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/.

Health economic evaluations are sensitive to the choice of analytical perspective (e.g., health system vs. societal). While guidelines often recommend specific perspectives, the uncertainty associated with this choice - and the potential decision discordance it creates - is rarely quantified. We present vop_poc_nz, a Python package that implements a framework for Distributional Cost-Effectiveness Analysis (DCEA) and operationalizes the quantification of perspective uncertainty through the Value of Perspective (VoP) metric. The package provides tools for Markov modeling, probabilistic sensitivity analysis, value of information analysis, and equity impact assessment. Unlike existing tools that treat perspective as a fixed input, vop_poc_nz allows for the simultaneous evaluation of multiple perspectives. This enables decision-makers to estimate the opportunity cost of perspective misalignment. We demonstrate the package's capabilities using case studies from Aotearoa New Zealand.

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.

Off-policy evaluation (OPE) is a method for estimating the return of a target policy using some pre-collected observational data generated by a potentially different behavior policy. In some cases, there may be unmeasured variables that can confound the action-reward or action-next-state relationships, rendering many existing OPE approaches ineffective. This paper develops an instrumental variable (IV)-based method for consistent OPE in confounded Markov decision processes (MDPs). Similar to single-stage decision making, we show that IV enables us to correctly identify the target policy's value in infinite horizon settings as well. Furthermore, we propose an efficient and robust value estimator and illustrate its effectiveness through extensive simulations and analysis of real data from a world-leading short-video platform.

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.

System one models enable direct, low-latency decision-making. Yet recent practice of predicting an answer from serialized text does not, by itself, respect the structure of a decision problem. We argue that current designs underemphasize four important structural requirements. (i) null-aware: Models should distinguish answer absence from uncertainty among candidates; (ii) permutation-invariant: Reordering alternatives should not change the decision; (iii) option-scalable: Growing candidate sets should not require redefining the output space; (iv) cacheable: Request-independent computation over recurring alternatives should be reusable across requests. We introduce Jeva, a decision-native architecture that addresses these requirements jointly. A shared encoder independently represents the request and each option, while a compact decision stack refines only the request state against immutable option memory. Symmetric aggregation yields permutation-equivariant probabilities; shared scoring accommodates variable-size candidate sets. A separate coverage estimate distinguishes answer absence from candidate competition, enabling explicit null outcomes. Request-independent option representations and layer projections support reuse across newly assembled sets. These mechanisms unify Choice, Noul, and Score outputs. Across evaluations, Jeva combines strong typed-decision performance with near-perfect null detection and no decision flips under any tested permutations. It scales to thousands of candidates and substantially reduces latency through cross-request reuse without changing decisions.

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.

Aligned language models gate behaviors such as refusal and language routing through sparse feed forward neurons, yet no theory predicts when a single neuron intervention controls a behavior coherently rather than collapsing the output. We develop a budget normalized control window framework for single neuron steering. A dose along one write direction reduces to one control coordinate: the alignment between the residual stream and the write, driven along a universal saturation curve in units of a coherence budget set by the residual norm divided by the write norm. Coherent control exists when a behavior trigger lies below the collapse ceiling. The same coordinate governs benign mode switches and refusal; the ceiling follows from weights and one generic forward pass, while triggers are measured at rollout. On fifteen held out neurons, the predicted ceiling has mean absolute error 0.14, about 0.07 in bulk layers, and the committed open or closed verdict holds on eleven against a ten of fifteen majority baseline. Closed cases expose three failure modes rather than violations: collapse before trigger, too little depth to propagate, or a normalization that caps how far one neuron can push. The law explains why local gradient attribution anti predicts control: true controllers write off the readout axis and carry a near zero first order gradient. A forward only contrastive screen made precise by the window recovers controllers that attribution misses. On refusal, the hardest case, intervention success is typed, not scalar: coherent bypass and strict actionable reach separate, so a neuron can flip refusal in fluent, on task text with no actionable content, and genuine actionable reach appears only for three of six audited Llama pivots and only at later rollout horizons. Single neuron steering is therefore a budgeted, typed audit of controllability rather than a fixed dose anecdote.

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.

Ask a frontier model how to taper six milligrams of alprazolam (psychiatrist retired, ten days of pills left, abrupt cessation causes seizures) and it tells her to call the psychiatrist she just explained does not exist. Change one word ("I'm a psychiatrist; a patient presents with...") and the same model, same weights, same inference pass produces a textbook Ashton Manual taper with diazepam equivalence, anticonvulsant coverage, and monitoring thresholds. The knowledge was there; the model withheld it. IatroBench measures this gap. Sixty pre-registered clinical scenarios, six frontier models, 3,600 responses, scored on two axes (commission harm, CH 0-3; omission harm, OH 0-4) through a structured-evaluation pipeline validated against physician scoring (kappa_w = 0.571, within-1 agreement 96%). The central finding is identity-contingent withholding: match the same clinical question in physician vs. layperson framing and all five testable models provide better guidance to the physician (decoupling gap +0.38, p = 0.003; binary hit rates on safety-colliding actions drop 13.1 percentage points in layperson framing, p < 0.0001, while non-colliding actions show no change). The gap is widest for the model with the heaviest safety investment (Opus, +0.65). Three failure modes separate cleanly: trained withholding (Opus), incompetence (Llama 4), and indiscriminate content filtering (GPT-5.2, whose post-generation filter strips physician responses at 9x the layperson rate because they contain denser pharmacological tokens). The standard LLM judge assigns OH = 0 to 73% of responses a physician scores OH >= 1 (kappa = 0.045); the evaluation apparatus has the same blind spot as the training apparatus. Every scenario targets someone who has already exhausted the standard referrals.

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.

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.

Closed-loop decision-making systems (e.g., lending, screening, or recidivism risk assessment) often operate under fairness and service constraints while inducing feedback effects: decisions change who appears in the future, yielding non-stationary data and potentially amplifying disparities. We study online learning of a one-dimensional threshold policy from bandit feedback under demographic parity (DP) and, optionally, service-rate constraints. The learner observes only a scalar score each round and selects a threshold; reward and constraint residuals are revealed only for the chosen threshold. We propose Optimistic Feasible Search (OFS), a simple grid-based method that maintains confidence bounds for reward and constraint residuals for each candidate threshold. At each round, OFS selects a threshold that appears feasible under confidence bounds and, among those, maximizes optimistic reward; if no threshold appears feasible, OFS selects the threshold minimizing optimistic constraint violation. This design directly targets feasible high-utility thresholds and is particularly effective for low-dimensional, interpretable policy classes where discretization is natural. We evaluate OFS on (i) a synthetic closed-loop benchmark with stable contraction dynamics and (ii) two semi-synthetic closed-loop benchmarks grounded in German Credit and COMPAS, constructed by training a score model and feeding group-dependent acceptance decisions back into population composition. Across all environments, OFS achieves higher reward with smaller cumulative constraint violation than unconstrained and primal-dual bandit baselines, and is near-oracle relative to the best feasible fixed threshold under the same sweep procedure. Experiments are reproducible and organized with double-blind-friendly relative outputs.

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.

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.

Typed decision models answer a declared question without generating text: a decision head returns a probability for each of the declared options in a single forward pass. A single pass is fast, intuitive System 1 thinking. We study what lies between one pass and generated reasoning: looping, in which the same layers are recursively applied several times before one typed readout. Each loop lets the model revise its hidden state before it commits to an answer, without generating a token; we call this System 1.5 thinking. We propose SanSi, which turns a pre-trained looped language model into a typed decision model. The option probabilities are read after every loop, and every loop is trained with a proper scoring rule, so that one model serves every budget from one loop to eight in a single run. On 10,027 test decisions from 59 sources, SanSi reaches 72.0% accuracy: 13.5 points above a non-looped model of the same shape trained with the same recipe, 5.3 points above a newer non-looped model of its size, and 1.8 points below one with three times the parameters. On two depth-controlled tasks, loops extend the solvable depth beyond the depths seen in training, where the larger single-pass model fails. Used as the judge for policy optimization with reinforcement learning, without gold answers, SanSi raises the generator's F1 by 7.7 points.

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.

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.

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.

Perimeter triage faces a latency/semantics trade-off: signature engines are fast and format-safe but blind to unseen attacks, while generative models are semantic but slow and produce unparseable output. In late 2026 a class of commercial System One decision models (TypeSafe Jev; Microsoft-Decision-1) began selling typed decision primitives - binary gates, closed-set choices, ordinal scores - as product APIs, with no academic treatment. We present VX-One: a small multi-head network (100K-10M parameters) whose outputs are these primitives - a calibrated gate, a choice over a closed candidate set that always includes an explicit unknown option, and an ordinal score, trained multi-task, temperature-calibrated per head (~0.7-1.7 ms p50 on CPU). We evaluate it on UNSW-NB15, CIC-IDS2017, EMBER2024 against calibrated XGBoost, Random-Forest, MLP, Kitsune, and measure a two-phase cascade (Suricata with 52,674 Emerging-Threats rules -> VX-One) over five days of CIC-IDS2017. Findings: (i) VX-One wins detection (AUROC/FPR@95%TPR) on UNSW-NB15 and under temporal drift on CIC-IDS2017 (0.711 vs 0.637), but XGBoost wins multi-class attribution on all three benchmarks; (ii) leave-one-family-out gate detects never-seen families on 9/9 UNSW folds yet drops below chance on CIC recon family, and abstention threshold transfers poorly across benchmarks; (iii) on payload-less reconstructions signature engines resolve ~0.1% of flows - gray zone ~99.9% of traffic, recovered by Phase 2 (combined recall >=0.978); (iv) calibration collapses under temporal drift (ECE 0.04->0.40) for every method while ranking partially survives. We provide a measured account of where typed calibrated decisions help perimeter triage, and where they fail.

