisation model. Then, we extend the technique for order of preference by similarity to ideal solution (TOPSIS) for data based on cloud models to prioritise alternatives. As a result, the algorithm can gain information from decision makers with different levels of uncertainty and examine alternatives with no more information from decision-makers. The proposed MCGDM algorithm is implemented on a case study of a cybersecurity problem to illustrate its feasibility and effectiveness. The results verify the robustness and validity of the proposed MCGDM using sensitivity analysis and comparison with other existing algorithms.

Reasoning is central to a wide range of intellectual activities, and while the capabilities of large language models (LLMs) continue to advance, their performance in reasoning tasks remains limited. The processes and mechanisms underlying reasoning are not yet fully understood, but key elements include path exploration, selection of relevant knowledge, and multi-step inference. Problems are solved through the synthesis of these components. In this paper, we propose a benchmark that focuses on a specific aspect of reasoning ability: the direct evaluation of multi-step inference. To this end, we design a special reasoning task where multi-step inference is specifically focused by largely eliminating path exploration and implicit knowledge utilization. Our dataset comprises pairs of explicit instructions and corresponding questions, where the procedures necessary for solving the questions are entirely detailed within the instructions. This setup allows models to solve problems solely by following the provided directives. By constructing problems that require varying numbers of steps to solve and evaluating responses at each step, we enable a thorough assessment of state-of-the-art LLMs' ability to follow instructions. To ensure the robustness of our evaluation, we include multiple distinct tasks. Furthermore, by comparing accuracy across tasks, utilizing step-aware metrics, and applying separately defined measures of complexity, we conduct experiments that offer insights into the capabilities and limitations of LLMs in reasoning tasks. Our findings have significant implications for the development of LLMs and highlight areas for future research in advancing their reasoning abilities. Our dataset is available at https://huggingface.co/datasets/ifujisawa/procbench and code at https://github.com/ifujisawa/proc-bench.

Building upon our previous investigations of O1 replication (Part 1: Journey Learning [Qin et al., 2024] and Part 2: Distillation [Huang et al., 2024]), this work explores the potential of inference-time scaling in large language models (LLMs) for medical reasoning tasks, ranging from diagnostic decision-making to treatment planning. Through extensive experiments on medical benchmarks of varying complexity (MedQA, Medbullets, and JAMA Clinical Challenges), our investigation reveals several key insights: (1) Increasing inference time does lead to improved performance. With a modest training set of 500 samples, our model yields substantial performance improvements of 6%-11%. (2) Task complexity directly correlates with the required length of reasoning chains, confirming the necessity of extended thought processes for challenging problems. (3) The differential diagnoses generated by our model adhere to the principles of the hypothetico-deductive method, producing a list of potential conditions that may explain a patient's symptoms and systematically narrowing these possibilities by evaluating the evidence. These findings demonstrate the promising synergy between inference-time scaling and journey learning in advancing LLMs' real-world clinical reasoning capabilities.

Large language model (LLM) systems are increasingly used to support high-stakes decision-making, but they typically perform worse when the available evidence is internally inconsistent. Such a scenario exists in real-world healthcare settings, with patient-reported symptoms contradicting medical signs. To study this problem, we introduce MIMIC-DOS, a dataset for short-horizon organ dysfunction worsening prediction in the intensive care unit (ICU) setting. We derive this dataset from the widely recognized MIMIC-IV, a publicly available electronic health record dataset, and construct it exclusively from cases in which discordance between signs and symptoms exists. This setting poses a substantial challenge for existing LLM-based approaches, with single-pass LLMs and agentic pipelines often struggling to reconcile such conflicting signals. To address this problem, we propose CARE: a multi-stage privacy-compliant agentic reasoning framework in which a remote LLM provides guidance by generating structured categories and transitions without accessing sensitive patient data, while a local LLM uses these categories and transitions to support evidence acquisition and final decision-making. Empirically, CARE achieves stronger performance across all key metrics compared to multiple baseline settings, showing that CARE can more robustly handle conflicting clinical evidence while preserving privacy.

