Daily Papers

Off-policy reinforcement learning (RL) has proven to be a powerful framework for guiding agents' actions in environments with stochastic rewards and unknown or noisy state dynamics. In many real-world settings, these agents must operate in multiple environments, each with slightly different dynamics. For example, we may be interested in developing policies to guide medical treatment for patients with and without a given disease, or policies to navigate curriculum design for students with and without a learning disability. Here, we introduce nested policy fitted Q-iteration (NFQI), an RL framework that finds optimal policies in environments that exhibit such a structure. Our approach develops a nested Q-value function that takes advantage of the shared structure between two groups of observations from two separate environments while allowing their policies to be distinct from one another. We find that NFQI yields policies that rely on relevant features and perform at least as well as a policy that does not consider group structure. We demonstrate NFQI's performance using an OpenAI Gym environment and a clinical decision making RL task. Our results suggest that NFQI can develop policies that are better suited to many real-world clinical environments.

Reinforcement learning from verifiable rewards (RLVR) has recently gained attention for its ability to elicit self-evolved reasoning capabilitie from base language models without explicit reasoning supervisions, as demonstrated by DeepSeek-R1. While prior work on RLVR has primarily focused on mathematical and coding domains, its applicability to other tasks and domains remains unexplored. In this work, we investigate whether medical reasoning can emerge from RLVR. We introduce Med-RLVR as an initial study of RLVR in the medical domain leveraging medical multiple-choice question answering (MCQA) data as verifiable labels. Our results demonstrate that RLVR is not only effective for math and coding but also extends successfully to medical question answering. Notably, Med-RLVR achieves performance comparable to traditional supervised fine-tuning (SFT) on in-distribution tasks while significantly improving out-of-distribution generalization, with an 8-point accuracy gain. Further analysis of training dynamics reveals that, with no explicit reasoning supervision, reasoning emerges from the 3B-parameter base model. These findings underscore the potential of RLVR in domains beyond math and coding, opening new avenues for its application in knowledge-intensive fields such as medicine.

Vision-Language Models (VLM) can support clinicians by analyzing medical images and engaging in natural language interactions to assist in diagnostic and treatment tasks. However, VLMs often exhibit "hallucinogenic" behavior, generating textual outputs not grounded in contextual multimodal information. This challenge is particularly pronounced in the medical domain, where we do not only require VLM outputs to be accurate in single interactions but also to be consistent with clinical reasoning and diagnostic pathways throughout multi-turn conversations. For this purpose, we propose a new alignment algorithm that uses symbolic representations of clinical reasoning to ground VLMs in medical knowledge. These representations are utilized to (i) generate GPT-4-guided visual instruction tuning data at scale, simulating clinician-VLM conversations with demonstrations of clinical reasoning, and (ii) create an automatic reward function that evaluates the clinical validity of VLM generations throughout clinician-VLM interactions. Our algorithm eliminates the need for human involvement in training data generation or reward model construction, reducing costs compared to standard reinforcement learning with human feedback (RLHF). We apply our alignment algorithm to develop Dr-LLaVA, a conversational VLM finetuned for analyzing bone marrow pathology slides, demonstrating strong performance in multi-turn medical conversations.

This research tests the role of Large Language Models (LLMs) as formal second opinion tools in professional decision-making, particularly focusing on complex medical cases where even experienced physicians seek peer consultation. The work analyzed 183 challenging medical cases from Medscape over a 20-month period, testing multiple LLMs' performance against crowd-sourced physician responses. A key finding was the high overall score possible in the latest foundational models (>80% accuracy compared to consensus opinion), which exceeds most human metrics reported on the same clinical cases (450 pages of patient profiles, test results). The study rates the LLMs' performance disparity between straightforward cases (>81% accuracy) and complex scenarios (43% accuracy), particularly in these cases generating substantial debate among human physicians. The research demonstrates that LLMs may be valuable as generators of comprehensive differential diagnoses rather than as primary diagnostic tools, potentially helping to counter cognitive biases in clinical decision-making, reduce cognitive loads, and thus remove some sources of medical error. The inclusion of a second comparative legal dataset (Supreme Court cases, N=21) provides added empirical context to the AI use to foster second opinions, though these legal challenges proved considerably easier for LLMs to analyze. In addition to the original contributions of empirical evidence for LLM accuracy, the research aggregated a novel benchmark for others to score highly contested question and answer reliability between both LLMs and disagreeing human practitioners. These results suggest that the optimal deployment of LLMs in professional settings may differ substantially from current approaches that emphasize automation of routine tasks.

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

Large Language Models (LLMs) have attained human-level accuracy on medical question-answer (QA) benchmarks. However, their limitations in navigating open-ended clinical scenarios have recently been shown, raising concerns about the robustness and generalizability of LLM reasoning across diverse, real-world medical tasks. To probe potential LLM failure modes in clinical problem-solving, we present the medical abstraction and reasoning corpus (M-ARC). M-ARC assesses clinical reasoning through scenarios designed to exploit the Einstellung effect -- the fixation of thought arising from prior experience, targeting LLM inductive biases toward inflexible pattern matching from their training data rather than engaging in flexible reasoning. We find that LLMs, including current state-of-the-art o1 and Gemini models, perform poorly compared to physicians on M-ARC, often demonstrating lack of commonsense medical reasoning and a propensity to hallucinate. In addition, uncertainty estimation analyses indicate that LLMs exhibit overconfidence in their answers, despite their limited accuracy. The failure modes revealed by M-ARC in LLM medical reasoning underscore the need to exercise caution when deploying these models in clinical settings.

In response to the pressing need for advanced clinical problem-solving tools in healthcare, we introduce BooksMed, a novel framework based on a Large Language Model (LLM). BooksMed uniquely emulates human cognitive processes to deliver evidence-based and reliable responses, utilizing the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework to effectively quantify evidence strength. For clinical decision-making to be appropriately assessed, an evaluation metric that is clinically aligned and validated is required. As a solution, we present ExpertMedQA, a multispecialty clinical benchmark comprised of open-ended, expert-level clinical questions, and validated by a diverse group of medical professionals. By demanding an in-depth understanding and critical appraisal of up-to-date clinical literature, ExpertMedQA rigorously evaluates LLM performance. BooksMed outperforms existing state-of-the-art models Med-PaLM 2, Almanac, and ChatGPT in a variety of medical scenarios. Therefore, a framework that mimics human cognitive stages could be a useful tool for providing reliable and evidence-based responses to clinical inquiries.