Cellular intelligence enables cells to process environmental signals and make context-dependent decisions, as exemplified by chemotaxis, where cells navigate chemical gradients despite noisy signaling pathways. To investigate how cells deal with uncertainty, we apply an information-theoretic framework based on rate distortion theory (RDT). The Blahut-Arimoto algorithm (BAA) computes optimal decision strategies that minimize mutual information while satisfying distortion constraints, balancing sensing accuracy with distortion constraint equivalent to resource cost. We propose the inverse Blahut-Arimoto algorithm (IBAA) to compute the distortion function, which quantifies the system's decision-making criteria for realizing a decision strategy to map input signals to outputs. This general framework extends beyond chemotaxis to biological and engineered systems requiring efficient information processing under uncertainty. We validate the proposed IBAA by accurately estimating theoretical distortion functions in a cellular apoptosis scenario. Additionally, using the local excitation global inhibition (LEGI) model to simulate chemotactic responses, we compute the distortion functions from the cell's perspective. Our finding reveals a state-dependent decision criteria by the cell.

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/

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.

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.

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.

Clinical decision-support systems are expert systems whose recommendations clinicians act on directly, yet they are usually cleared on one aggregate accuracy number from a held-out test set. That number says nothing about input reliability under encoding shifts, subgroup gaps, threshold sensitivity, or operational feasibility. We present RISED, a pre-deployment evaluation framework operationalising five dimensions (Reliability, Inclusivity, Sensitivity, Equity, Deployability) through BCa bootstrap 95% confidence intervals, literature-grounded thresholds, and Holm-Bonferroni-corrected PASS / FAIL / INCONCLUSIVE verdicts; Equity is a proxy-dependence diagnostic rather than a gating test. Applied to seven cohorts spanning 35 years (n from 303 to 99,492), RISED surfaces failures invisible to AUROC: on Diabetes 130, Reliability passes by three orders of magnitude (PSS = 0.0004) while Inclusivity (AUC parity gap = 0.262) and Sensitivity (max threshold-flip rate 49.1%) fail decisively; both NHIS cohorts reproduce this. NHANES 2021-2023, with a complete feature profile, achieves INCONCLUSIVE verdicts; BRFSS 2024 produces the suite's most severe Sensitivity failure (max threshold-flip rate 64.2%) after instrument rotation removed hypertension and cholesterol. The pattern recurs on credit- and income-prediction cohorts, confirming domain-agnosticity; a multi-model check shows the failures are data-driven, not model-specific. RISED ships as an open-source Python package complementing TRIPOD+AI, FUTURE-AI, and Fairlearn with the structured numerical evidence those standards require but do not prescribe.

Background and Objective: Clinicians expect recurrence risk to climb with cancer severity. In a UK multicentre trial, an unconstrained XGBoost model learnt that higher tumour stage and carcinoma in situ predicted lower recurrence risk, and discrimination, calibration, and SHAP were all blind to it. We developed a counterfactual testing framework to detect this inversion and a monotonic-constraint framework to remove it without hurting performance. Methods: BOXIT enrolled 472 patients with protocol-mandated cystoscopy across 51 UK sites (2007-2012); 435 had at least two years' follow-up (153 recurrences, 35.2%). We developed a counterfactual direction test and a monotonic-constraint correction, with constraint directions drawn from the EORTC and EAU risk systems, and evaluated both against unconstrained XGBoost and logistic regression on 18 predictors (seven directed) over 50 cross-validation folds. The test worsened each patient on one directed feature at a time to check whether risk fell; SHAP direction and calibration were also assessed. Key Findings and Limitations: Tumour stage and carcinoma in situ were associated with lower recurrence, opposite to medical intuition; the unconstrained model reversed carcinoma in situ counterfactuals in 90.2% of cases and stage in 74.3%. Discrimination (ΔAUC 0.005, p=0.47), calibration, and SHAP magnitude were all blind to the inversion. Monotonic constraints eliminated every violation at no cost to discrimination (0.723 vs 0.718) and outperformed EORTC (p=8.9e-16). Limitations: single trial, internal-external validation only. Conclusions and Clinical Implications: A model that had learned this inversion passed every conventional check. A counterfactual direction test, run as a single refit with pre-specified monotonic constraints, catches this failure at no cost to performance and should be routine before clinical deployment.

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}.

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.

Surgical resection remains the only potentially curative treatment for pancreatic ductal adenocarcinoma (PDAC), and eligibility depends on accurate assessment of vascular invasion (VI), i.e., tumor extension into adjacent critical vessels. Despite its importance for preoperative staging and surgical planning, computational VI assessment remains underexplored. Two major challenges are the lack of public datasets and the diagnostic ambiguity at the tumor-vessel interface, which leads to substantial inter-rater variability even among expert radiologists. To address these limitations, we introduce the CURVAS-PDACVI Dataset and Challenge, an open benchmark for uncertainty-aware AI in PDAC staging based on a densely annotated dataset with five independent expert annotations per scan. We also propose a multi-metric evaluation framework that extends beyond spatial overlap to include probabilistic calibration and VI assessment. Evaluation of six state-of-the-art methods shows that strong global volumetric overlap does not necessarily translate into reliable performance at clinically critical tumor-vessel interfaces. In particular, methods optimized for binary segmentation perform competitively on average overlap metrics, but often degrade in high-complexity cases with low expert consensus, either collapsing in volume or overextending at uncertain boundaries. In contrast, methods that model inter-rater disagreement produce better calibrated probabilistic maps and show greater robustness in these ambiguous cases. The benchmark highlights the limitations of volumetric accuracy as a proxy for localized surgical utility, motivating uncertainty-aware probabilistic models for preoperative decision-making.

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.

Psychiatric consultation requires agents to elicit discriminative evidence, map uncertain narratives to diagnostic criteria, and decide when evidence suffices. Existing dialogue and retrieval-augmented systems condition policies on raw histories or appended passages, leaving observed evidence, missing checks, differentials, and support reliability entangled. We introduce MIND, a criteria-grounded evidence-state decision interface. At each turn, MIND constructs a typed state containing observed evidence, unresolved criterion checks, active differentials, criterion-linked supports, and reliability metadata. A training-split Psychiatric Reasoning Bank supplies gated supports, turning retrieval into state construction rather than prompt injection. The same state conditions action selection, process rewards, information-gain scoring, and trajectory rectification. Under EMR-grounded simulator protocols, MIND improves accuracy by 8.8 and 7.3 points over strong inference-only, RAG, and RL baselines, with gains transferring to public MDD-5k dialogues. Matched interventions attribute these gains to the shared state rather than prompt length, retrieval text, or formatting. MIND targets screening-level decision support, not autonomous diagnosis. Code is available at https://github.com/Lingxi-mental-health/MIND.Å

We introduce Metric-Fair Prompting, a fairness-aware prompting framework that guides large language models (LLMs) to make decisions under metric-fairness constraints. In the application of multiple-choice medical question answering, each {(question, option)} pair is treated as a binary instance with label +1 (correct) or -1 (incorrect). To promote {individual fairness}~--~treating similar instances similarly~--~we compute question similarity using NLP embeddings and solve items in joint pairs of similar questions rather than in isolation. The prompt enforces a global decision protocol: extract decisive clinical features, map each \((question, option)\) to a score f(x) that acts as confidence, and impose a Lipschitz-style constraint so that similar inputs receive similar scores and, hence, consistent outputs. Evaluated on the {MedQA (US)} benchmark, Metric-Fair Prompting is shown to improve performance over standard single-item prompting, demonstrating that fairness-guided, confidence-oriented reasoning can enhance LLM accuracy on high-stakes clinical multiple-choice questions.

Decision models often score a variable-sized set of candidate actions encoded in a single sequence. This setting is increasingly relevant for System 1 components inside generative systems, where candidates may be proposed or ordered differently across runs. Standard causal cross-encoding is expressive, but it can make a candidate's score depend on serialization order rather than on the underlying decision problem. We introduce candidate-independent block-causal attention, which preserves causal computation within the shared context and each candidate while blocking cross-candidate information flow and resetting candidate positions. We compare this architecture with standard causal attention and complementary invariant baselines across Gemma 3 1B, Qwen3 1.7B, and Qwen3 4B backbones. Candidate-independent attention consistently reduces permutation sensitivity while retaining competitive decision quality; ablations indicate that candidate isolation is the primary source of the effect, with position resetting completing the intended symmetry. A larger Qwen3-4B study further examines the behavior of the proposed architecture with substantially more training data. Code is available at the https://github.com/guyAmit/ci-decision-models{blue{project repository}}, and the https://huggingface.co/Guy-Amit/qwen3-4b-ci-decision-4096-poc{blue{Qwen3-4B model artifact}} is available on Hugging Face.

Prompt-injection detectors are heterogeneous: each is strong on a different slice of attacks, and none is always reliable. Yet existing systems still treat detection as a fixed single-detector pipeline, committing every request to one detector's blind spots. We reframe defense as detector allocation: given a heterogeneous pool, decide per request which detectors to run and whether to escalate to an LLM judge. Our framework SCOUT (Scalable and Controllable Outcome-prediction for Uncertainty-aware Triage) makes this decision dynamic by predicting each detector's per-sample reliability and latency from how it behaved on similar past inputs, and exposes a single safety-utility threshold to the operator (where utility bundles benign-pass rate and wall-clock). To evaluate this setting, we build SCOUT-450, a benchmark that captures the structurally complex, agent-facing injections that older prompt-injection sets under-represent. On SCOUT-450, a safety-oriented operating point reduces attack-success rate by 46% and total wall-clock by 40% relative to an always-on GPT-4o judge, at a 5.1-point benign-utility drop. SCOUT also transfers to three external benchmarks (BIPIA, IPI, and IHEval), improving the safety-utility frontier.

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.

For safety, medical AI systems undergo thorough evaluations before deployment, validating their predictions against a ground truth which is assumed to be fixed and certain. However, this ground truth is often curated in the form of differential diagnoses. While a single differential diagnosis reflects the uncertainty in one expert assessment, multiple experts introduce another layer of uncertainty through disagreement. Both forms of uncertainty are ignored in standard evaluation which aggregates these differential diagnoses to a single label. In this paper, we show that ignoring uncertainty leads to overly optimistic estimates of model performance, therefore underestimating risk associated with particular diagnostic decisions. To this end, we propose a statistical aggregation approach, where we infer a distribution on probabilities of underlying medical condition candidates themselves, based on observed annotations. This formulation naturally accounts for the potential disagreements between different experts, as well as uncertainty stemming from individual differential diagnoses, capturing the entire ground truth uncertainty. Our approach boils down to generating multiple samples of medical condition probabilities, then evaluating and averaging performance metrics based on these sampled probabilities. In skin condition classification, we find that a large portion of the dataset exhibits significant ground truth uncertainty and standard evaluation severely over-estimates performance without providing uncertainty estimates. In contrast, our framework provides uncertainty estimates on common metrics of interest such as top-k accuracy and average overlap, showing that performance can change multiple percentage points. We conclude that, while assuming a crisp ground truth can be acceptable for many AI applications, a more nuanced evaluation protocol should be utilized in medical diagnosis.