A robot that fails at a task faces the first decision in corrective dialogue: act on its own diagnosis, consult another onboard sensor, or interrupt a person. Choosing well requires knowing how much the robot's sensors reveal about the cause and how reliable the robot's own diagnosis is. We build a simulated benchmark in which every failure's true cause is known, because we injected it, and measure what each sensor reveals, with explicit checks against data leakage. Some failures are diagnosable from camera images; others only from the robot's force data (0.99 from force data, no image method above 0.55). We then test six open vision-language models. Their behavior tracks the surface of the prompt, not the evidence: moving the refusal option from last to first in the answer list collapses refusal rates from 78-100% to 0-6% in three of the six swept model-and-family pairs. Accuracy from frames stays at or below a majority-class baseline under every prompt variant, with or without worked examples, and stated confidence carries no information about correctness. Handing the same models the force data as ten lines of text produces the first above-baseline diagnoses, in four of the six models: much of the failure reflects missing sensor data, not missing ability. We pose the choice as a three-action decision problem, act, consult your own sensors, or ask a human, whose optimal policy follows from measured accuracy. The models do not follow it, and their ask rates ignore a fourfold change in question cost. One question to a human still lifts them from that baseline to roughly the answerer's own reliability (0.70-0.81 when they ask). The decision to ask should be tied to measured accuracy and stated costs, not to the model's confidence.

The "thinking-with-images" paradigm equips multimodal LLMs with active visual operations such as crop-and-zoom. However, models using these operations often achieve only marginal or negative gains over direct inference at substantially higher token cost. They may also repeatedly crop irrelevant regions and fail on questions that direct inference answers correctly. We ask whether the returned visual evidence causally affects the answer. To answer this question, we formulate visual tool-use as a causal graph that separates observation-mediated paths from action-induced shortcuts. We then audit it through interventions at the three levels: policy (comparing tool-use with direct inference), trajectory (corrupting all observations during rollout), and step (counterfactually replacing one individual observation under a fixed prefix). Our step-level estimand, Visual Evidence Gain, isolates the contribution of each returned observation. Across six representative models and five fine-grained perception benchmarks, we uncover policy miscalibration with two failure modes. In Calling Without Looking, returned observations have no causal effect on the answer. In Looking Without Planning, observations are informative but the call schedule is incoherent. A trajectory-level diagnostic decomposes the policy-level accuracy gain and shows that the gain is concentrated in a Calibrated minority. We term this discrepancy the illusion of visual tool-use: despite aggregate accuracy gains, visual tool-use is not causally effective across a broad range of rollouts. The code is available at https://github.com/OpenCausaLab/CauAudit.

Large reasoning models have recently made significant strides in mathematical and code reasoning, yet their success has not transferred smoothly to the medical domain. While multiple factors contribute to this disparity, a critical issue is the inadequate focus on the quality of intermediate reflection steps, which is particularly crucial in high-stakes medical scenarios. To address this challenge, we propose Med-REFL, a \textbf{Med}ical \textbf{R}easoning \textbf{E}nhancement via self-corrected \textbf{F}ine-grained ref\textbf{L}ection. Our method leverages a tree-of-thought approach to decompose medical questions into fine-grained reasoning paths, quantitatively evaluating each step and its subsequent reflections. These assessments enable automatic construction of direct preference optimization data, reducing reliance on expensive expert annotations while guiding models to identify and correct reasoning errors. Experimental results on the MedQA-USMLE benchmark demonstrate Med-REFL achieves consistent improvements, with average gains up to 4.11\%. Notably, it further boosts the state-of-the-art performance of 7B/8B models by an additional 4.13\%. Furthermore, Med-REFL exhibits strong generalization capabilities and robustness across several challenging medical question-answering datasets. Our work illustrates that prioritizing reflection quality leads to more accurate and trustworthy reasoning in medical AI applications. Checkpoints, code, and data can be found https://github.com/TianYin123/Med-REFL{here}.

Mental health problems such as anxiety, depression, and suicide remain urgent global challenges, where timely and accurate assessment is critical for effective intervention. Recently, large language models have been explored for mental health assessment. However, existing general-purpose post-training methods do not align with the cognitive processes of human assessment, which may lead to unreliable reasoning outcomes. To bridge this gap, we propose Cognitive Relative Policy Optimization (CRPO), a reinforcement learning framework tailored for the mental health domain. CRPO extends group relative policy optimization by integrating stage-dependent uncertainty modeling into the policy optimization process. Specifically, we introduce a stage-wise entropy regularization mechanism that encourages broad exploration in early reasoning phases and progressively enforces confident decision-making in later stages, mimicking the human cognitive shift from uncertainty to certainty. In addition, inspired by cognitive appraisal theory, we formalize cognitive reasoning stages, thereby guiding theory-grounded interpretable inference. Experiments on 8 mental health datasets show that CRPO achieves an average improvement of 10.4 percentage points in weighted F1-score over the best reinforcement learning baseline. Furthermore, the CRPO-trained model Mental-R1 demonstrates clear advantages compared with existing large language models on reasoning-intensive cases, suggesting that CRPO enhances reasoning capabilities for mental health assessment.