Medical Visual Question Answering (MedVQA), which offers language responses to image-based medical inquiries, represents a challenging task and significant advancement in healthcare. It assists medical experts to swiftly interpret medical images, thereby enabling faster and more accurate diagnoses. However, the model interpretability and transparency of existing MedVQA solutions are often limited, posing challenges in understanding their decision-making processes. To address this issue, we devise a semi-automated annotation process to streamline data preparation and build new benchmark MedVQA datasets R-RAD, R-SLAKE and R-Path. These datasets provide intermediate medical decision-making rationales generated by multimodal large language models and human annotations for question-answering pairs in existing MedVQA datasets, i.e., VQA-RAD, SLAKE and PathVQA. Moreover, we design a novel framework, MedThink, which finetunes lightweight pretrained generative models by incorporating medical decision-making rationales. MedThink includes three distinct strategies to generate decision outcomes and corresponding rationales, thereby clearly showcasing the medical decision-making process during reasoning. Our comprehensive experiments show that our method achieves an accuracy of 83.5% on R-RAD, 86.3% on R-SLAKE and 87.2% on R-Path. These results significantly exceed those of existing state-of-the-art models with comparable parameters. Datasets and code will be released.

The meaningful use of electronic health records (EHR) continues to progress in the digital era with clinical decision support systems augmented by artificial intelligence. A priority in improving provider experience is to overcome information overload and reduce the cognitive burden so fewer medical errors and cognitive biases are introduced during patient care. One major type of medical error is diagnostic error due to systematic or predictable errors in judgment that rely on heuristics. The potential for clinical natural language processing (cNLP) to model diagnostic reasoning in humans with forward reasoning from data to diagnosis and potentially reduce the cognitive burden and medical error has not been investigated. Existing tasks to advance the science in cNLP have largely focused on information extraction and named entity recognition through classification tasks. We introduce a novel suite of tasks coined as Diagnostic Reasoning Benchmarks, DR.BENCH, as a new benchmark for developing and evaluating cNLP models with clinical diagnostic reasoning ability. The suite includes six tasks from ten publicly available datasets addressing clinical text understanding, medical knowledge reasoning, and diagnosis generation. DR.BENCH is the first clinical suite of tasks designed to be a natural language generation framework to evaluate pre-trained language models. Experiments with state-of-the-art pre-trained generative language models using large general domain models and models that were continually trained on a medical corpus demonstrate opportunities for improvement when evaluated in DR. BENCH. We share DR. BENCH as a publicly available GitLab repository with a systematic approach to load and evaluate models for the cNLP community.

As opposed to evaluating computation and logic-based reasoning, current benchmarks for evaluating large language models (LLMs) in medicine are primarily focused on question-answering involving domain knowledge and descriptive reasoning. While such qualitative capabilities are vital to medical diagnosis, in real-world scenarios, doctors frequently use clinical calculators that follow quantitative equations and rule-based reasoning paradigms for evidence-based decision support. To this end, we propose MedCalc-Bench, a first-of-its-kind dataset focused on evaluating the medical calculation capability of LLMs. MedCalc-Bench contains an evaluation set of over 1000 manually reviewed instances from 55 different medical calculation tasks. Each instance in MedCalc-Bench consists of a patient note, a question requesting to compute a specific medical value, a ground truth answer, and a step-by-step explanation showing how the answer is obtained. While our evaluation results show the potential of LLMs in this area, none of them are effective enough for clinical settings. Common issues include extracting the incorrect entities, not using the correct equation or rules for a calculation task, or incorrectly performing the arithmetic for the computation. We hope our study highlights the quantitative knowledge and reasoning gaps in LLMs within medical settings, encouraging future improvements of LLMs for various clinical calculation tasks.

Large Language Models (LLMs) hold great promise to revolutionize current clinical systems for their superior capacities on medical text processing tasks and medical licensing exams. Meanwhile, traditional ML models such as SVM and XGBoost have still been mainly adopted in clinical prediction tasks. An emerging question is Can LLMs beat traditional ML models in clinical prediction? Thus, we build a new benchmark ClinicalBench to comprehensively study the clinical predictive modeling capacities of both general-purpose and medical LLMs, and compare them with traditional ML models. ClinicalBench embraces three common clinical prediction tasks, two databases, 14 general-purpose LLMs, 8 medical LLMs, and 11 traditional ML models. Through extensive empirical investigation, we discover that both general-purpose and medical LLMs, even with different model scales, diverse prompting or fine-tuning strategies, still cannot beat traditional ML models in clinical prediction yet, shedding light on their potential deficiency in clinical reasoning and decision-making. We call for caution when practitioners adopt LLMs in clinical applications. ClinicalBench can be utilized to bridge the gap between LLMs' development for healthcare and real-world clinical practice.

Although large language models (LLMs) have been assessed for general medical knowledge using medical licensing exams, their ability to effectively support clinical decision-making tasks, such as selecting and using medical calculators, remains uncertain. Here, we evaluate the capability of both medical trainees and LLMs to recommend medical calculators in response to various multiple-choice clinical scenarios such as risk stratification, prognosis, and disease diagnosis. We assessed eight LLMs, including open-source, proprietary, and domain-specific models, with 1,009 question-answer pairs across 35 clinical calculators and measured human performance on a subset of 100 questions. While the highest-performing LLM, GPT-4o, provided an answer accuracy of 74.3% (CI: 71.5-76.9%), human annotators, on average, outperformed LLMs with an accuracy of 79.5% (CI: 73.5-85.0%). With error analysis showing that the highest-performing LLMs continue to make mistakes in comprehension (56.6%) and calculator knowledge (8.1%), our findings emphasize that humans continue to surpass LLMs on complex clinical tasks such as calculator recommendation.

Large language models (LLMs) have exhibited remarkable capabilities across various domains and tasks, pushing the boundaries of our knowledge in learning and cognition. The latest model, OpenAI's o1, stands out as the first LLM with an internalized chain-of-thought technique using reinforcement learning strategies. While it has demonstrated surprisingly strong capabilities on various general language tasks, its performance in specialized fields such as medicine remains unknown. To this end, this report provides a comprehensive exploration of o1 on different medical scenarios, examining 3 key aspects: understanding, reasoning, and multilinguality. Specifically, our evaluation encompasses 6 tasks using data from 37 medical datasets, including two newly constructed and more challenging question-answering (QA) tasks based on professional medical quizzes from the New England Journal of Medicine (NEJM) and The Lancet. These datasets offer greater clinical relevance compared to standard medical QA benchmarks such as MedQA, translating more effectively into real-world clinical utility. Our analysis of o1 suggests that the enhanced reasoning ability of LLMs may (significantly) benefit their capability to understand various medical instructions and reason through complex clinical scenarios. Notably, o1 surpasses the previous GPT-4 in accuracy by an average of 6.2% and 6.6% across 19 datasets and two newly created complex QA scenarios. But meanwhile, we identify several weaknesses in both the model capability and the existing evaluation protocols, including hallucination, inconsistent multilingual ability, and discrepant metrics for evaluation. We release our raw data and model outputs at https://ucsc-vlaa.github.io/o1_medicine/ for future research.