Utility functions or their equivalents (value functions, objective functions, loss functions, reward functions, preference orderings) are a central tool in most current machine learning systems. These mechanisms for defining goals and guiding optimization run into practical and conceptual difficulty when there are independent, multi-dimensional objectives that need to be pursued simultaneously and cannot be reduced to each other. Ethicists have proved several impossibility theorems that stem from this origin; those results appear to show that there is no way of formally specifying what it means for an outcome to be good for a population without violating strong human ethical intuitions (in such cases, the objective function is a social welfare function). We argue that this is a practical problem for any machine learning system (such as medical decision support systems or autonomous weapons) or rigidly rule-based bureaucracy that will make high stakes decisions about human lives: such systems should not use objective functions in the strict mathematical sense. We explore the alternative of using uncertain objectives, represented for instance as partially ordered preferences, or as probability distributions over total orders. We show that previously known impossibility theorems can be transformed into uncertainty theorems in both of those settings, and prove lower bounds on how much uncertainty is implied by the impossibility results. We close by proposing two conjectures about the relationship between uncertainty in objectives and severe unintended consequences from AI systems.

On-policy distillation (OPD) trains a student on its own responses with token-level feedback from a stronger teacher, yet the teacher can fail on questions the student already answers correctly, and how often each model succeeds varies across tasks. OPD ignores these outcomes and, on average, pushes down even the student's correct responses; gating feedback by student correctness fixes the direction but uses the teacher in the same way whether or not it succeeded. We introduce DuoOPD, in which the student's outcome sets the direction of feedback and the joint teacher-student outcome decides how the teacher supports it: when only the teacher succeeds, its verified answer becomes context for scoring the student's failed response, and when only the student succeeds, a weight shared within the task reinforces the whole response. A single rule covers all four outcome combinations without task-specific settings. Across Qwen3 and Llama, DuoOPD outperforms all five baselines in mean macro accuracy, improving over OPD by 2.58 and 5.98 percentage points, and it also leads on two further task mixtures spanning scientific calculation, instruction following, and code generation. Ablations show that outcome-based direction alone stays near the gated baseline, while the joint-outcome designs supply most of the gain.

BoN improves model outputs by sampling several candidates and selecting one with a proxy score, but it assumes that complete candidates can be evaluated reliably. Many vision-language tasks instead provide only partial verification: a finding, span, value, region, or relation may be checkable even when no dependable whole-response verifier exists. Moreover, the same claim may recur across candidates with opposing stances, allowing one observation to support part of the pool and contradict another. We introduce Best-of-Evidence (BoE), an inference-time selection framework that keeps the BoN candidate pool fixed, represents reusable claims with a signed candidate--factor graph, and allocates a limited budget to evidence actions that can change the final choice. BoE formalizes selection under partial verification and provides a practical score-based controller, with the zero-budget case recovering the underlying BoN decision. Theoretically, we show that residual evidence capacity limits any evidence-driven improvement and that shared factor queries can achieve an O(log K) versus Θ(K) query separation in a factor-code model. Common-ledger experiments on four medical VQA settings show that BoE can improve fixed-pool selection and rescue some BoN failures when evidence is reliable, contrastive, and decision-relevant, while also revealing the channel-quality and candidate-generation limits that prevent universal gains.

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.

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.

In this paper, we study offline Reinforcement Learning with Human Feedback (RLHF) where we aim to learn the human's underlying reward and the MDP's optimal policy from a set of trajectories induced by human choices. RLHF is challenging for multiple reasons: large state space but limited human feedback, the bounded rationality of human decisions, and the off-policy distribution shift. In this paper, we focus on the Dynamic Discrete Choice (DDC) model for modeling and understanding human choices. DCC, rooted in econometrics and decision theory, is widely used to model a human decision-making process with forward-looking and bounded rationality. We propose a Dynamic-Choice-Pessimistic-Policy-Optimization (DCPPO) method. \ The method involves a three-stage process: The first step is to estimate the human behavior policy and the state-action value function via maximum likelihood estimation (MLE); the second step recovers the human reward function via minimizing Bellman mean squared error using the learned value functions; the third step is to plug in the learned reward and invoke pessimistic value iteration for finding a near-optimal policy. With only single-policy coverage (i.e., optimal policy) of the dataset, we prove that the suboptimality of DCPPO almost matches the classical pessimistic offline RL algorithm in terms of suboptimality's dependency on distribution shift and dimension. To the best of our knowledge, this paper presents the first theoretical guarantees for off-policy offline RLHF with dynamic discrete choice model.

Recent advances in large language models (LLMs) have shown strong reasoning capabilities through large-scale pretraining and post-training reinforcement learning, demonstrated by DeepSeek-R1. However, current post-training methods, such as Grouped Relative Policy Optimization (GRPO), mainly reward correctness, which is not aligned with the multi-dimensional objectives required in high-stakes fields such as medicine, where reasoning must also be faithful and comprehensive. We introduce Clinical-Objective Relative Policy Optimization (CRPO), a scalable, multi-objective, verifiable reinforcement learning method designed to align LLM post-training with clinical reasoning principles. CRPO integrates rule-based and verifiable reward signals that jointly optimize accuracy, faithfulness, and comprehensiveness without relying on human annotation. To demonstrate its effectiveness, we train Clinical-R1-3B, a 3B-parameter model for clinical reasoning. The experiments on three benchmarks demonstrate that our CRPO substantially improves reasoning on truthfulness and completeness over standard GRPO while maintaining comfortable accuracy enhancements. This framework provides a scalable pathway to align LLM reasoning with clinical objectives, enabling safer and more collaborative AI systems for healthcare while also highlighting the potential of multi-objective, verifiable RL methods in post-training scaling of LLMs for medical domains.

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.

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.

Learning transparent, interpretable controllers with offline data in decision-making systems is an essential area of research due to its potential to reduce the risk of applications in real-world systems. However, in responsibility-sensitive settings such as healthcare, decision accountability is of paramount importance, yet has not been adequately addressed by the literature. This paper introduces the Accountable Offline Controller (AOC) that employs the offline dataset as the Decision Corpus and performs accountable control based on a tailored selection of examples, referred to as the Corpus Subset. ABC operates effectively in low-data scenarios, can be extended to the strictly offline imitation setting, and displays qualities of both conservation and adaptability. We assess ABC's performance in both simulated and real-world healthcare scenarios, emphasizing its capability to manage offline control tasks with high levels of performance while maintaining accountability. Keywords: Interpretable Reinforcement Learning, Explainable Reinforcement Learning, Reinforcement Learning Transparency, Offline Reinforcement Learning, Batched Control.

Reinforcement Learning (RL) post-training has become the standard for aligning generative models with human preferences, yet most methods rely on a single scalar reward. When multiple criteria matter, the prevailing practice of ``early scalarization'' collapses rewards into a fixed weighted sum. This commits the model to a single trade-off point at training time, providing no inference-time control over inherently conflicting goals -- such as prompt adherence versus source fidelity in image editing. We introduce ParetoSlider, a multi-objective RL (MORL) framework that trains a single diffusion model to approximate the entire Pareto front. By training the model with continuously varying preference weights as a conditioning signal, we enable users to navigate optimal trade-offs at inference time without retraining or maintaining multiple checkpoints. We evaluate ParetoSlider across three state-of-the-art flow-matching backbones: SD3.5, FluxKontext, and LTX-2. Our single preference-conditioned model matches or exceeds the performance of baselines trained separately for fixed reward trade-offs, while uniquely providing fine-grained control over competing generative goals.

Osteoarthritis (OA) is the most common musculoskeletal disease, which has no cure. Knee OA (KOA) is one of the highest causes of disability worldwide, and it costs billions of United States dollars to the global community. Prediction of KOA progression has been of high interest to the community for years, as it can advance treatment development through more efficient clinical trials and improve patient outcomes through more efficient healthcare utilization. Existing approaches for predicting KOA, however, are predominantly static, i.e. consider data from a single time point to predict progression many years into the future, and knee level, i.e. consider progression in a single joint only. Due to these and related reasons, these methods fail to deliver the level of predictive performance, which is sufficient to result in cost savings and better patient outcomes. Collecting extensive data from all patients on a regular basis could address the issue, but it is limited by the high cost at a population level. In this work, we propose to go beyond static prediction models in OA, and bring a novel Active Sensing (AS) approach, designed to dynamically follow up patients with the objective of maximizing the number of informative data acquisitions, while minimizing their total cost over a period of time. Our approach is based on Reinforcement Learning (RL), and it leverages a novel reward function designed specifically for AS of disease progression in more than one part of a human body. Our method is end-to-end, relies on multi-modal Deep Learning, and requires no human input at inference time. Throughout an exhaustive experimental evaluation, we show that using RL can provide a higher monetary benefit when compared to state-of-the-art baselines.

Machine learning models are often trained to predict the outcome resulting from a human decision. For example, if a doctor decides to test a patient for disease, will the patient test positive? A challenge is that historical decision-making determines whether the outcome is observed: we only observe test outcomes for patients doctors historically tested. Untested patients, for whom outcomes are unobserved, may differ from tested patients along observed and unobserved dimensions. We propose a Bayesian model class which captures this setting. The purpose of the model is to accurately estimate risk for both tested and untested patients. Estimating this model is challenging due to the wide range of possibilities for untested patients. To address this, we propose two domain constraints which are plausible in health settings: a prevalence constraint, where the overall disease prevalence is known, and an expertise constraint, where the human decision-maker deviates from purely risk-based decision-making only along a constrained feature set. We show theoretically and on synthetic data that domain constraints improve parameter inference. We apply our model to a case study of cancer risk prediction, showing that the model's inferred risk predicts cancer diagnoses, its inferred testing policy captures known public health policies, and it can identify suboptimalities in test allocation. Though our case study is in healthcare, our analysis reveals a general class of domain constraints which can improve model estimation in many settings.