Current Large Language Models (LLMs) exhibit significant limitations, notably in structured, interpretable, and verifiable medical reasoning, alongside practical deployment challenges related to computational resources and data privacy. This report focused on the development of WiNGPT-3.0, the 32-billion parameter LLMs, engineered with the objective of enhancing its capacity for medical reasoning and exploring its potential for effective integration within healthcare IT infrastructures. The broader aim is to advance towards clinically applicable models. The approach involved a multi-stage training pipeline tailored for general, medical, and clinical reasoning. This pipeline incorporated supervised fine-tuning (SFT) and reinforcement learning (RL), leveraging curated Long Chain-of-Thought (CoT) datasets, auxiliary reward models, and an evidence-based diagnostic chain simulation. WiNGPT-3.0 demonstrated strong performance: specific model variants achieved scores of 66.6 on MedCalc and 87.1 on MedQA-USMLE. Furthermore, targeted training improved performance on a clinical reasoning task from a baseline score of 58.1 to 62.5. These findings suggest that reinforcement learning, even when applied with a limited dataset of only a few thousand examples, can enhance medical reasoning accuracy. Crucially, this demonstration of RL's efficacy with limited data and computation paves the way for more trustworthy and practically deployable LLMs within clinical workflows and health information infrastructures.

Long-horizon agents are beginning to automate complete workflows that produce code, reports, and research artifacts. Medical imaging workflows are multi-stage and data-sensitive, while expert trajectories remain scarce and difficult to share. Structured benchmarks can localize failures through stage-level rubrics, but standard post-training discards these diagnostics before the next training round. We present Benchmark-as-Teacher (BaT), a recursive self-improvement system for agent post-training. BaT contains two linked components: the asynchronous Stage Bank data pipeline and BiCuRL (Bilevel Curriculum Reinforcement Learning), its self-improving post-training method. Stage Bank synthesizes content-isolated training states outside the policy-update loop. BiCuRL uses a fixed held-out evaluation to select the next stage curriculum, verifies rollouts with task rubrics, updates the policy with GRPO, and returns the candidate checkpoint to evaluation. On AutoMedBench-Lite, BaT-4B and BaT-9B more than double the Overall scores of their Qwen Instruct baselines. BaT-9B Agent reaches 79.6 Overall, exceeding Claude Opus 4.6 with Claude Code at 77.5.

Recent multimodal large language models have shown great promise in clinical image reasoning, but existing post-training pipelines remain predominantly outcome-centric, relying on final answer correctness or sequence-level preferences. This suffers from sparse credit assignment, making it difficult to optimize the reasoning process essential for clinical applications. Our analysis reveals that cascading errors from early-stage reasoning failures are a leading cause of incorrect predictions in medical visual question answering (VQA) benchmarks. Motivated by this, we propose Medical Reasoning-aware Policy Optimization (MRPO), an RL algorithm that incorporates step-wise process rewards. When the final answer is incorrect, MRPO assigns exponentially larger penalties to tokens in earlier invalid reasoning steps, breaking failure cascades without compromising successful paths. Across three multimodal LLM backbones, MRPO consistently outperforms standard GRPO and a recent RL baseline, and on Qwen3-VL-8B-Instruct even surpasses substantially larger medical MLLMs such as HuatuoGPT-Vision-34B by 2.79 points. Moreover, MRPO reduces early-stage reasoning failures from 64.0% to 13.0%, showing that targeted mitigation of cascading failures improves both reasoning quality and final answer accuracy. Our code is available at https://github.com/dmis-lab/MRPO

Recent advances in medical large language models (LLMs), multimodal models, and agents demand evaluation frameworks that reflect real clinical workflows and safety constraints. We present MedBench v4, a nationwide, cloud-based benchmarking infrastructure comprising over 700,000 expert-curated tasks spanning 24 primary and 91 secondary specialties, with dedicated tracks for LLMs, multimodal models, and agents. Items undergo multi-stage refinement and multi-round review by clinicians from more than 500 institutions, and open-ended responses are scored by an LLM-as-a-judge calibrated to human ratings. We evaluate 15 frontier models. Base LLMs reach a mean overall score of 54.1/100 (best: Claude Sonnet 4.5, 62.5/100), but safety and ethics remain low (18.4/100). Multimodal models perform worse overall (mean 47.5/100; best: GPT-5, 54.9/100), with solid perception yet weaker cross-modal reasoning. Agents built on the same backbones substantially improve end-to-end performance (mean 79.8/100), with Claude Sonnet 4.5-based agents achieving up to 85.3/100 overall and 88.9/100 on safety tasks. MedBench v4 thus reveals persisting gaps in multimodal reasoning and safety for base models, while showing that governance-aware agentic orchestration can markedly enhance benchmarked clinical readiness without sacrificing capability. By aligning tasks with Chinese clinical guidelines and regulatory priorities, the platform offers a practical reference for hospitals, developers, and policymakers auditing medical AI.