Diagnosing and managing a patient is a complex, sequential decision making process that requires physicians to obtain information -- such as which tests to perform -- and to act upon it. Recent advances in artificial intelligence (AI) and large language models (LLMs) promise to profoundly impact clinical care. However, current evaluation schemes overrely on static medical question-answering benchmarks, falling short on interactive decision-making that is required in real-life clinical work. Here, we present AgentClinic: a multimodal benchmark to evaluate LLMs in their ability to operate as agents in simulated clinical environments. In our benchmark, the doctor agent must uncover the patient's diagnosis through dialogue and active data collection. We present two open medical agent benchmarks: a multimodal image and dialogue environment, AgentClinic-NEJM, and a dialogue-only environment, AgentClinic-MedQA. We embed cognitive and implicit biases both in patient and doctor agents to emulate realistic interactions between biased agents. We find that introducing bias leads to large reductions in diagnostic accuracy of the doctor agents, as well as reduced compliance, confidence, and follow-up consultation willingness in patient agents. Evaluating a suite of state-of-the-art LLMs, we find that several models that excel in benchmarks like MedQA are performing poorly in AgentClinic-MedQA. We find that the LLM used in the patient agent is an important factor for performance in the AgentClinic benchmark. We show that both having limited interactions as well as too many interaction reduces diagnostic accuracy in doctor agents. The code and data for this work is publicly available at https://AgentClinic.github.io.

The breakthrough of OpenAI o1 highlights the potential of enhancing reasoning to improve LLM. Yet, most research in reasoning has focused on mathematical tasks, leaving domains like medicine underexplored. The medical domain, though distinct from mathematics, also demands robust reasoning to provide reliable answers, given the high standards of healthcare. However, verifying medical reasoning is challenging, unlike those in mathematics. To address this, we propose verifiable medical problems with a medical verifier to check the correctness of model outputs. This verifiable nature enables advancements in medical reasoning through a two-stage approach: (1) using the verifier to guide the search for a complex reasoning trajectory for fine-tuning LLMs, (2) applying reinforcement learning (RL) with verifier-based rewards to enhance complex reasoning further. Finally, we introduce HuatuoGPT-o1, a medical LLM capable of complex reasoning, which outperforms general and medical-specific baselines using only 40K verifiable problems. Experiments show complex reasoning improves medical problem-solving and benefits more from RL. We hope our approach inspires advancements in reasoning across medical and other specialized domains.

Large language models (LLMs) represent a transformative class of AI tools capable of revolutionizing various aspects of healthcare by generating human-like responses across diverse contexts and adapting to novel tasks following human instructions. Their potential application spans a broad range of medical tasks, such as clinical documentation, matching patients to clinical trials, and answering medical questions. In this primer paper, we propose an actionable guideline to help healthcare professionals more efficiently utilize LLMs in their work, along with a set of best practices. This approach consists of several main phases, including formulating the task, choosing LLMs, prompt engineering, fine-tuning, and deployment. We start with the discussion of critical considerations in identifying healthcare tasks that align with the core capabilities of LLMs and selecting models based on the selected task and data, performance requirements, and model interface. We then review the strategies, such as prompt engineering and fine-tuning, to adapt standard LLMs to specialized medical tasks. Deployment considerations, including regulatory compliance, ethical guidelines, and continuous monitoring for fairness and bias, are also discussed. By providing a structured step-by-step methodology, this tutorial aims to equip healthcare professionals with the tools necessary to effectively integrate LLMs into clinical practice, ensuring that these powerful technologies are applied in a safe, reliable, and impactful manner.

Radiology report generation (RRG) has attracted significant attention due to its potential to reduce the workload of radiologists. Current RRG approaches are still unsatisfactory against clinical standards. This paper introduces a novel RRG method, LM-RRG, that integrates large models (LMs) with clinical quality reinforcement learning to generate accurate and comprehensive chest X-ray radiology reports. Our method first designs a large language model driven feature extractor to analyze and interpret different regions of the chest X-ray image, emphasizing specific regions with medical significance. Next, based on the large model's decoder, we develop a multimodal report generator that leverages multimodal prompts from visual features and textual instruction to produce the radiology report in an auto-regressive way. Finally, to better reflect the clinical significant and insignificant errors that radiologists would normally assign in the report, we introduce a novel clinical quality reinforcement learning strategy. It utilizes the radiology report clinical quality (RadCliQ) metric as a reward function in the learning process. Extensive experiments on the MIMIC-CXR and IU-Xray datasets demonstrate the superiority of our method over the state of the art.

Throughout the course of my Ph.D., I have been designing the user experience (UX) of various machine learning (ML) systems. In this workshop, I share two projects as case studies in which people engage with ML in much more complicated and nuanced ways than the technical HCML work might assume. The first case study describes how cardiology teams in three hospitals used a clinical decision-support system that helps them decide whether and when to implant an artificial heart to a heart failure patient. I demonstrate that physicians cannot draw on their decision-making experience by seeing only patient data on paper. They are also confused by some fundamental premises upon which ML operates. For example, physicians asked: Are ML predictions made based on clinicians' best efforts? Is it ethical to make decisions based on previous patients' collective outcomes? In the second case study, my collaborators and I designed an intelligent text editor, with the goal of improving authors' writing experience with NLP (Natural Language Processing) technologies. We prototyped a number of generative functionalities where the system provides phrase-or-sentence-level writing suggestions upon user request. When writing with the prototype, however, authors shared that they need to "see where the sentence is going two paragraphs later" in order to decide whether the suggestion aligns with their writing; Some even considered adopting machine suggestions as plagiarism, therefore "is simply wrong". By sharing these unexpected and intriguing responses from these real-world ML users, I hope to start a discussion about such previously-unknown complexities and nuances of -- as the workshop proposal states -- "putting ML at the service of people in a way that is accessible, useful, and trustworthy to all".

Large language models (LLMs) are increasingly applied to clinical decision-making. However, their potential to exhibit bias poses significant risks to clinical equity. Currently, there is a lack of benchmarks that systematically evaluate such clinical bias in LLMs. While in downstream tasks, some biases of LLMs can be avoided such as by instructing the model to answer "I'm not sure...", the internal bias hidden within the model still lacks deep studies. We introduce CLIMB (shorthand for A Benchmark of Clinical Bias in Large Language Models), a pioneering comprehensive benchmark to evaluate both intrinsic (within LLMs) and extrinsic (on downstream tasks) bias in LLMs for clinical decision tasks. Notably, for intrinsic bias, we introduce a novel metric, AssocMAD, to assess the disparities of LLMs across multiple demographic groups. Additionally, we leverage counterfactual intervention to evaluate extrinsic bias in a task of clinical diagnosis prediction. Our experiments across popular and medically adapted LLMs, particularly from the Mistral and LLaMA families, unveil prevalent behaviors with both intrinsic and extrinsic bias. This work underscores the critical need to mitigate clinical bias and sets a new standard for future evaluations of LLMs' clinical bias.