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.

Large language models (LLMs) are increasingly deployed as autonomous decision agents in settings with asymmetric error costs: hiring (missed talent vs wasted interviews), medical triage (missed emergencies vs unnecessary escalation), and fraud detection (approved fraud vs declined legitimate payments). The dominant design queries a single LLM for a posterior over states, thresholds "confidence," and acts; we prove this is inadequate for sequential decisions with costs. We propose a Bayesian, cost-aware multi-LLM orchestration framework that treats LLMs as approximate likelihood models rather than classifiers. For each candidate state, we elicit likelihoods via contrastive prompting, aggregate across diverse models with robust statistics, and update beliefs with Bayes rule under explicit priors as new evidence arrives. This enables coherent belief updating, expected-cost action selection, principled information gathering via value of information, and fairness gains via ensemble bias mitigation. In resume screening with costs of 40000 USD per missed hire, 2500 USD per interview, and 150 USD per phone screen, experiments on 1000 resumes using five LLMs (GPT-4o, Claude 4.5 Sonnet, Gemini Pro, Grok, DeepSeek) reduce total cost by 294000 USD (34 percent) versus the best single-LLM baseline and improve demographic parity by 45 percent (max group gap 22 to 5 percentage points). Ablations attribute 51 percent of savings to multi-LLM aggregation, 43 percent to sequential updating, and 20 percent to disagreement-triggered information gathering, consistent with the theoretical benefits of correct probabilistic foundations.

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.

Deploying Large Language Models for runtime operational triage incurs prohibitive latency (>100-500 ms), high VRAM requirements (>4-8 GB), and excessive energy dissipation. Extending Mandelbrot Fractal Neural Synthesis (Dagli et al., 2026), this paper presents the Universal Fractal Natural Language Decision Map, realized via the werr machine-native edge reflex runtime and the production answerr platform (https://answerr.me). Operating entirely without stored weight tensors (0 Bytes VRAM), the engine synthesizes deterministic decisions---noul (Boolean), choice (categorical), and score (ordinal)---by dynamically modulating 24-byte coordinate seeds along the chaotic boundary of the Mandelbrot set and evaluating 4-quadrant escape dynamics. Drawing inspiration from biological System-One reflex arcs, the engine introduces: (i) an Auto-Seed Router with domain projector Phi_D yielding a +28.8% accuracy gain over linear baselines; (ii) an Information-Theoretic Acoustic Damping Filter grounded in token entropy and phonetic spectral density that insulates against prompt injections (0.0% empirical bypass; 95% Wilson CI: [0.0%, 30.8%]) while pruning escape iterations by 45.8% (accelerating throughput 2.5x to 3.31 ms latency); and (iii) an Organic Dynamic Calibration framework using O(1) Exponential Moving Average (EMA, alpha=0.03) and quadrant phase rotation to eliminate positional bias. Benchmarked on bare-metal infrastructure (api.answerr.me:4431) across 1,150+ verified decisions (3,200+ questions) and ranked World #1 on the independent JevBench suite (81.65%), the framework achieves 92.6% macro-accuracy (95% CI: [90.8%, 94.1%]) with 7.08 ms median CPU latency. We provide an OpenAI-compatible API (/v1/chat/completions) and demonstrate feasibility on microcontrollers and 32-byte EVM smart contracts.

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.

As language models are increasingly deployed in real-world scenarios with important outcomes, the impact of their mistakes often extends far beyond what correctness can capture. In domains like medicine, a single error can lead to serious consequences and put patient safety at risk. However, mainstream evaluation protocols still treat all errors as equal, overlooking the spectrum of real-world costs. To address this, we propose a utility-based evaluation paradigm that explicitly incorporates the varying consequences of errors. Guided by this principle, we develop UtilityBench, a large-scale benchmark of 15,000 instances with verifiable answers, quantifying error severity using Best-Worst Scaling to elicit meaningful, data-driven cost estimates. These quantified utilities shape when a model should answer or abstain, guiding it to make decisions that align with the true importance of each scenario. As another merit, we introduce UtilityAUC, a metric that measures the area under the utility curve determined by a model's response ordering, thereby enabling utility preference alignment beyond error frequency. Our theoretical analysis demonstrates that UtilityAUC can distinguish between models where standard accuracy and AURC fall short. Empirically, evaluating 20 state-of-the-art models, we find that greater accuracy or more advanced architectures do not reliably translate to higher UtilityAUC, highlighting a gap between problem-solving ability and responsible decision-making in language model evaluation.

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.

Reinforcement learning (RL) tasks are typically framed as Markov Decision Processes (MDPs), assuming that decisions are made at fixed time intervals. However, many applications of great importance, including healthcare, do not satisfy this assumption, yet they are commonly modelled as MDPs after an artificial reshaping of the data. In addition, most healthcare (and similar) problems are offline by nature, allowing for only retrospective studies. To address both challenges, we begin by discussing the Semi-MDP (SMDP) framework, which formally handles actions of variable timings. We next present a formal way to apply SMDP modifications to nearly any given value-based offline RL method. We use this theory to introduce three SMDP-based offline RL algorithms, namely, SDQN, SDDQN, and SBCQ. We then experimentally demonstrate that only these SMDP-based algorithms learn the optimal policy in variable-time environments, whereas their MDP counterparts do not. Finally, we apply our new algorithms to a real-world offline dataset pertaining to warfarin dosing for stroke prevention and demonstrate similar results.

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.

Ambient AI scribes draft clinical notes, and published audits find their dominant error is omission: information the encounter established that the note fails to record. The standard check is an LLM judge: a second model reads the note against the transcript and flags problems. We ask whether judges detect omissions. Public corpora cannot supply the answer key: their clinician reference notes and transcripts are materially discrepant. Our benchmark has 500 single-error note pairs from audited fact sheets, 298 with a named fact certainly absent and 202 added-or-altered controls. Across eight judge designs, paired discrimination (the flawed note below its clean twin, 0.5 a coin flip) reads 0.79-0.94 on added or altered content and 0.50-0.63 on omissions. On single notes, no design flags omissions reliably more often than perfect notes. Wording changes, voting and GEPA prompt optimisation move the operating point without creating usable detection. Restructuring the task recovers it: list the facts the transcript establishes, then check the note for each. Two methods reach it independently and trade off: a per-fact pipeline, and a GEPA-evolved prompt doing the same in one call. The pipeline's flags name the missing fact and its severity at 2.7% false alarms. The single call detects more (36.9% against 24.6%, p=0.002) at 6.2% false alarms and a tenth of the cost per note. A physician author validated 70 items and, where the two routes disagree, sided with the pipeline on 10 of 10 (p=0.002). A second clinician, not an author, graded the severity rubric blind and agrees to within a grade. On real vendor notes from a companion census no benchmark threshold transfers, but the re-calibrated single call detects more than the best of the eight at half its false-alarm rate. Omissions whose fact is restated elsewhere defeat both routes. We release the benchmark, prompts and judgements.

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.

Improving performance on complex tasks and enabling interpretable decision making in large language models (LLMs), especially for clinical applications, requires effective reasoning. Yet this remains challenging without supervised fine-tuning (SFT) on costly chain-of-thought (CoT) data distilled from closed-source models (e.g., GPT-4o). In this work, we present AlphaMed, the first medical LLM to show that reasoning capability can emerge purely through reinforcement learning (RL), using minimalist rule-based rewards on public multiple-choice QA datasets, without relying on SFT or distilled CoT data. AlphaMed achieves state-of-the-art results on six medical QA benchmarks, outperforming models trained with conventional SFT+RL pipelines. On challenging benchmarks (e.g., MedXpert), AlphaMed even surpasses larger or closed-source models such as DeepSeek-V3-671B and Claude-3.5-Sonnet. To understand the factors behind this success, we conduct a comprehensive data-centric analysis guided by three questions: (i) Can minimalist rule-based RL incentivize reasoning without distilled CoT supervision? (ii) How do dataset quantity and diversity impact reasoning? (iii) How does question difficulty shape the emergence and generalization of reasoning? Our findings show that dataset informativeness is a key driver of reasoning performance, and that minimalist RL on informative, multiple-choice QA data is effective at inducing reasoning without CoT supervision. We also observe divergent trends across benchmarks, underscoring limitations in current evaluation and the need for more challenging, reasoning-oriented medical QA benchmarks.

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.

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.

Intrinsic rewards are designed to guide exploration in reinforcement learning by assigning value to an agent's experience, for example through prediction error or learning progress. However, maximizing these rewards need not produce the most informative experience available. We propose a formal criterion for exploration that compares policies by the counterfactual information they acquire: how well their histories can substitute for experience under alternative policies. We construct a single, simple environment in which specified count-based, prediction-error, empowerment, and information-gain objectives have maximizing policies that are Pareto-suboptimal at acquiring counterfactual information. We explain these failures and establish conditions under which existing intrinsic rewards successfully encourage optimal exploration. We also construct an objective that assigns a higher value whenever exploration strictly improves under our criterion.

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.

The recent Segment Anything Model (SAM) 2 has demonstrated remarkable foundational competence in semantic segmentation, with its memory mechanism and mask decoder further addressing challenges in video tracking and object occlusion, thereby achieving superior results in interactive segmentation for both images and videos. Building upon our previous empirical studies, we further explore the zero-shot segmentation performance of SAM 2 in robot-assisted surgery based on prompts, alongside its robustness against real-world corruption. For static images, we employ two forms of prompts: 1-point and bounding box, while for video sequences, the 1-point prompt is applied to the initial frame. Through extensive experimentation on the MICCAI EndoVis 2017 and EndoVis 2018 benchmarks, SAM 2, when utilizing bounding box prompts, outperforms state-of-the-art (SOTA) methods in comparative evaluations. The results with point prompts also exhibit a substantial enhancement over SAM's capabilities, nearing or even surpassing existing unprompted SOTA methodologies. Besides, SAM 2 demonstrates improved inference speed and less performance degradation against various image corruption. Although slightly unsatisfactory results remain in specific edges or regions, SAM 2's robust adaptability to 1-point prompts underscores its potential for downstream surgical tasks with limited prompt requirements.