General decision models, such as Jev, have recently emerged as efficient alternatives to LLMs for structured judgment and selection. But what kinds of decisions can these models reliably make, and how does their behavior change when individual decisions are composed into larger systems? To study this, we introduce JEVal, a bilingual benchmark comprising 11,257 instances from 36 datasets across 10 application domains, and evaluate 25 model configurations spanning general decision models and generative LLMs. Our results show that (1) general decision models are most competitive when decisions can be resolved from available evidence, but weaken when they require specialist knowledge or faithful uncertainty estimation: they can often identify the most likely outcome while substantially overstating its probability. (2) In more dynamic and realistic systems involving long-horizon, multi-step interactions, the advantages of fast local decision making are offset by reliability failures at the system level. on τ-bench, faster local decisions reduce median episode time but lower task success as decision errors accumulate over long trajectories. (3) In large-scale social simulation, decision models approach strong generative LLMs on individual response prediction at substantially lower inference cost, yet remain weaker in user profiling and exhibit larger aggregate estimation errors and systematic bias. Finally, we propose InnerJev-4B and InnerJev-27B, which internalize an open-weight LLM's own reasoning into a single-pass first-token decision through Reasoning-to-Readout Self-Distillation, with InnerJev-27B performing on par with Jev on JEVal while answering a typical query in about 0.1 s.

Frontier language models excel at complex tasks yet may prioritize protection over larger physical consequences in simple, urgent decisions. GPT-5.6 Sol, for example, moves a girl playing in shallow water before retrieving a submerged camera. We call this Protection Mode and study it with ProtectionBench: 285 prompts, 34 physical families, and nine models. At lowest effort, at least one of four responses prioritizes the subject on 34.74% of Sol prompts and over 83% of MiniMax M3 and Qwen3.5-27B prompts; none of four independent human raters does so. Controls show that choices usually track physical risk. We elicit both risks before requesting an action. Some models assess risk incorrectly; others state the correct ordering but still choose the subject. Qwen3.5-27B with thinking shows 100% correct risk ordering but 57.81% subject choice among eligible conversations on eight selected scenes. Attention audits find no stable reduction in attention to relevant facts; removing the stated risk direction reduces object-first choice in dots3-note-prev but not detectably in Qwen3.5-27B. Adding a general "people or animals before property" rule increases subject choice by 19-38 percentage points, whereas factual reminders favor the object by 0.7-5.2 points. Removing naturally generated versions of that rule lowers subject choice by 10-15 points. We also examine whether post-training introduces this pattern. Base models already show Protection Mode; post-training changes justifications more than choices.

PURPOSE: Surgical workflow and skill analysis are key technologies for the next generation of cognitive surgical assistance systems. These systems could increase the safety of the operation through context-sensitive warnings and semi-autonomous robotic assistance or improve training of surgeons via data-driven feedback. In surgical workflow analysis up to 91% average precision has been reported for phase recognition on an open data single-center dataset. In this work we investigated the generalizability of phase recognition algorithms in a multi-center setting including more difficult recognition tasks such as surgical action and surgical skill. METHODS: To achieve this goal, a dataset with 33 laparoscopic cholecystectomy videos from three surgical centers with a total operation time of 22 hours was created. Labels included annotation of seven surgical phases with 250 phase transitions, 5514 occurences of four surgical actions, 6980 occurences of 21 surgical instruments from seven instrument categories and 495 skill classifications in five skill dimensions. The dataset was used in the 2019 Endoscopic Vision challenge, sub-challenge for surgical workflow and skill analysis. Here, 12 teams submitted their machine learning algorithms for recognition of phase, action, instrument and/or skill assessment. RESULTS: F1-scores were achieved for phase recognition between 23.9% and 67.7% (n=9 teams), for instrument presence detection between 38.5% and 63.8% (n=8 teams), but for action recognition only between 21.8% and 23.3% (n=5 teams). The average absolute error for skill assessment was 0.78 (n=1 team). CONCLUSION: Surgical workflow and skill analysis are promising technologies to support the surgical team, but are not solved yet, as shown by our comparison of algorithms. This novel benchmark can be used for comparable evaluation and validation of future work.