Synthesizing clinical evidence largely relies on systematic reviews of clinical trials and retrospective analyses from medical literature. However, the rapid expansion of publications presents challenges in efficiently identifying, summarizing, and updating clinical evidence. Here, we introduce TrialMind, a generative artificial intelligence (AI) pipeline for facilitating human-AI collaboration in three crucial tasks for evidence synthesis: study search, screening, and data extraction. To assess its performance, we chose published systematic reviews to build the benchmark dataset, named TrialReviewBench, which contains 100 systematic reviews and the associated 2,220 clinical studies. Our results show that TrialMind excels across all three tasks. In study search, it generates diverse and comprehensive search queries to achieve high recall rates (Ours 0.711-0.834 v.s. Human baseline 0.138-0.232). For study screening, TrialMind surpasses traditional embedding-based methods by 30% to 160%. In data extraction, it outperforms a GPT-4 baseline by 29.6% to 61.5%. We further conducted user studies to confirm its practical utility. Compared to manual efforts, human-AI collaboration using TrialMind yielded a 71.4% recall lift and 44.2% time savings in study screening and a 23.5% accuracy lift and 63.4% time savings in data extraction. Additionally, when comparing synthesized clinical evidence presented in forest plots, medical experts favored TrialMind's outputs over GPT-4's outputs in 62.5% to 100% of cases. These findings show the promise of LLM-based approaches like TrialMind to accelerate clinical evidence synthesis via streamlining study search, screening, and data extraction from medical literature, with exceptional performance improvement when working with human experts.

This paper surveys research in the rapidly growing field of enhancing large language models (LLMs) with reinforcement learning (RL), a technique that enables LLMs to improve their performance by receiving feedback in the form of rewards based on the quality of their outputs, allowing them to generate more accurate, coherent, and contextually appropriate responses. In this work, we make a systematic review of the most up-to-date state of knowledge on RL-enhanced LLMs, attempting to consolidate and analyze the rapidly growing research in this field, helping researchers understand the current challenges and advancements. Specifically, we (1) detail the basics of RL; (2) introduce popular RL-enhanced LLMs; (3) review researches on two widely-used reward model-based RL techniques: Reinforcement Learning from Human Feedback (RLHF) and Reinforcement Learning from AI Feedback (RLAIF); and (4) explore Direct Preference Optimization (DPO), a set of methods that bypass the reward model to directly use human preference data for aligning LLM outputs with human expectations. We will also point out current challenges and deficiencies of existing methods and suggest some avenues for further improvements. Project page of this work can be found at: https://github.com/ShuheWang1998/Reinforcement-Learning-Enhanced-LLMs-A-Survey.

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

Prompt learning is a new paradigm in the Natural Language Processing (NLP) field which has shown impressive performance on a number of natural language tasks with common benchmarking text datasets in full, few-shot, and zero-shot train-evaluation setups. Recently, it has even been observed that large but frozen pre-trained language models (PLMs) with prompt learning outperform smaller but fine-tuned models. However, as with many recent NLP trends, the performance of even the largest PLMs such as GPT-3 do not perform well on specialized domains (e.g. medical text), and the common practice to achieve State of the Art (SoTA) results still consists of pre-training and fine-tuning the PLMs on downstream tasks. The reliance on fine-tuning large PLMs is problematic in clinical settings where data is often held in non-GPU environments, and more resource efficient methods of training specialized domain models is crucial. We investigated the viability of prompt learning on clinically meaningful decision tasks and directly compared with more traditional fine-tuning methods. Results are partially in line with the prompt learning literature, with prompt learning able to match or improve on traditional fine-tuning with substantially fewer trainable parameters and requiring less training data. We argue that prompt learning therefore provides lower computational resource costs applicable to clinical settings, that can serve as an alternative to fine-tuning ever increasing in size PLMs. Complementary code to reproduce experiments presented in this work can be found at: https://github.com/NtaylorOX/Public_Clinical_Prompt.

As AI systems become more capable, we would like to enlist their help to supervise other AIs. We experiment with methods for training a harmless AI assistant through self-improvement, without any human labels identifying harmful outputs. The only human oversight is provided through a list of rules or principles, and so we refer to the method as 'Constitutional AI'. The process involves both a supervised learning and a reinforcement learning phase. In the supervised phase we sample from an initial model, then generate self-critiques and revisions, and then finetune the original model on revised responses. In the RL phase, we sample from the finetuned model, use a model to evaluate which of the two samples is better, and then train a preference model from this dataset of AI preferences. We then train with RL using the preference model as the reward signal, i.e. we use 'RL from AI Feedback' (RLAIF). As a result we are able to train a harmless but non-evasive AI assistant that engages with harmful queries by explaining its objections to them. Both the SL and RL methods can leverage chain-of-thought style reasoning to improve the human-judged performance and transparency of AI decision making. These methods make it possible to control AI behavior more precisely and with far fewer human labels.

Large-language models have recently demonstrated impressive zero-shot capabilities in a variety of natural language tasks such as summarization, dialogue generation, and question-answering. Despite many promising applications in clinical medicine, adoption of these models in real-world settings has been largely limited by their tendency to generate incorrect and sometimes even toxic statements. In this study, we develop Almanac, a large language model framework augmented with retrieval capabilities for medical guideline and treatment recommendations. Performance on a novel dataset of clinical scenarios (n = 130) evaluated by a panel of 5 board-certified and resident physicians demonstrates significant increases in factuality (mean of 18% at p-value < 0.05) across all specialties, with improvements in completeness and safety. Our results demonstrate the potential for large language models to be effective tools in the clinical decision-making process, while also emphasizing the importance of careful testing and deployment to mitigate their shortcomings.

We introduce RJUA-QA, a novel medical dataset for question answering (QA) and reasoning with clinical evidence, contributing to bridge the gap between general large language models (LLMs) and medical-specific LLM applications. RJUA-QA is derived from realistic clinical scenarios and aims to facilitate LLMs in generating reliable diagnostic and advice. The dataset contains 2,132 curated Question-Context-Answer pairs, corresponding about 25,000 diagnostic records and clinical cases. The dataset covers 67 common urological disease categories, where the disease coverage exceeds 97.6\% of the population seeking medical services in urology. Each data instance in RJUA-QA comprises: (1) a question mirroring real patient to inquiry about clinical symptoms and medical conditions, (2) a context including comprehensive expert knowledge, serving as a reference for medical examination and diagnosis, (3) a doctor response offering the diagnostic conclusion and suggested examination guidance, (4) a diagnosed clinical disease as the recommended diagnostic outcome, and (5) clinical advice providing recommendations for medical examination. RJUA-QA is the first medical QA dataset for clinical reasoning over the patient inquiries, where expert-level knowledge and experience are required for yielding diagnostic conclusions and medical examination advice. A comprehensive evaluation is conducted to evaluate the performance of both medical-specific and general LLMs on the RJUA-QA dataset.