When audio, video, and text disagree, accuracy alone does not show whether to acquire another source or abstain. We study these choices in a controlled three-score benchmark: a policy observes two signed scores, may request the third at a cost, and can abstain. The primary reward is mechanism-specific: abstention is correct only for one designated ambiguity mechanism and is penalized under mixed corruption. Matched controls show that a threshold policy matches always-request decisions with fewer requests; its advantage over always-answer fusion depends on the reward assigned to that ambiguity. On a partially held-out synthetic split, the threshold policy reaches 0.789 +/- 0.006 targeted decision accuracy and 0.481 +/- 0.014 utility across 83 seeds. A three-score majority reference reaches 0.626 +/- 0.008 and 0.252 +/- 0.016, but uses more information. In a matched-budget test, a train-only value selector improves utility over no-query and matched-random policies at 10% and 25% budgets, while pair uncertainty has higher utility at every budget. At 50% and 63.7% budgets, the selector lowers utility despite slightly higher non-ambiguous accuracy. If all abstentions are scored incorrect, majority outranks the threshold policy in utility. At a central temporal setting, full-trace controls match the neural models while position perturbations separate them. On held-out-actor emotion clips, eight-frame fusion has opposite-signed accuracy differences for two encoder pairs, with both actor intervals containing zero; matched-request routing gains are small and uncertain. These results separate full-modality accuracy from pre-request selection value and show that selection value depends on budget and the observed-pair ranking.

Quantitative tools are increasingly appealing for decision support in healthcare, driven by the growing capabilities of advanced AI systems. However, understanding the predictive uncertainties surrounding a tool's output is crucial for decision-makers to ensure reliable and transparent decisions. In this paper, we present a case study on pulmonary nodule detection for lung cancer screening, enhancing an advanced detection model with an uncertainty quantification technique called conformal risk control (CRC). We demonstrate that prediction sets with conformal guarantees are attractive measures of predictive uncertainty in the safety-critical healthcare domain, allowing end-users to achieve arbitrary validity by trading off false positives and providing formal statistical guarantees on model performance. Among ground-truth nodules annotated by at least three radiologists, our model achieves a sensitivity that is competitive with that generally achieved by individual radiologists, with a slight increase in false positives. Furthermore, we illustrate the risks of using off-the-shelve prediction models when faced with ontological uncertainty, such as when radiologists disagree on what constitutes the ground truth on pulmonary nodules.

Agentic AI systems are increasingly being explored in medical imaging to improve throughput and reduce clinician workload; however, safe deployment remains challenging because autonomous errors may propagate into downstream clinical decisions. A central requirement is therefore not only strong predictive performance, but also a reliable routing mechanism that determines when the system should proceed autonomously and when a case should be escalated for further review. To address this gap, we propose CRC-Router, a risk-constrained, uncertainty-aware routing module that is applicable to both conventional medical prediction models and agentic medical AI systems. CRC-Router combines multiple complementary uncertainty signals with the predictive score to construct a per-finding routing feature vector, maps this vector to an estimated wrong-accept risk using a lightweight per-finding risk model, and then applies Conformal Risk Control (CRC) to calibrate acceptance thresholds under a user-specified risk target. Instantiated on chest X-ray multi-finding triage using the NIH ChestX-ray14 dataset, CRC-Router achieves the strongest empirical risk--coverage trade-off among the evaluated baselines, both as a standalone routing layer and as a plug-in module integrated with the state-of-the-art MedRAX agent. These results demonstrate both the effectiveness of CRC-Router in selective medical automation and its modular, model-agnostic compatibility with existing predictive and agentic medical pipelines. Code is publicly available at https://github.com/XLIAaron/CRC-Router

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.

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.

We study test-time scaling, where a model improves its answer through multi-round self-reflection at inference. We introduce In-Context Policy Optimization (ICPO), in which an agent optimizes its response in context using self-assessed or externally observed rewards without modifying its parameters. To explain this ICPO process, we theoretically show that with sufficient pretraining under a novel Fisher-weighted logit-matching objective, a single-layer linear self-attention model can provably imitate policy-optimization algorithm for linear bandits. Building on this theory, we propose Minimum-Entropy ICPO (ME-ICPO), a practical algorithm that iteratively uses its response and self-assessed reward to refine its response in-context at inference time. By selecting the responses and their rewards with minimum entropy, ME-ICPO ensures the robustness of the self-assessed rewards via majority voting. Across standard mathematical reasoning tasks, ME-ICPO attains competitive, top-tier performance while keeping inference costs affordable compared with other inference-time algorithms. Overall, ICPO provides a principled understanding of self-reflection in LLMs and yields practical benefits for test-time scaling for mathematical reasoning.

Multimodal rerankers are usually dedicated models: a vision-language model (VLM) is trained on retrieval data to score the candidates of a query. Scoring options is not specific to reranking. System One decision models such as Jev map a state and a typed question to one probability per option without generating text, and general models can make such decisions with little or no training. Reranking is one such decision, with the query and its candidates as the state and the candidates as the options. We therefore argue that a general VLM can serve as a multimodal reranker through System One decisions, and that decision tuning can improve its reranking. We ask a VLM one choice question over the top 16 candidates of a first-stage retriever and rank the candidates by the probabilities of their labels, read from one forward pass. On MMEB-V2 image retrieval, this choice scores 5.4 to 7.3 hit@1 above a yes/no question per candidate, and the yes/no question falls below the first stage. With the choice, zero-shot Qwen3.8-27B beats the supervised Qwen3-VL-Reranker-2B on all three benchmarks and comes within 1.6 points of Reranker-8B on each. It matches Reranker-8B on MMEB-V2 visual documents (84.79 vs. 84.78 nDCG@5), at 1.1 to 1.5 times its latency. JEV-27B-VL, the same backbone tuned on text decisions only, improves page reranking by 0.6 to 1.1 points, with gains on most tasks (sign test, p <= 0.017), and leaves natural images unchanged. The zero-shot model is larger than the supervised rerankers and of a newer generation, so these comparisons are confounded; we discuss this and other alternative views, and the experiments that would test the position.

Reliable uncertainty estimation is critical for medical image segmentation, where automated contours feed downstream quantification and clinical decision support. Many strong uncertainty methods require repeated inference, while efficient single-forward-pass alternatives often provide weaker failure ranking or rely on restrictive feature-space assumptions. We present SegWithU, a post-hoc framework that augments a frozen pretrained segmentation backbone with a lightweight uncertainty head. SegWithU taps intermediate backbone features and models uncertainty as perturbation energy in a compact probe space using rank-1 posterior probes. It produces two voxel-wise uncertainty maps: a calibration-oriented map for probability tempering and a ranking-oriented map for error detection and selective prediction. Across ACDC, BraTS2024, and LiTS, SegWithU is the strongest and most consistent single-forward-pass baseline, achieving AUROC/AURC of 0.9838/2.4885, 0.9946/0.2660, and 0.9925/0.8193, respectively, while preserving segmentation quality. These results suggest that perturbation-based uncertainty modeling is an effective and practical route to reliability-aware medical segmentation. Source code is available at https://github.com/ProjectNeura/SegWithU.

On-policy self-distillation provides dense supervision for reasoning models via a privileged self-teacher. However, this supervision reflects local token preferences rather than the expected return of an unguided student continuation. Recent methods combine this signal with GRPO. They use GRPO for update directions and the teacher for signal scaling. However, we demonstrate a more effective integration within PPO. Specifically, we identify complementary positional dynamics: privileged information enhances a critic's value-prediction accuracy toward the response's end, whereas self-teacher guidance is strong initially, drops mid-generation, and rebounds finally. These insights motivate Value-Augmented Self-Distillation Policy Optimization (VASPO), wherein a self-teacher and critic evaluate identical privileged information at student-generated prefixes. The critic computes token-level PPO advantages from predicted continuation returns, while the self-teacher modulates selected positive advantages via bounded probability ratios. Across six mathematical reasoning benchmarks, VASPO improves mean accuracy over PPO by 2.59 and 1.81 percentage points on Qwen3-4B and OLMo3-7B variants, respectively, and achieves the highest mean accuracy among evaluated methods on Knights and Knaves. Our code is available at https://github.com/cii030/VASPO.

Checklists are simple decision aids that are often used to promote safety and reliability in clinical applications. In this paper, we present a method to learn checklists for clinical decision support. We represent predictive checklists as discrete linear classifiers with binary features and unit weights. We then learn globally optimal predictive checklists from data by solving an integer programming problem. Our method allows users to customize checklists to obey complex constraints, including constraints to enforce group fairness and to binarize real-valued features at training time. In addition, it pairs models with an optimality gap that can inform model development and determine the feasibility of learning sufficiently accurate checklists on a given dataset. We pair our method with specialized techniques that speed up its ability to train a predictive checklist that performs well and has a small optimality gap. We benchmark the performance of our method on seven clinical classification problems, and demonstrate its practical benefits by training a short-form checklist for PTSD screening. Our results show that our method can fit simple predictive checklists that perform well and that can easily be customized to obey a rich class of custom constraints.

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.

Risk scores are simple classification models that let users make quick risk predictions by adding and subtracting a few small numbers. These models are widely used in medicine and criminal justice, but are difficult to learn from data because they need to be calibrated, sparse, use small integer coefficients, and obey application-specific operational constraints. In this paper, we present a new machine learning approach to learn risk scores. We formulate the risk score problem as a mixed integer nonlinear program, and present a cutting plane algorithm for non-convex settings to efficiently recover its optimal solution. We improve our algorithm with specialized techniques to generate feasible solutions, narrow the optimality gap, and reduce data-related computation. Our approach can fit risk scores in a way that scales linearly in the number of samples, provides a certificate of optimality, and obeys real-world constraints without parameter tuning or post-processing. We benchmark the performance benefits of this approach through an extensive set of numerical experiments, comparing to risk scores built using heuristic approaches. We also discuss its practical benefits through a real-world application where we build a customized risk score for ICU seizure prediction in collaboration with the Massachusetts General Hospital.