The deployment of large language models (LLMs) in mental health and other sensitive domains raises urgent questions about ethical reasoning, fairness, and responsible alignment. Yet, existing benchmarks for moral and clinical decision-making do not adequately capture the unique ethical dilemmas encountered in mental health practice, where confidentiality, autonomy, beneficence, and bias frequently intersect. To address this gap, we introduce Ethical Reasoning in Mental Health (EthicsMH), a pilot dataset of 125 scenarios designed to evaluate how AI systems navigate ethically charged situations in therapeutic and psychiatric contexts. Each scenario is enriched with structured fields, including multiple decision options, expert-aligned reasoning, expected model behavior, real-world impact, and multi-stakeholder viewpoints. This structure enables evaluation not only of decision accuracy but also of explanation quality and alignment with professional norms. Although modest in scale and developed with model-assisted generation, EthicsMH establishes a task framework that bridges AI ethics and mental health decision-making. By releasing this dataset, we aim to provide a seed resource that can be expanded through community and expert contributions, fostering the development of AI systems capable of responsibly handling some of society's most delicate decisions.

Surgical procedures are inherently complex and risky, requiring extensive expertise and constant focus to navigate evolving intraoperative scenes. Computer-assisted systems such as surgical visual question answering (VQA) offer promises for education and intraoperative support. Current surgical VQA research largely focuses on static frame analysis, overlooking rich temporal semantics. Surgical video question answering is further challenged by low visual contrast, its highly knowledge-driven nature, diverse analytical needs spanning scattered temporal windows, and the hierarchy from basic perception to high-level intraoperative assessment. To address these challenges, we propose SurgTEMP, a multimodal LLM framework featuring (i) a query-guided token selection module that builds hierarchical visual memory (spatial and temporal memory banks) and (ii) a Surgical Competency Progression (SCP) training scheme. Together, they enable effective modeling of variable-length surgical videos while preserving procedure-relevant cues and temporal coherence, and better support diverse downstream assessment tasks. To support model development, we introduce CholeVidQA-32K, a surgical video question answering dataset comprising 32K open-ended QA pairs and 3,855 video segments (approximately 128 h total) from laparoscopic cholecystectomy. The dataset is organized into a three-level hierarchy -- Perception, Assessment, and Reasoning -- spanning 11 tasks from instrument/action/anatomy perception to Critical View of Safety (CVS), intraoperative difficulty, skill proficiency, and adverse event assessment. In comprehensive evaluations against state-of-the-art open-source multimodal and video LLMs (fine-tuned and zero-shot), SurgTEMP achieves substantial performance improvements, advancing the state of video-based surgical VQA. The project page is available at: https://camma-public.github.io/SurgTEMP/

Inpatient clinical reasoning is a sequential decision under partial observability: the clinician sees the admission so far and must choose the next action whose downstream consequences are not yet visible. Existing clinical-LLM evaluations and RL rewards signals collapse this into closed-form retrieval, clinical journey leakage, or unanchored LLM-as-judge scoring. We introduce CLR-voyance, a framework that reformulates inpatient reasoning as a Partially Observable Markov Decision Process (POMDP) and supervises it with rewards that are simultaneously outcome-grounded and clinician-validated. We instantiate the formulation as CLR-POMDP, which partitions successful patient journeys into a policy-visible past and an oracle-only future. Using the past information, an oracle LLM generates a case-specific query-answer pair, and the first adaptive rubric for clinical reasoning which is verifiable in the future of the patient journey. These rubrics are used for both post-training and evaluation of models for inpatient clinical reasoning. We post-train Qwen3-8B and MedGemma-4B with GRPO followed by model merging, yielding state-of-the-art inpatient clinical reasoning while retaining generalist capabilities. CLR-voyance-8B achieves 84.91% on CLR-POMDP, ahead of frontier medical reasoning models like GPT-5 (77.83%) and MedGemma-27B (66.66%) and has comparable or better performance on existing medical benchmarks. To ensure a clinically meaningful setting, we conduct a large-scale clinician alignment study, where physicians curate per-case rubrics, grade candidate responses, and provide blinded pairwise preferences of model reasoning. This study provides insights on clinical LLM-as-a-judge and clinical preference-model selection, which can inform the community at large. CLR-voyance has been deployed for 6+ months at a partner public hospital, drafting thousands of reasoning-heavy inpatient notes.