Objective: Using natural language processing (NLP) to find sentences that state treatment plans in a clinical note, would automate plan extraction and would further enable their use in tools that help providers and care managers. However, as in the most NLP tasks on clinical text, creating gold standard to train and test NLP models is tedious and expensive. Fortuitously, sometimes but not always clinical notes contain sections with a heading that identifies the section as a plan. Leveraging contents of such labeled sections as a noisy training data, we assessed accuracy of NLP models trained with the data. Methods: We used common variations of plan headings and rule-based heuristics to find plan sections with headings in clinical notes, and we extracted sentences from them and formed a noisy training data of plan sentences. We trained Support Vector Machine (SVM) and Convolutional Neural Network (CNN) models with the data. We measured accuracy of the trained models on the noisy dataset using ten-fold cross validation and separately on a set-aside manually annotated dataset. Results: About 13% of 117,730 clinical notes contained treatment plans sections with recognizable headings in the 1001 longitudinal patient records that were obtained from Cleveland Clinic under an IRB approval. We were able to extract and create a noisy training data of 13,492 plan sentences from the clinical notes. CNN achieved best F measures, 0.91 and 0.97 in the cross-validation and set-aside evaluation experiments respectively. SVM slightly underperformed with F measures of 0.89 and 0.96 in the same experiments. Conclusion: Our study showed that the training supervised learning models using noisy plan sentences was effective in identifying them in all clinical notes. More broadly, sections with informal headings in clinical notes can be a good source for generating effective training data.

There are two main barriers to using large language models (LLMs) in clinical reasoning. Firstly, while LLMs exhibit significant promise in Natural Language Processing (NLP) tasks, their performance in complex reasoning and planning falls short of expectations. Secondly, LLMs use uninterpretable methods to make clinical decisions that are fundamentally different from the clinician's cognitive processes. This leads to user distrust. In this paper, we present a multi-agent framework called ArgMed-Agents, which aims to enable LLM-based agents to make explainable clinical decision reasoning through interaction. ArgMed-Agents performs self-argumentation iterations via Argumentation Scheme for Clinical Discussion (a reasoning mechanism for modeling cognitive processes in clinical reasoning), and then constructs the argumentation process as a directed graph representing conflicting relationships. Ultimately, use symbolic solver to identify a series of rational and coherent arguments to support decision. We construct a formal model of ArgMed-Agents and present conjectures for theoretical guarantees. ArgMed-Agents enables LLMs to mimic the process of clinical argumentative reasoning by generating explanations of reasoning in a self-directed manner. The setup experiments show that ArgMed-Agents not only improves accuracy in complex clinical decision reasoning problems compared to other prompt methods, but more importantly, it provides users with decision explanations that increase their confidence.

Reinforcement Learning and recently Deep Reinforcement Learning are popular methods for solving sequential decision making problems modeled as Markov Decision Processes. RL modeling of a problem and selecting algorithms and hyper-parameters require careful considerations as different configurations may entail completely different performances. These considerations are mainly the task of RL experts; however, RL is progressively becoming popular in other fields where the researchers and system designers are not RL experts. Besides, many modeling decisions, such as defining state and action space, size of batches and frequency of batch updating, and number of timesteps are typically made manually. For these reasons, automating different components of RL framework is of great importance and it has attracted much attention in recent years. Automated RL provides a framework in which different components of RL including MDP modeling, algorithm selection and hyper-parameter optimization are modeled and defined automatically. In this article, we explore the literature and present recent work that can be used in automated RL. Moreover, we discuss the challenges, open questions and research directions in AutoRL.

Large language models (LLMs) often fail to ask effective questions under uncertainty, making them unreliable in domains where proactive information-gathering is essential for decisionmaking. We present ALFA, a framework that improves LLM question-asking by (i) decomposing the notion of a "good" question into a set of theory-grounded attributes (e.g., clarity, relevance), (ii) controllably synthesizing attribute-specific question variations, and (iii) aligning models via preference-based optimization to explicitly learn to ask better questions along these fine-grained attributes. Focusing on clinical reasoning as a case study, we introduce the MediQ-AskDocs dataset, composed of 17k real-world clinical interactions augmented with 80k attribute-specific preference pairs of follow-up questions, as well as a novel expert-annotated interactive healthcare QA task to evaluate question-asking abilities. Models aligned with ALFA reduce diagnostic errors by 56.6% on MediQ-AskDocs compared to SOTA instruction-tuned LLMs, with a question-level win-rate of 64.4% and strong generalizability. Our findings suggest that explicitly guiding question-asking with structured, fine-grained attributes offers a scalable path to improve LLMs, especially in expert application domains.

Large language models (LLMs), particularly those with reasoning capabilities, have rapidly advanced in recent years, demonstrating significant potential across a wide range of applications. However, their deployment in healthcare, especially in disease reasoning tasks, is hindered by the challenge of acquiring expert-level cognitive data. In this paper, we introduce Citrus, a medical language model that bridges the gap between clinical expertise and AI reasoning by emulating the cognitive processes of medical experts. The model is trained on a large corpus of simulated expert disease reasoning data, synthesized using a novel approach that accurately captures the decision-making pathways of clinicians. This approach enables Citrus to better simulate the complex reasoning processes involved in diagnosing and treating medical conditions.To further address the lack of publicly available datasets for medical reasoning tasks, we release the last-stage training data, including a custom-built medical diagnostic dialogue dataset. This open-source contribution aims to support further research and development in the field. Evaluations using authoritative benchmarks such as MedQA, covering tasks in medical reasoning and language understanding, show that Citrus achieves superior performance compared to other models of similar size. These results highlight Citrus potential to significantly enhance medical decision support systems, providing a more accurate and efficient tool for clinical decision-making.

Reinforcement Learning from Human Feedback (RLHF) has emerged as a dominant approach for aligning LLM outputs with human preferences. Inspired by the success of RLHF, we study the performance of multiple algorithms that learn from feedback (Expert Iteration, Proximal Policy Optimization (PPO), Return-Conditioned RL) on improving LLM reasoning capabilities. We investigate both sparse and dense rewards provided to the LLM both heuristically and via a learned reward model. We additionally start from multiple model sizes and initializations both with and without supervised fine-tuning (SFT) data. Overall, we find all algorithms perform comparably, with Expert Iteration performing best in most cases. Surprisingly, we find the sample complexity of Expert Iteration is similar to that of PPO, requiring at most on the order of 10^6 samples to converge from a pretrained checkpoint. We investigate why this is the case, concluding that during RL training models fail to explore significantly beyond solutions already produced by SFT models. Additionally, we discuss a trade off between maj@1 and pass@96 metric performance during SFT training and how conversely RL training improves both simultaneously. We then conclude by discussing the implications of our findings for RLHF and the future role of RL in LLM fine-tuning.

We present ICU-Sepsis, an environment that can be used in benchmarks for evaluating reinforcement learning (RL) algorithms. Sepsis management is a complex task that has been an important topic in applied RL research in recent years. Therefore, MDPs that model sepsis management can serve as part of a benchmark to evaluate RL algorithms on a challenging real-world problem. However, creating usable MDPs that simulate sepsis care in the ICU remains a challenge due to the complexities involved in acquiring and processing patient data. ICU-Sepsis is a lightweight environment that models personalized care of sepsis patients in the ICU. The environment is a tabular MDP that is widely compatible and is challenging even for state-of-the-art RL algorithms, making it a valuable tool for benchmarking their performance. However, we emphasize that while ICU-Sepsis provides a standardized environment for evaluating RL algorithms, it should not be used to draw conclusions that guide medical practice.