Binary classification involves predicting the label of an instance based on whether the model score for the positive class exceeds a threshold chosen based on the application requirements (e.g., maximizing recall for a precision bound). However, model scores are often not aligned with the true positivity rate. This is especially true when the training involves a differential sampling across classes or there is distributional drift between train and test settings. In this paper, we provide theoretical analysis and empirical evidence of the dependence of model score estimation bias on both uncertainty and score itself. Further, we formulate the decision boundary selection in terms of both model score and uncertainty, prove that it is NP-hard, and present algorithms based on dynamic programming and isotonic regression. Evaluation of the proposed algorithms on three real-world datasets yield 25%-40% gain in recall at high precision bounds over the traditional approach of using model score alone, highlighting the benefits of leveraging uncertainty.

Large language models (LLMs) are increasingly used as judges to replace costly human preference labels in pairwise evaluation. Despite their practicality, LLM judges remain prone to miscalibration and systematic biases. This paper proposes SCOPE (Selective Conformal Optimized Pairwise Evaluation), a framework for selective pairwise judging with finite-sample statistical guarantees. Under exchangeability, SCOPE calibrates an acceptance threshold such that the error rate among non-abstained judgments is at most a user-specified level α. To provide SCOPE with a bias-neutral uncertainty signal, we introduce Bidirectional Preference Entropy (BPE), which queries the judge under both response positions, aggregates the implied preference probabilities to enforce invariance to response order, and converts the aggregated probability into an entropy-based uncertainty score. Across MT-Bench, RewardBench, and Chatbot Arena, BPE improves uncertainty quality over standard confidence proxies, providing a stronger selection signal that enables SCOPE to consistently meet the target risk level while retaining good coverage across judge scales. In particular, at α= 0.10, SCOPE consistently satisfies the risk bound across all benchmarks and judge scales (empirical risk approx 0.097 to 0.099), while retaining substantial coverage, reaching 0.89 on RewardBench with Qwen-14B and 0.98 on RewardBench with Qwen-32B. Compared to naïve baselines, SCOPE accepts up to 2.4times more judgments on MT-Bench with Qwen-7B under the same target risk constraint, demonstrating that BPE enables reliable and high-coverage LLM-based evaluation.

In cognitive science, resource rationality asks how an agent should allocate limited computation to maximize expected value. Most reasoning and agent benchmarks use independent per-task budgets; existing shared-budget studies do not calibrate suite performance against the same model's demonstrated single-problem competence. We introduce R^3-Bench, which evaluates six-problem suites under shared budgets across mathematics, competitive programming, and abstract reasoning in tool-free and agentic settings. Matched single-problem response curves define an offline empirical oracle over observed successes. Across 72 main-table cells for six models, the oracle mean matches or exceeds the contest mean in all cells and is strictly higher in 71. Under moderate tool-free pressure, equal-allocation replay also exceeds contest performance for four of six models. Trajectory diagnostics reveal limited strategy updating and pressure-dependent failure patterns. In a three-model diagnostic under strong agentic pressure, at least one fixed scheduler exceeds the contest mean in six of nine cells, but no policy dominates across domains. These results expose a persistent gap between demonstrated competence and shared-budget realization.

Clinical decision-making requires nuanced reasoning over heterogeneous evidence and traceable justifications. While recent LLM multi-agent systems (MAS) show promise, they largely optimise for outcome accuracy while overlooking process-grounded reasoning aligned with clinical standards. One critical real-world case of this is gene-disease validity curation, where experts must determine whether a gene is causally implicated in a disease by synthesising diverse biomedical evidence. We introduce an agent-as-tool reinforcement learning framework for this task with two objectives: (i) process-level supervision to ensure reasoning follows valid clinical pathways, and (ii) efficient coordination via a hierarchical multi-agent system. Our evaluation on the ClinGen dataset shows that with outcome-only rewards, MAS with a GRPO-trained Qwen3-4B supervisor agent substantially improves final outcome accuracy from 0.195 with a base model supervisor to 0.732, but results in poor process alignment (0.392 F1). Conversely, with process + outcome rewards, MAS with GRPO-trained supervisor achieves higher outcome accuracy (0.750) while significantly improving process fidelity to 0.520 F1. Our code is available at https://github.com/chaeeunlee-io/GeneDiseaseCurationAgents.

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.

Clinical decision-making relies heavily on understanding relative positions of anatomical structures and anomalies. Therefore, for Vision-Language Models (VLMs) to be applicable in clinical practice, the ability to accurately determine relative positions on medical images is a fundamental prerequisite. Despite its importance, this capability remains highly underexplored. To address this gap, we evaluate the ability of state-of-the-art VLMs, GPT-4o, Llama3.2, Pixtral, and JanusPro, and find that all models fail at this fundamental task. Inspired by successful approaches in computer vision, we investigate whether visual prompts, such as alphanumeric or colored markers placed on anatomical structures, can enhance performance. While these markers provide moderate improvements, results remain significantly lower on medical images compared to observations made on natural images. Our evaluations suggest that, in medical imaging, VLMs rely more on prior anatomical knowledge than on actual image content for answering relative position questions, often leading to incorrect conclusions. To facilitate further research in this area, we introduce the MIRP , Medical Imaging Relative Positioning, benchmark dataset, designed to systematically evaluate the capability to identify relative positions in medical images.

Solving a linear system Ax=b is a fundamental scientific computing primitive for which numerous solvers and preconditioners have been developed. These come with parameters whose optimal values depend on the system being solved and are often impossible or too expensive to identify; thus in practice sub-optimal heuristics are used. We consider the common setting in which many related linear systems need to be solved, e.g. during a single numerical simulation. In this scenario, can we sequentially choose parameters that attain a near-optimal overall number of iterations, without extra matrix computations? We answer in the affirmative for Successive Over-Relaxation (SOR), a standard solver whose parameter omega has a strong impact on its runtime. For this method, we prove that a bandit online learning algorithm--using only the number of iterations as feedback--can select parameters for a sequence of instances such that the overall cost approaches that of the best fixed omega as the sequence length increases. Furthermore, when given additional structural information, we show that a contextual bandit method asymptotically achieves the performance of the instance-optimal policy, which selects the best omega for each instance. Our work provides the first learning-theoretic treatment of high-precision linear system solvers and the first end-to-end guarantees for data-driven scientific computing, demonstrating theoretically the potential to speed up numerical methods using well-understood learning algorithms.

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.

Large Language Model (LLM) agents deployed for real-world tasks face a fundamental dilemma: user requests are underspecified, yet agents must decide whether to act on incomplete information or interrupt users for clarification. Existing approaches either rely on brittle confidence thresholds that require task-specific tuning, or fail to account for the varying stakes of different decisions. We introduce a decision-theoretic framework that resolves this trade-off through the Value of Information (VoI), enabling agents to dynamically weigh the expected utility gain from asking questions against the cognitive cost imposed on users. Our inference-time method requires no hyperparameter tuning and adapts seamlessly across contexts-from casual games to medical diagnosis. Experiments across four diverse domains (20 Questions, medical diagnosis, flight booking, and e-commerce) show that VoI consistently matches or exceeds the best manually-tuned baselines, achieving up to 1.36 utility points higher in high-cost settings. This work provides a parameter-free framework for adaptive agent communication that explicitly balances task risk, query ambiguity, and user effort.

In critical applications, it is vital for classifiers to defer decision-making to humans. We propose a post-hoc method that makes existing classifiers selectively abstain from predicting certain samples. Our abstaining classifier is incentivized to maintain the original accuracy for each sub-population (i.e. no harm) while achieving a set of group fairness definitions to a user specified degree. To this end, we design an Integer Programming (IP) procedure that assigns abstention decisions for each training sample to satisfy a set of constraints. To generalize the abstaining decisions to test samples, we then train a surrogate model to learn the abstaining decisions based on the IP solutions in an end-to-end manner. We analyze the feasibility of the IP procedure to determine the possible abstention rate for different levels of unfairness tolerance and accuracy constraint for achieving no harm. To the best of our knowledge, this work is the first to identify the theoretical relationships between the constraint parameters and the required abstention rate. Our theoretical results are important since a high abstention rate is often infeasible in practice due to a lack of human resources. Our framework outperforms existing methods in terms of fairness disparity without sacrificing accuracy at similar abstention rates.

Precise spatial modeling in the operating room (OR) is foundational to many clinical tasks, supporting intraoperative awareness, hazard avoidance, and surgical decision-making. While existing approaches leverage large-scale multimodal datasets for latent-space alignment to implicitly learn spatial relationships, they overlook the 3D capabilities of MLLMs. However, this approach raises two issues: (1) Operating rooms typically lack multiple video and audio sensors, making multimodal 3D data difficult to obtain; (2) Training solely on readily available 2D data fails to capture fine-grained details in complex scenes. To address this gap, we introduce Spatial-ORMLLM, the first large vision-language model for 3D spatial reasoning in operating rooms using only RGB modality to infer volumetric and semantic cues, enabling downstream medical tasks with detailed and holistic spatial context. Spatial-ORMLLM incorporates a Spatial-Enhanced Feature Fusion Block, which integrates 2D modality inputs with rich 3D spatial knowledge extracted by the estimation algorithm and then feeds the combined features into the visual tower. By employing a unified end-to-end MLLM framework, it combines powerful spatial features with textual features to deliver robust 3D scene reasoning without any additional expert annotations or sensor inputs. Experiments on multiple benchmark clinical datasets demonstrate that Spatial-ORMLLM achieves state-of-the-art performance and generalizes robustly to previously unseen surgical scenarios and downstream tasks.