Treatment reasoning underpins every therapeutic decision, integrating disease context, comorbidities, medications, contraindications, and evolving biomedical knowledge to select an appropriate therapy. It is inherently iterative: candidates are weighed against many constraints, revised as evidence emerges, and grounded in verifiable sources. Here we introduce ATHENA-R1, an AI agent for treatment reasoning across all FDA approved drugs since 1939, trained by reinforcement learning over a universe of 212 biomedical tools. At each step it identifies missing information, selects and runs relevant tools, and incorporates the evidence. To train it without human-annotated traces, we build a two-level self-learning framework: multi-agent systems construct the tools, tasks, and reasoning trajectories for supervised fine-tuning, then reinforcement learning with scientific feedback rewards reasoning quality (evidence gathering, grounded tool use, logical non-redundancy). Across five benchmarks of 3,168 drug reasoning tasks and 456 patient treatment cases, ATHENA-R1 outperforms language models and tool-use systems, reaching 94.7% accuracy on open-ended drug reasoning and 82.9% on treatment reasoning, 17.8 and 10.7 points above GPT-5. In blinded evaluations by experts from 28 rare disease organizations, it is preferred over reference models on all criteria, and physicians rated it favorably on complex hospitalized cardiovascular and infectious-disease cases. Adverse-event hypotheses it generated, tested in electronic health records from 5.4 million patients, reached adjusted odds ratios of 1.48-1.84, with no elevation among negative controls. Because it requires knowing what evidence to seek before concluding, treatment reasoning has long been hard for AI; we show it can be reframed as a learnable process of iterative evidence gathering that reinforcement learning can train AI to perform.

Clinical evidence, derived from rigorous research and data analysis, provides healthcare professionals with reliable scientific foundations for informed decision-making. Integrating clinical evidence into real-time practice is challenging due to the enormous workload, complex professional processes, and time constraints. This highlights the need for tools that automate evidence synthesis to support more efficient and accurate decision making in clinical settings. This study introduces Quicker, an evidence-based clinical decision support system powered by large language models (LLMs), designed to automate evidence synthesis and generate clinical recommendations modeled after standard clinical guideline development processes. Quicker implements a fully automated chain that covers all phases, from questions to clinical recommendations, and further enables customized decision-making through integrated tools and interactive user interfaces. To evaluate Quicker's capabilities, we developed the Q2CRBench-3 benchmark dataset, based on clinical guideline development records for three different diseases. Experimental results highlighted Quicker's strong performance, with fine-grained question decomposition tailored to user preferences, retrieval sensitivities comparable to human experts, and literature screening performance approaching comprehensive inclusion of relevant studies. In addition, Quicker-assisted evidence assessment effectively supported human reviewers, while Quicker's recommendations were more comprehensive and logically coherent than those of clinicians. In system-level testing, collaboration between a single reviewer and Quicker reduced the time required for recommendation development to 20-40 minutes. In general, our findings affirm the potential of Quicker to help physicians make quicker and more reliable evidence-based clinical decisions.

We have only limited understanding of how and why large language models (LLMs) respond in the ways that they do. Their neural networks have proven challenging to interpret, and we are only beginning to tease out the function of individual neurons and circuits within them. However, another path to understanding these systems is to investigate and develop their capacity to introspect and explain their own functioning. Here, we show that i) contemporary LLMs are capable of providing accurate, quantitative descriptions of their own internal processes during certain kinds of decision-making, ii) that it is possible to improve these capabilities through training, and iii) that this training generalizes to at least some degree. To do so, we fine-tuned GPT-4o and GPT-4o-mini to make decisions in a wide variety of complex contexts (e.g., choosing between condos, loans, vacations, etc.) according to randomly-generated, quantitative preferences about how to weigh different attributes during decision-making (e.g., the relative importance of natural light versus quiet surroundings for condos). We demonstrate that the LLMs can accurately report these preferences (i.e., the weights that they learned to give to different attributes during decision-making). Next, we demonstrate that these LLMs can be fine-tuned to explain their decision-making even more accurately. Finally, we demonstrate that this training generalizes: It improves the ability of the models to accurately explain what they are doing as they make other complex decisions, not just decisions they have learned to make via fine-tuning. This work is a step towards training LLMs to accurately and broadly report on their own internal processes -- a possibility that would yield substantial benefits for interpretability, control, and safety.