Reinforcement learning from human feedback (RLHF) is a variant of reinforcement learning (RL) that learns from human feedback instead of relying on an engineered reward function. Building on prior work on the related setting of preference-based reinforcement learning (PbRL), it stands at the intersection of artificial intelligence and human-computer interaction. This positioning offers a promising avenue to enhance the performance and adaptability of intelligent systems while also improving the alignment of their objectives with human values. The training of Large Language Models (LLMs) has impressively demonstrated this potential in recent years, where RLHF played a decisive role in targeting the model's capabilities toward human objectives. This article provides a comprehensive overview of the fundamentals of RLHF, exploring the intricate dynamics between machine agents and human input. While recent focus has been on RLHF for LLMs, our survey adopts a broader perspective, examining the diverse applications and wide-ranging impact of the technique. We delve into the core principles that underpin RLHF, shedding light on the symbiotic relationship between algorithms and human feedback, and discuss the main research trends in the field. By synthesizing the current landscape of RLHF research, this article aims to provide researchers as well as practitioners with a comprehensive understanding of this rapidly growing field of research.

Reward models (RMs) are at the crux of successful RLHF to align pretrained models to human preferences, yet there has been relatively little study that focuses on evaluation of those reward models. Evaluating reward models presents an opportunity to understand the opaque technologies used for alignment of language models and which values are embedded in them. To date, very few descriptors of capabilities, training methods, or open-source reward models exist. In this paper, we present RewardBench, a benchmark dataset and code-base for evaluation, to enhance scientific understanding of reward models. The RewardBench dataset is a collection of prompt-win-lose trios spanning chat, reasoning, and safety, to benchmark how reward models perform on challenging, structured and out-of-distribution queries. We created specific comparison datasets for RMs that have subtle, but verifiable reasons (e.g. bugs, incorrect facts) why one answer should be preferred to another. On the RewardBench leaderboard, we evaluate reward models trained with a variety of methods, such as the direct MLE training of classifiers and the implicit reward modeling of Direct Preference Optimization (DPO), and on a spectrum of datasets. We present many findings on propensity for refusals, reasoning limitations, and instruction following shortcomings of various reward models towards a better understanding of the RLHF process.

There is increasing interest in the application large language models (LLMs) to the medical field, in part because of their impressive performance on medical exam questions. While promising, exam questions do not reflect the complexity of real patient-doctor interactions. In reality, physicians' decisions are shaped by many complex factors, such as patient compliance, personal experience, ethical beliefs, and cognitive bias. Taking a step toward understanding this, our hypothesis posits that when LLMs are confronted with clinical questions containing cognitive biases, they will yield significantly less accurate responses compared to the same questions presented without such biases. In this study, we developed BiasMedQA, a benchmark for evaluating cognitive biases in LLMs applied to medical tasks. Using BiasMedQA we evaluated six LLMs, namely GPT-4, Mixtral-8x70B, GPT-3.5, PaLM-2, Llama 2 70B-chat, and the medically specialized PMC Llama 13B. We tested these models on 1,273 questions from the US Medical Licensing Exam (USMLE) Steps 1, 2, and 3, modified to replicate common clinically-relevant cognitive biases. Our analysis revealed varying effects for biases on these LLMs, with GPT-4 standing out for its resilience to bias, in contrast to Llama 2 70B-chat and PMC Llama 13B, which were disproportionately affected by cognitive bias. Our findings highlight the critical need for bias mitigation in the development of medical LLMs, pointing towards safer and more reliable applications in healthcare.

How do we most effectively treat a disease or condition? Ideally, we could consult a database of evidence gleaned from clinical trials to answer such questions. Unfortunately, no such database exists; clinical trial results are instead disseminated primarily via lengthy natural language articles. Perusing all such articles would be prohibitively time-consuming for healthcare practitioners; they instead tend to depend on manually compiled systematic reviews of medical literature to inform care. NLP may speed this process up, and eventually facilitate immediate consult of published evidence. The Evidence Inference dataset was recently released to facilitate research toward this end. This task entails inferring the comparative performance of two treatments, with respect to a given outcome, from a particular article (describing a clinical trial) and identifying supporting evidence. For instance: Does this article report that chemotherapy performed better than surgery for five-year survival rates of operable cancers? In this paper, we collect additional annotations to expand the Evidence Inference dataset by 25\%, provide stronger baseline models, systematically inspect the errors that these make, and probe dataset quality. We also release an abstract only (as opposed to full-texts) version of the task for rapid model prototyping. The updated corpus, documentation, and code for new baselines and evaluations are available at http://evidence-inference.ebm-nlp.com/.

With the rapid development of artificial intelligence, large language models (LLMs) have shown promising capabilities in mimicking human-level language comprehension and reasoning. This has sparked significant interest in applying LLMs to enhance various aspects of healthcare, ranging from medical education to clinical decision support. However, medicine involves multifaceted data modalities and nuanced reasoning skills, presenting challenges for integrating LLMs. This paper provides a comprehensive review on the applications and implications of LLMs in medicine. It begins by examining the fundamental applications of general-purpose and specialized LLMs, demonstrating their utilities in knowledge retrieval, research support, clinical workflow automation, and diagnostic assistance. Recognizing the inherent multimodality of medicine, the review then focuses on multimodal LLMs, investigating their ability to process diverse data types like medical imaging and EHRs to augment diagnostic accuracy. To address LLMs' limitations regarding personalization and complex clinical reasoning, the paper explores the emerging development of LLM-powered autonomous agents for healthcare. Furthermore, it summarizes the evaluation methodologies for assessing LLMs' reliability and safety in medical contexts. Overall, this review offers an extensive analysis on the transformative potential of LLMs in modern medicine. It also highlights the pivotal need for continuous optimizations and ethical oversight before these models can be effectively integrated into clinical practice. Visit https://github.com/mingze-yuan/Awesome-LLM-Healthcare for an accompanying GitHub repository containing latest papers.

Large Language Models (LLMs) and multi-agent systems have shown impressive capabilities in natural language tasks but face challenges in clinical trial applications, primarily due to limited access to external knowledge. Recognizing the potential of advanced clinical trial tools that aggregate and predict based on the latest medical data, we propose an integrated solution to enhance their accessibility and utility. We introduce Clinical Agent System (ClinicalAgent), a clinical multi-agent system designed for clinical trial tasks, leveraging GPT-4, multi-agent architectures, LEAST-TO-MOST, and ReAct reasoning technology. This integration not only boosts LLM performance in clinical contexts but also introduces novel functionalities. The proposed method achieves competitive predictive performance in clinical trial outcome prediction (0.7908 PR-AUC), obtaining a 0.3326 improvement over the standard prompt Method. Publicly available code can be found at https://anonymous.4open.science/r/ClinicalAgent-6671.