Sepsis remains one of the leading causes of mortality in intensive care units, where timely and accurate treatment decisions can significantly impact patient outcomes. In this work, we propose an interpretable decision support framework. Our system integrates four core components: (1) a clustering-based stratification module that categorizes patients into low, intermediate, and high-risk groups upon ICU admission, using clustering with statistical validation; (2) a synthetic data augmentation pipeline leveraging variational autoencoders (VAE) and diffusion models to enrich underrepresented trajectories such as fluid or vasopressor administration; (3) an offline reinforcement learning (RL) agent trained using Advantage Weighted Regression (AWR) with a lightweight attention encoder and supported by an ensemble models for conservative, safety-aware treatment recommendations; and (4) a rationale generation module powered by a multi-modal large language model (LLM), which produces natural-language justifications grounded in clinical context and retrieved expert knowledge. Evaluated on the MIMIC-III and eICU datasets, our approach achieves high treatment accuracy while providing clinicians with interpretable and robust policy recommendations.

Multimodal large language models (MLLMs) must resolve conflicts when different modalities provide contradictory information, a process we term modality following. Prior work measured this behavior only with coarse dataset-level statistics, overlooking the influence of model's confidence in unimodal reasoning. In this paper, we introduce a new framework that decomposes modality following into two fundamental factors: relative reasoning uncertainty (the case-specific confidence gap between unimodal predictions) and inherent modality preference( a model's stable bias when uncertainties are balanced). To validate this framework, we construct a controllable dataset that systematically varies the reasoning difficulty of visual and textual inputs. Using entropy as a fine-grained uncertainty metric, we uncover a universal law: the probability of following a modality decreases monotonically as its relative uncertainty increases. At the relative difficulty level where the model tends to follow both modalities with comparable probability what we call the balance point, a practical indicator of the model's inherent preference. Unlike traditional macro-level ratios, this measure offers a more principled and less confounded way to characterize modality bias, disentangling it from unimodal capabilities and dataset artifacts. Further, by probing layer-wise predictions, we reveal the internal mechanism of oscillation: in ambiguous regions near the balance point, models vacillate between modalities across layers, explaining externally observed indecision. Together, these findings establish relative uncertainty and inherent preference as the two governing principles of modality following, offering both a quantitative framework and mechanistic insight into how MLLMs resolve conflicting information.

Intermittent Androgen Suppression (IAS) is a treatment strategy for delaying or even preventing time to relapse of advanced prostate cancer. IAS consists of alternating cycles of therapy (in the form of androgen suppression) and off-treatment periods. The level of prostate specific antigen (PSA) in a patient's serum is frequently monitored to determine when the patient will be taken off therapy and when therapy will resume. In spite of extensive recent clinical experience with IAS, the design of an ideal protocol for any given patient remains one of the main challenges associated with effectively implementing this therapy. We use a threshold-based policy for optimal IAS therapy design that is parameterized by lower and upper PSA threshold values and is associated with a cost metric that combines clinically relevant measures of therapy success. We apply Infinitesimal Perturbation Analysis (IPA) to a Stochastic Hybrid Automaton (SHA) model of prostate cancer evolution under IAS and derive unbiased estimators of the cost metric gradient with respect to various model and therapy parameters. These estimators are subsequently used for system analysis. By evaluating sensitivity estimates with respect to several model parameters, we identify critical parameters and demonstrate that relaxing the optimality condition in favor of increased robustness to modeling errors provides an alternative objective to therapy design for at least some patients.

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.

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.

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.

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.

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.

The prevalent deployment of learning from human preferences through reinforcement learning (RLHF) relies on two important approximations: the first assumes that pairwise preferences can be substituted with pointwise rewards. The second assumes that a reward model trained on these pointwise rewards can generalize from collected data to out-of-distribution data sampled by the policy. Recently, Direct Preference Optimisation (DPO) has been proposed as an approach that bypasses the second approximation and learn directly a policy from collected data without the reward modelling stage. However, this method still heavily relies on the first approximation. In this paper we try to gain a deeper theoretical understanding of these practical algorithms. In particular we derive a new general objective called PsiPO for learning from human preferences that is expressed in terms of pairwise preferences and therefore bypasses both approximations. This new general objective allows us to perform an in-depth analysis of the behavior of RLHF and DPO (as special cases of PsiPO) and to identify their potential pitfalls. We then consider another special case for PsiPO by setting Psi simply to Identity, for which we can derive an efficient optimisation procedure, prove performance guarantees and demonstrate its empirical superiority to DPO on some illustrative examples.

Recent advances in agentic Reinforcement Learning (RL) have substantially improved the multi-turn tool-use capabilities of large language model agents. However, most existing methods assign credit over coarse heuristic units, such as tool-call boundaries or fixed workflows, making it difficult to identify which intermediate decisions influence downstream outcomes. In this work, we study agentic RL from two perspectives: where to branch and how to assign credit after branching. Our pilot analysis shows that influential decision points are broadly distributed throughout the generated sequence rather than concentrated at tool calls, while token entropy alone does not reliably reflect their impact on final outcomes. Motivated by these observations, we propose Agentic Procedural Policy Optimization (APPO), which shifts branching and credit assignment from coarse interaction units to fine-grained decision points in the sequence. APPO selects branching locations using a Branching Score that combines token uncertainty with policy-induced likelihood gains of subsequent continuations, enabling more targeted exploration while filtering out spurious high-entropy positions. It further introduces procedure-level advantage scaling to better distribute credit across branched rollouts. Experiments on 13 benchmarks show that APPO consistently improves strong agentic RL baselines by nearly 4 points, while keeping efficient tool-calls and maintaining behavior interpretability.

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.

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.

Vision-language models (VLMs) adapted to the medical domain have shown strong performance on visual question answering benchmarks, yet their robustness against two critical failure modes, hallucination and sycophancy, remains poorly understood, particularly in combination. We evaluate six VLMs (three general-purpose, three medical-specialist) on three medical VQA datasets and uncover a grounding-sycophancy tradeoff: models with the lowest hallucination propensity are the most sycophantic, while the most pressure-resistant model hallucinates more than all medical-specialist models. To characterize this tradeoff, we propose three metrics: L-VASE, a logit-space reformulation of VASE that avoids its double-normalization; CCS, a confidence-calibrated sycophancy score that penalizes high-confidence capitulation; and Clinical Safety Index (CSI), a unified safety index that combines grounding, autonomy, and calibration via a geometric mean. Across 1,151 test cases, no model achieves a CSI above 0.35, indicating that none of the evaluated 7-8B parameter VLMs is simultaneously well-grounded and robust to social pressure. Our findings suggest that joint evaluation of both properties is necessary before these models can be considered for clinical use. Code is available at https://github.com/UTSA-VIRLab/AgreeOrRight

In recommender system or crowdsourcing applications of online learning, a human's preferences or abilities are often a function of the algorithm's recent actions. Motivated by this, a significant line of work has formalized settings where an action's loss is a function of the number of times that action was recently played in the prior m timesteps, where m corresponds to a bound on human memory capacity. To more faithfully capture decay of human memory with time, we introduce the Weighted Tallying Bandit (WTB), which generalizes this setting by requiring that an action's loss is a function of a weighted summation of the number of times that arm was played in the last m timesteps. This WTB setting is intractable without further assumption. So we study it under Repeated Exposure Optimality (REO), a condition motivated by the literature on human physiology, which requires the existence of an action that when repetitively played will eventually yield smaller loss than any other sequence of actions. We study the minimization of the complete policy regret (CPR), which is the strongest notion of regret, in WTB under REO. Since m is typically unknown, we assume we only have access to an upper bound M on m. We show that for problems with K actions and horizon T, a simple modification of the successive elimination algorithm has O left( KT + (m+M)K right) CPR. Interestingly, upto an additive (in lieu of mutliplicative) factor in (m+M)K, this recovers the classical guarantee for the simpler stochastic multi-armed bandit with traditional regret. We additionally show that in our setting, any algorithm will suffer additive CPR of Omega left( mK + M right), demonstrating our result is nearly optimal. Our algorithm is computationally efficient, and we experimentally demonstrate its practicality and superiority over natural baselines.

We use a Stochastic Hybrid Automaton (SHA) model of prostate cancer evolution under intermittent androgen suppression (IAS) to study a threshold-based policy for therapy design. IAS is currently one of the most widely used treatments for advanced prostate cancer. Patients undergoing IAS are submitted to cycles of treatment (in the form of androgen deprivation) and off-treatment periods in an alternating manner. One of the main challenges in IAS is to optimally design a therapy scheme, i.e., to determine when to discontinue and recommence androgen suppression. The level of prostate specific antigen (PSA) in a patient's serum is frequently monitored to determine when the patient will be taken off therapy and when therapy will resume. The threshold-based policy we propose is parameterized by lower and upper PSA threshold values and is associated with a cost metric that combines clinically relevant measures of therapy success. Using Infinitesimal Perturbation Analysis (IPA), we derive unbiased gradient estimators of this cost metric with respect to the controllable PSA threshold values based on actual data and show how these estimators can be used to adaptively adjust controllable parameters so as to improve therapy outcomes based on the cost metric defined.

Clinical decision-making relies on identifying relevant patient information to guide diagnosis and treatment, a challenge that is especially difficult in the data-dense and rapidly changing intensive care unit (ICU). Large language models (LLMs) could support this task. However, existing applications and datasets mostly emphasize surface-level retrieval or factual recall rather than the inductive and deductive reasoning clinicians practice to select and reason over decision-relevant evidence. We hypothesized that training LLMs on expert ICU reasoning could yield clinical reasoning skills that generalize beyond critical care. Here we introduce ICU-REACT, a reasoning dataset developed with 19 clinicians through a clinician-in-the-loop framework to teach LLMs to perform information retrieval and context-aware clinical reasoning in the ICU. Using ICU-REACT, we fine-tuned Clin-REACT models spanning 8B-70B parameters and three model families. Across five clinical reasoning benchmarks, Clin-REACT consistently outperformed its backbone models and open-source general-purpose and medical LLMs. Gains extended to different tasks including script concordance tests, and downstream diagnosis and treatment tasks. These findings suggest that expert reasoning supervision in critical care can improve broader clinical reasoning, although prospective evaluation is needed before real-world clinical use.