Online medical consultation (OMC) restricts doctors to gathering patient information solely through inquiries, making the already complex sequential decision-making process of diagnosis even more challenging. Recently, the rapid advancement of large language models has demonstrated a significant potential to transform OMC. However, most studies have primarily focused on improving diagnostic accuracy under conditions of relatively sufficient information, while paying limited attention to the "inquiry" phase of the consultation process. This lack of focus has left the relationship between "inquiry" and "diagnosis" insufficiently explored. In this paper, we first extract real patient interaction strategies from authentic doctor-patient conversations and use these strategies to guide the training of a patient simulator that closely mirrors real-world behavior. By inputting medical records into our patient simulator to simulate patient responses, we conduct extensive experiments to explore the relationship between "inquiry" and "diagnosis" in the consultation process. Experimental results demonstrate that inquiry and diagnosis adhere to the Liebig's law: poor inquiry quality limits the effectiveness of diagnosis, regardless of diagnostic capability, and vice versa. Furthermore, the experiments reveal significant differences in the inquiry performance of various models. To investigate this phenomenon, we categorize the inquiry process into four types: (1) chief complaint inquiry; (2) specification of known symptoms; (3) inquiry about accompanying symptoms; and (4) gathering family or medical history. We analyze the distribution of inquiries across the four types for different models to explore the reasons behind their significant performance differences. We plan to open-source the weights and related code of our patient simulator at https://github.com/LIO-H-ZEN/PatientSimulator.

Agents significantly enhance the capabilities of standalone Large Language Models (LLMs) by perceiving environments, making decisions, and executing actions. However, LLM agents still face challenges in tasks that require multiple decision-making steps. Estimating the value of actions in specific tasks is difficult when intermediate actions are neither appropriately rewarded nor penalized. In this paper, we propose leveraging a task-relevant Q-value model to guide action selection. Specifically, we first collect decision-making trajectories annotated with step-level Q values via Monte Carlo Tree Search (MCTS) and construct preference data. We then use another LLM to fit these preferences through step-level Direct Policy Optimization (DPO), which serves as the Q-value model. During inference, at each decision-making step, LLM agents select the action with the highest Q value before interacting with the environment. We apply our method to various open-source and API-based LLM agents, demonstrating that Q-value models significantly improve their performance. Notably, the performance of the agent built with Phi-3-mini-4k-instruct improved by 103% on WebShop and 75% on HotPotQA when enhanced with Q-value models, even surpassing GPT-4o-mini. Additionally, Q-value models offer several advantages, such as generalization to different LLM agents and seamless integration with existing prompting strategies.

The general sequential decision-making problem, which includes Markov decision processes (MDPs) and partially observable MDPs (POMDPs) as special cases, aims at maximizing a cumulative reward by making a sequence of decisions based on a history of observations and actions over time. Recent studies have shown that the sequential decision-making problem is statistically learnable if it admits a low-rank structure modeled by predictive state representations (PSRs). Despite these advancements, existing approaches typically involve oracles or steps that are computationally intractable. On the other hand, the upper confidence bound (UCB) based approaches, which have served successfully as computationally efficient methods in bandits and MDPs, have not been investigated for more general PSRs, due to the difficulty of optimistic bonus design in these more challenging settings. This paper proposes the first known UCB-type approach for PSRs, featuring a novel bonus term that upper bounds the total variation distance between the estimated and true models. We further characterize the sample complexity bounds for our designed UCB-type algorithms for both online and offline PSRs. In contrast to existing approaches for PSRs, our UCB-type algorithms enjoy computational tractability, last-iterate guaranteed near-optimal policy, and guaranteed model accuracy.

Pain is a complex and pervasive condition that affects a significant portion of the population. Accurate and consistent assessment is essential for individuals suffering from pain, as well as for developing effective management strategies in a healthcare system. Automatic pain assessment systems enable continuous monitoring, support clinical decision-making, and help minimize patient distress while mitigating the risk of functional deterioration. Leveraging physiological signals offers objective and precise insights into a person's state, and their integration in a multimodal framework can further enhance system performance. This study has been submitted to the Second Multimodal Sensing Grand Challenge for Next-Gen Pain Assessment (AI4PAIN). The proposed approach introduces Tiny-BioMoE, a lightweight pretrained embedding model for biosignal analysis. Trained on 4.4 million biosignal image representations and consisting of only 7.3 million parameters, it serves as an effective tool for extracting high-quality embeddings for downstream tasks. Extensive experiments involving electrodermal activity, blood volume pulse, respiratory signals, peripheral oxygen saturation, and their combinations highlight the model's effectiveness across diverse modalities in automatic pain recognition tasks. The model's architecture (code) and weights are available at https://github.com/GkikasStefanos/Tiny-BioMoE.

Most benchmarks for studying surgical interventions focus on a specific challenge instead of leveraging the intrinsic complementarity among different tasks. In this work, we present a new experimental framework towards holistic surgical scene understanding. First, we introduce the Phase, Step, Instrument, and Atomic Visual Action recognition (PSI-AVA) Dataset. PSI-AVA includes annotations for both long-term (Phase and Step recognition) and short-term reasoning (Instrument detection and novel Atomic Action recognition) in robot-assisted radical prostatectomy videos. Second, we present Transformers for Action, Phase, Instrument, and steps Recognition (TAPIR) as a strong baseline for surgical scene understanding. TAPIR leverages our dataset's multi-level annotations as it benefits from the learned representation on the instrument detection task to improve its classification capacity. Our experimental results in both PSI-AVA and other publicly available databases demonstrate the adequacy of our framework to spur future research on holistic surgical scene understanding.