Passively collected behavioral health data from ubiquitous sensors holds significant promise to provide mental health professionals insights from patient's daily lives; however, developing analysis tools to use this data in clinical practice requires addressing challenges of generalization across devices and weak or ambiguous correlations between the measured signals and an individual's mental health. To address these challenges, we take a novel approach that leverages large language models (LLMs) to synthesize clinically useful insights from multi-sensor data. We develop chain of thought prompting methods that use LLMs to generate reasoning about how trends in data such as step count and sleep relate to conditions like depression and anxiety. We first demonstrate binary depression classification with LLMs achieving accuracies of 61.1% which exceed the state of the art. While it is not robust for clinical use, this leads us to our key finding: even more impactful and valued than classification is a new human-AI collaboration approach in which clinician experts interactively query these tools and combine their domain expertise and context about the patient with AI generated reasoning to support clinical decision-making. We find models like GPT-4 correctly reference numerical data 75% of the time, and clinician participants express strong interest in using this approach to interpret self-tracking data.

Automatic disease diagnosis has become increasingly valuable in clinical practice. The advent of large language models (LLMs) has catalyzed a paradigm shift in artificial intelligence, with growing evidence supporting the efficacy of LLMs in diagnostic tasks. Despite the increasing attention in this field, a holistic view is still lacking. Many critical aspects remain unclear, such as the diseases and clinical data to which LLMs have been applied, the LLM techniques employed, and the evaluation methods used. In this article, we perform a comprehensive review of LLM-based methods for disease diagnosis. Our review examines the existing literature across various dimensions, including disease types and associated clinical specialties, clinical data, LLM techniques, and evaluation methods. Additionally, we offer recommendations for applying and evaluating LLMs for diagnostic tasks. Furthermore, we assess the limitations of current research and discuss future directions. To our knowledge, this is the first comprehensive review for LLM-based disease diagnosis.

Reinforcement learning from human feedback (RLHF) has emerged as a powerful technique to make large language models (LLMs) more capable in complex settings. RLHF proceeds as collecting human preference data, training a reward model on said data, and optimizing a base ML model with respect to said reward for extrinsic evaluation metrics (e.g. MMLU, GSM8k). RLHF relies on many assumptions about how the various pieces fit together, such as a reward model capturing human preferences and an RL optimizer extracting the right signal from a reward model. As the RLHF process involves many distinct design decisions, it is easy to assume that multiple processes are correlated and therefore numerically linked. This apparent correlation is often not true, where reward models are easily overoptimized or RL optimizers can reduce performance on tasks not modeled in the data. Notable manifestations of models trained with imperfect RLHF systems are those that are prone to refusing basic requests for safety reasons or appearing lazy in generations. As chat model evaluation becomes increasingly nuanced, the reliance on a perceived link between reward model training, RL scores, and downstream performance drives these issues, which we describe as an objective mismatch. In this paper, we illustrate the causes of this issue, reviewing relevant literature from model-based reinforcement learning, and argue for solutions. By solving objective mismatch in RLHF, the ML models of the future will be more precisely aligned to user instructions for both safety and helpfulness.

Reward models have been increasingly critical for improving the reasoning capability of LLMs. Existing research has shown that a well-trained reward model can substantially improve model performances at inference time via search. However, the potential of reward models during RL training time still remains largely under-explored. It is currently unclear whether these reward models can provide additional training signals to enhance the reasoning capabilities of LLMs in RL training that uses sparse success rewards, which verify the correctness of solutions. In this work, we evaluate popular reward models for RL training, including the Outcome-supervised Reward Model (ORM) and the Process-supervised Reward Model (PRM), and train a collection of LLMs for math problems using RL by combining these learned rewards with success rewards. Surprisingly, even though these learned reward models have strong inference-time performances, they may NOT help or even hurt RL training, producing worse performances than LLMs trained with the success reward only. Our analysis reveals that an LLM can receive high rewards from some of these reward models by repeating correct but unnecessary reasoning steps, leading to a severe reward hacking issue. Therefore, we introduce two novel reward refinement techniques, including Clipping and Delta. The key idea is to ensure the accumulative reward of any reasoning trajectory is upper-bounded to keep a learned reward model effective without being exploited. We evaluate our techniques with multiple reward models over a set of 1.5B and 7B LLMs on MATH and GSM8K benchmarks and demonstrate that with a carefully designed reward function, RL training without any additional supervised tuning can improve all the evaluated LLMs, including the state-of-the-art 7B LLM Qwen2.5-Math-7B-Instruct on MATH and GSM8K benchmarks.

In this paper, we propose R^3: Learning Reasoning through Reverse Curriculum Reinforcement Learning (RL), a novel method that employs only outcome supervision to achieve the benefits of process supervision for large language models. The core challenge in applying RL to complex reasoning is to identify a sequence of actions that result in positive rewards and provide appropriate supervision for optimization. Outcome supervision provides sparse rewards for final results without identifying error locations, whereas process supervision offers step-wise rewards but requires extensive manual annotation. R^3 overcomes these limitations by learning from correct demonstrations. Specifically, R^3 progressively slides the start state of reasoning from a demonstration's end to its beginning, facilitating easier model exploration at all stages. Thus, R^3 establishes a step-wise curriculum, allowing outcome supervision to offer step-level signals and precisely pinpoint errors. Using Llama2-7B, our method surpasses RL baseline on eight reasoning tasks by 4.1 points on average. Notebaly, in program-based reasoning on GSM8K, it exceeds the baseline by 4.2 points across three backbone models, and without any extra data, Codellama-7B + R^3 performs comparable to larger models or closed-source models.

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.

Models that can predict the occurrence of events ahead of time with low false-alarm rates are critical to the acceptance of decision support systems in the medical community. This challenging task is typically treated as a simple binary classification, ignoring temporal dependencies between samples, whereas we propose to exploit this structure. We first introduce a common theoretical framework unifying dynamic survival analysis and early event prediction. Following an analysis of objectives from both fields, we propose Temporal Label Smoothing (TLS), a simpler, yet best-performing method that preserves prediction monotonicity over time. By focusing the objective on areas with a stronger predictive signal, TLS improves performance over all baselines on two large-scale benchmark tasks. Gains are particularly notable along clinically relevant measures, such as event recall at low false-alarm rates. TLS reduces the number of missed events by up to a factor of two over previously used approaches in early event prediction.

LLMs have demonstrated impressive performance in answering medical questions, such as passing scores on medical licensing examinations. However, medical board exam questions or general clinical questions do not capture the complexity of realistic clinical cases. Moreover, the lack of reference explanations means we cannot easily evaluate the reasoning of model decisions, a crucial component of supporting doctors in making complex medical decisions. To address these challenges, we construct two new datasets: JAMA Clinical Challenge and Medbullets. JAMA Clinical Challenge consists of questions based on challenging clinical cases, while Medbullets comprises USMLE Step 2&3 style clinical questions. Both datasets are structured as multiple-choice question-answering tasks, where each question is accompanied by an expert-written explanation. We evaluate four LLMs on the two datasets using various prompts. Experiments demonstrate that our datasets are harder than previous benchmarks. The inconsistency between automatic and human evaluations of model-generated explanations highlights the need to develop new metrics to support future research on explainable medical QA.