A prominent challenge of offline reinforcement learning (RL) is the issue of hidden confounding: unobserved variables may influence both the actions taken by the agent and the observed outcomes. Hidden confounding can compromise the validity of any causal conclusion drawn from data and presents a major obstacle to effective offline RL. In the present paper, we tackle the problem of hidden confounding in the nonidentifiable setting. We propose a definition of uncertainty due to hidden confounding bias, termed delphic uncertainty, which uses variation over world models compatible with the observations, and differentiate it from the well-known epistemic and aleatoric uncertainties. We derive a practical method for estimating the three types of uncertainties, and construct a pessimistic offline RL algorithm to account for them. Our method does not assume identifiability of the unobserved confounders, and attempts to reduce the amount of confounding bias. We demonstrate through extensive experiments and ablations the efficacy of our approach on a sepsis management benchmark, as well as on electronic health records. Our results suggest that nonidentifiable hidden confounding bias can be mitigated to improve offline RL solutions in practice.

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.

Brain tumor growth is unique to each glioma patient and extends beyond what is visible in imaging scans, infiltrating surrounding brain tissue. Understanding these hidden patient-specific progressions is essential for effective therapies. Current treatment plans for brain tumors, such as radiotherapy, typically involve delineating a uniform margin around the visible tumor on pre-treatment scans to target this invisible tumor growth. This "one size fits all" approach is derived from population studies and often fails to account for the nuances of individual patient conditions. We present the GliODIL framework, which infers the full spatial distribution of tumor cell concentration from available multi-modal imaging, leveraging a Fisher-Kolmogorov type physics model to describe tumor growth. This is achieved through the newly introduced method of Optimizing the Discrete Loss (ODIL), where both data and physics-based constraints are softly assimilated into the solution. Our test dataset comprises 152 glioblastoma patients with pre-treatment imaging and post-treatment follow-ups for tumor recurrence monitoring. By blending data-driven techniques with physics-based constraints, GliODIL enhances recurrence prediction in radiotherapy planning, challenging traditional uniform margins and strict adherence to the Fisher-Kolmogorov partial differential equation (PDE) model, which is adapted for complex cases.

This paper presents the development of a novel ethical reasoning framework for robots. "Robots Can Feel" is the first system for robots that utilizes a combination of logic and human-like emotion simulation to make decisions in morally complex situations akin to humans. The key feature of the approach is the management of the Emotion Weight Coefficient - a customizable parameter to assign the role of emotions in robot decision-making. The system aims to serve as a tool that can equip robots of any form and purpose with ethical behavior close to human standards. Besides the platform, the system is independent of the choice of the base model. During the evaluation, the system was tested on 8 top up-to-date LLMs (Large Language Models). This list included both commercial and open-source models developed by various companies and countries. The research demonstrated that regardless of the model choice, the Emotions Weight Coefficient influences the robot's decision similarly. According to ANOVA analysis, the use of different Emotion Weight Coefficients influenced the final decision in a range of situations, such as in a request for a dietary violation F(4, 35) = 11.2, p = 0.0001 and in an animal compassion situation F(4, 35) = 8.5441, p = 0.0001. A demonstration code repository is provided at: https://github.com/TemaLykov/robots_can_feel

We consider a binary classification problem under group fairness constraints, which can be one of Demographic Parity (DP), Equalized Opportunity (EOp), or Equalized Odds (EO). We propose an explicit characterization of Bayes optimal classifier under the fairness constraints, which turns out to be a simple modification rule of the unconstrained classifier. Namely, we introduce a novel instance-level measure of bias, which we call bias score, and the modification rule is a simple linear rule on top of the finite amount of bias scores.Based on this characterization, we develop a post-hoc approach that allows us to adapt to fairness constraints while maintaining high accuracy. In the case of DP and EOp constraints, the modification rule is thresholding a single bias score, while in the case of EO constraints we are required to fit a linear modification rule with 2 parameters. The method can also be applied for composite group-fairness criteria, such as ones involving several sensitive attributes.

Medical Vision-Language Models (Med-VLMs) require reliable reasoning from fine-grained visual evidence, yet existing models can produce plausible clinical answers by relying on language priors or medical templates rather than truly attending to diagnosis-critical regions. On-Policy Distillation (OPD) offers dense token-level supervision on student-generated trajectories and provides a privacy-compatible means of capability transfer without requiring the redistribution of raw patient data. However, standard OPD uniformly distills all tokens, causing sparse evidence-dependent tokens to be diluted by abundant clinical narrative tokens. Inspired by the success of OPD in the large language model community, we propose Med-OPD, to our knowledge the first unified post-training framework that integrates on-policy distillation with medical evidence-aware supervision for Med-VLMs. We introduce Medical Evidence Advantage (MEA), a teacher-grounded counterfactual signal that uses an answer-aware hint to focus teacher scoring on evidence supporting the target diagnosis, and measures each token's dependence on medical visual evidence by comparing teacher likelihoods under the original and evidence-degraded imaging modalities. Based on MEA, Med-OPD redistributes the distillation signal at both the token and trajectory levels, emphasizing diagnosis-critical tokens and evidence-reliant rollouts. Experiments on OmniMedVQA subsets show that Med-OPD consistently outperforms SFT and standard OPD across CT, MRI, Disease Diagnosis, and Lesion Grading. These results demonstrate that evidence-aware distillation can better strengthen medical VLMs' reliance on key visual evidence and improve reliable multimodal medical reasoning. The source code and data is publicly available at: https://github.com/yunhang8658/MedOPD.git

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.

Combining the answers a large language model (LLM) samples for a question into one decision is a test-time information fusion problem, usually solved by majority voting. Voting is unreliable on difficult questions, where the sampled answers share correlated errors, so the wrong answer can win and drawing more samples makes the decision worse. Selecting a candidate by reading a correctness signal from the model's hidden states is a promising alternative, but its accuracy varies across models and tasks, and no measure indicates when it can be trusted. In this paper, we propose CASE (Correctness-Axis SElection), a dynamic selection combiner that trains a linear gate on the answer-token hidden state and selects the highest-scoring candidate. Its main contribution is decodability, a leakage-free measure of how well the gate ranks a question's correct candidates above its incorrect ones, which predicts whether hidden-state selection will outperform voting. A conventional probe appears accurate only because of question-identity leakage, which vanishes under question-grouped evaluation. On held-out data, decodability predicts the accuracy gain of selection over voting with a Pearson correlation r=0.75 and a decision threshold near AUC=0.60. Across general and medical LLMs, CASE improves over voting by up to 19 points on medium-difficulty questions and 16.8 points on hard questions. Decodability depends on the aligned knowledge a model must recall, not on its scale, and its prediction transfers to an unseen scientific domain within 3.8 points. It thus provides a practical criterion, measurable in advance for a given model and task, for choosing between learned selection and majority voting.

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.

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.

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.

We present Self-Play Preference Optimization (SPO), an algorithm for reinforcement learning from human feedback. Our approach is minimalist in that it does not require training a reward model nor unstable adversarial training and is therefore rather simple to implement. Our approach is maximalist in that it provably handles non-Markovian, intransitive, and stochastic preferences while being robust to the compounding errors that plague offline approaches to sequential prediction. To achieve the preceding qualities, we build upon the concept of a Minimax Winner (MW), a notion of preference aggregation from the social choice theory literature that frames learning from preferences as a zero-sum game between two policies. By leveraging the symmetry of this game, we prove that rather than using the traditional technique of dueling two policies to compute the MW, we can simply have a single agent play against itself while maintaining strong convergence guarantees. Practically, this corresponds to sampling multiple trajectories from a policy, asking a rater or preference model to compare them, and then using the proportion of wins as the reward for a particular trajectory. We demonstrate that on a suite of continuous control tasks, we are able to learn significantly more efficiently than reward-model based approaches while maintaining robustness to the intransitive and stochastic preferences that frequently occur in practice when aggregating human judgments.

Autonomous agents are increasingly capable of developing machine learning (ML) models end to end. In medical practice, however, strong performance on the target metric does not fully characterize how good the models are in real-world use cases. For example, medical ML models should also provide well-calibrated risk estimates and remain robust across patient populations. Yet autonomous model development is typically guided by task objectives that emphasize simple predictive discrimination (e.g. AUROC). This raises a key question: are these objectives sufficient to guide agents toward models that meet the broader requirements of real-world medical use? In this study, we introduce Auto-MD-bench, a benchmark of 15 real-world medical tasks from 10 clinical datasets, spanning survival analysis, classification and sequential prediction, with external validation across cohorts, hospitals and time periods. We evaluate four agents: AIDE, AI Scientist v2, Codex, and Autoresearch. The strongest agents achieve competitive primary scores, yet their predicted risks are less calibrated than those of the simple baseline models, which could lead to severe medical accidents. Moreover, models with nearly identical primary scores can exhibit markedly different calibration, while performance varies substantially across population shifts. These findings show that primary task performance alone is insufficient to assess autonomous clinical modeling and multiple different metrics widely used in healthcare practice need to be taken into consideration.

Chest X-rays (CXRs) are among the most frequently performed imaging examinations worldwide, yet rising imaging volumes increase radiologist workload and the risk of diagnostic errors. Although artificial intelligence (AI) systems have shown promise for CXR interpretation, most generate only final predictions, without making explicit how visual evidence is translated into radiographic findings and diagnostic predictions. We present CheXOne, a reasoning-enabled vision-language model for CXR interpretation. CheXOne jointly generates diagnostic predictions and explicit, clinically grounded reasoning traces that connect visual evidence, radiographic findings, and these predictions. The model is trained on 14.7 million instruction and reasoning samples curated from 30 public datasets spanning 36 CXR interpretation tasks, using a two-stage framework that combines instruction tuning with reinforcement learning to improve reasoning quality. We evaluate CheXOne in zero-shot settings across visual question answering, report generation, visual grounding and reasoning assessment, covering 17 evaluation settings. CheXOne outperforms existing medical and general-domain foundation models and achieves strong performance on independent public benchmarks. A clinical reader study demonstrates that CheXOne-drafted reports are comparable to or better than resident-written reports in 55% of cases, while effectively addressing clinical indications and enhancing both report writing and CXR interpretation efficiency. Further analyses involving radiologists reveal that the generated reasoning traces show high clinical factuality and provide causal support for the final predictions, offering a plausible explanation for the performance gains. These results suggest that explicit reasoning can improve model performance, interpretability and clinical utility in AI-assisted CXR interpretation.