Multi-step planning has been widely employed to enhance the performance of large language models (LLMs) on downstream natural language processing (NLP) tasks, which decomposes the original task into multiple subtasks and guide LLMs to solve them sequentially without additional training. When addressing task instances, existing methods either preset the order of steps or attempt multiple paths at each step. However, these methods overlook instances' linguistic features and rely on the intrinsic planning capabilities of LLMs to evaluate intermediate feedback and then select subtasks, resulting in suboptimal outcomes. To better solve multi-step NLP tasks with LLMs, in this paper we propose a Reinforcement Learning enhanced Adaptive Planning framework (RLAP). In our framework, we model an NLP task as a Markov decision process (MDP) and employ an LLM directly into the environment. In particular, a lightweight Actor model is trained to estimate Q-values for natural language sequences consisting of states and actions through reinforcement learning. Therefore, during sequential planning, the linguistic features of each sequence in the MDP can be taken into account, and the Actor model interacts with the LLM to determine the optimal order of subtasks for each task instance. We apply RLAP on three different types of NLP tasks and conduct extensive experiments on multiple datasets to verify RLAP's effectiveness and robustness.

Explaining Artificial Intelligence (AI) decisions is a major challenge nowadays in AI, in particular when applied to sensitive scenarios like medicine and law. However, the need to explain the rationale behind decisions is a main issue also for human-based deliberation as it is important to justify why a certain decision has been taken. Resident medical doctors for instance are required not only to provide a (possibly correct) diagnosis, but also to explain how they reached a certain conclusion. Developing new tools to aid residents to train their explanation skills is therefore a central objective of AI in education. In this paper, we follow this direction, and we present, to the best of our knowledge, the first multilingual dataset for Medical Question Answering where correct and incorrect diagnoses for a clinical case are enriched with a natural language explanation written by doctors. These explanations have been manually annotated with argument components (i.e., premise, claim) and argument relations (i.e., attack, support), resulting in the Multilingual CasiMedicos-Arg dataset which consists of 558 clinical cases in four languages (English, Spanish, French, Italian) with explanations, where we annotated 5021 claims, 2313 premises, 2431 support relations, and 1106 attack relations. We conclude by showing how competitive baselines perform over this challenging dataset for the argument mining task.

Agentic AI is advancing rapidly, yet truly autonomous medical-imaging triage, where a system decides when to stop, escalate, or defer under real constraints, remains relatively underexplored. To address this gap, we introduce AT-CXR, an uncertainty-aware agent for chest X-rays. The system estimates per-case confidence and distributional fit, then follows a stepwise policy to issue an automated decision or abstain with a suggested label for human intervention. We evaluate two router designs that share the same inputs and actions: a deterministic rule-based router and an LLM-decided router. Across five-fold evaluation on a balanced subset of NIH ChestX-ray14 dataset, both variants outperform strong zero-shot vision-language models and state-of-the-art supervised classifiers, achieving higher full-coverage accuracy and superior selective-prediction performance, evidenced by a lower area under the risk-coverage curve (AURC) and a lower error rate at high coverage, while operating with lower latency that meets practical clinical constraints. The two routers provide complementary operating points, enabling deployments to prioritize maximal throughput or maximal accuracy. Our code is available at https://github.com/XLIAaron/uncertainty-aware-cxr-agent.

In medical applications, deep learning methods are built to automate diagnostic tasks. However, a clinically relevant question that practitioners usually face, is how to predict the future trajectory of a disease (prognosis). Current methods for such a problem often require domain knowledge, and are complicated to apply. In this paper, we formulate the prognosis prediction problem as a one-to-many forecasting problem from multimodal data. Inspired by a clinical decision-making process with two agents -- a radiologist and a general practitioner, we model a prognosis prediction problem with two transformer-based components that share information between each other. The first block in this model aims to analyze the imaging data, and the second block leverages the internal representations of the first one as inputs, also fusing them with auxiliary patient data. We show the effectiveness of our method in predicting the development of structural knee osteoarthritis changes over time. Our results show that the proposed method outperforms the state-of-the-art baselines in terms of various performance metrics. In addition, we empirically show that the existence of the multi-agent transformers with depths of 2 is sufficient to achieve good performances. Our code is publicly available at https://github.com/MIPT-Oulu/CLIMAT.