Recent advancements in Large Language Models (LLMs) have garnered wide attention and led to successful products such as ChatGPT and GPT-4. Their proficiency in adhering to instructions and delivering harmless, helpful, and honest (3H) responses can largely be attributed to the technique of Reinforcement Learning from Human Feedback (RLHF). In this paper, we aim to link the research in conventional RL to RL techniques used in LLM research. Demystify this technique by discussing why, when, and how RL excels. Furthermore, we explore potential future avenues that could either benefit from or contribute to RLHF research. Highlighted Takeaways: 1. RLHF is Online Inverse RL with Offline Demonstration Data. 2. RLHF > SFT because Imitation Learning (and Inverse RL) > Behavior Cloning (BC) by alleviating the problem of compounding error. 3. The RM step in RLHF generates a proxy of the expensive human feedback, such an insight can be generalized to other LLM tasks such as prompting evaluation and optimization where feedback is also expensive. 4. The policy learning in RLHF is more challenging than conventional problems studied in IRL due to their high action dimensionality and feedback sparsity. 5. The main superiority of PPO over off-policy value-based methods is its stability gained from (almost) on-policy data and conservative policy updates.

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.

Reasoning is a critical frontier for advancing medical image analysis, where transparency and trustworthiness play a central role in both clinician trust and regulatory approval. Although Medical Visual Language Models (VLMs) show promise for radiological tasks, most existing VLMs merely produce final answers without revealing the underlying reasoning. To address this gap, we introduce MedVLM-R1, a medical VLM that explicitly generates natural language reasoning to enhance transparency and trustworthiness. Instead of relying on supervised fine-tuning (SFT), which often suffers from overfitting to training distributions and fails to foster genuine reasoning, MedVLM-R1 employs a reinforcement learning framework that incentivizes the model to discover human-interpretable reasoning paths without using any reasoning references. Despite limited training data (600 visual question answering samples) and model parameters (2B), MedVLM-R1 boosts accuracy from 55.11% to 78.22% across MRI, CT, and X-ray benchmarks, outperforming larger models trained on over a million samples. It also demonstrates robust domain generalization under out-of-distribution tasks. By unifying medical image analysis with explicit reasoning, MedVLM-R1 marks a pivotal step toward trustworthy and interpretable AI in clinical practice.

Objective: The reading level of health educational materials significantly influences the understandability and accessibility of the information, particularly for minoritized populations. Many patient educational resources surpass the reading level and complexity of widely accepted standards. There is a critical need for high-performing text simplification models in health information to enhance dissemination and literacy. This need is particularly acute in cancer education, where effective prevention and screening education can substantially reduce morbidity and mortality. Methods: We introduce Simplified Digestive Cancer (SimpleDC), a parallel corpus of cancer education materials tailored for health text simplification research, comprising educational content from the American Cancer Society, Centers for Disease Control and Prevention, and National Cancer Institute. Utilizing SimpleDC alongside the existing Med-EASi corpus, we explore Large Language Model (LLM)-based simplification methods, including fine-tuning, reinforcement learning (RL), reinforcement learning with human feedback (RLHF), domain adaptation, and prompt-based approaches. Our experimentation encompasses Llama 2 and GPT-4. A novel RLHF reward function is introduced, featuring a lightweight model adept at distinguishing between original and simplified texts, thereby enhancing the model's effectiveness with unlabeled data. Results: Fine-tuned Llama 2 models demonstrated high performance across various metrics. Our innovative RLHF reward function surpassed existing RL text simplification reward functions in effectiveness. The results underscore that RL/RLHF can augment fine-tuning, facilitating model training on unlabeled text and improving performance.

Several studies showed that Large Language Models (LLMs) can answer medical questions correctly, even outperforming the average human score in some medical exams. However, to our knowledge, no study has been conducted to assess the ability of language models to validate existing or generated medical text for correctness and consistency. In this paper, we introduce MEDEC (https://github.com/abachaa/MEDEC), the first publicly available benchmark for medical error detection and correction in clinical notes, covering five types of errors (Diagnosis, Management, Treatment, Pharmacotherapy, and Causal Organism). MEDEC consists of 3,848 clinical texts, including 488 clinical notes from three US hospital systems that were not previously seen by any LLM. The dataset has been used for the MEDIQA-CORR shared task to evaluate seventeen participating systems [Ben Abacha et al., 2024]. In this paper, we describe the data creation methods and we evaluate recent LLMs (e.g., o1-preview, GPT-4, Claude 3.5 Sonnet, and Gemini 2.0 Flash) for the tasks of detecting and correcting medical errors requiring both medical knowledge and reasoning capabilities. We also conducted a comparative study where two medical doctors performed the same task on the MEDEC test set. The results showed that MEDEC is a sufficiently challenging benchmark to assess the ability of models to validate existing or generated notes and to correct medical errors. We also found that although recent LLMs have a good performance in error detection and correction, they are still outperformed by medical doctors in these tasks. We discuss the potential factors behind this gap, the insights from our experiments, the limitations of current evaluation metrics, and share potential pointers for future research.

The rapid development of Large Language Models (LLMs) for healthcare applications has spurred calls for holistic evaluation beyond frequently-cited benchmarks like USMLE, to better reflect real-world performance. While real-world assessments are valuable indicators of utility, they often lag behind the pace of LLM evolution, likely rendering findings obsolete upon deployment. This temporal disconnect necessitates a comprehensive upfront evaluation that can guide model selection for specific clinical applications. We introduce MEDIC, a framework assessing LLMs across five critical dimensions of clinical competence: medical reasoning, ethics and bias, data and language understanding, in-context learning, and clinical safety. MEDIC features a novel cross-examination framework quantifying LLM performance across areas like coverage and hallucination detection, without requiring reference outputs. We apply MEDIC to evaluate LLMs on medical question-answering, safety, summarization, note generation, and other tasks. Our results show performance disparities across model sizes, baseline vs medically finetuned models, and have implications on model selection for applications requiring specific model strengths, such as low hallucination or lower cost of inference. MEDIC's multifaceted evaluation reveals these performance trade-offs, bridging the gap between theoretical capabilities and practical implementation in healthcare settings, ensuring that the most promising models are identified and adapted for diverse healthcare applications.

Large language models (LLMs) have demonstrated impressive capabilities in disease diagnosis. However, their effectiveness in identifying rarer diseases, which are inherently more challenging to diagnose, remains an open question. Rare disease performance is critical with the increasing use of LLMs in healthcare settings. This is especially true if a primary care physician needs to make a rarer prognosis from only a patient conversation so that they can take the appropriate next step. To that end, several clinical decision support systems are designed to support providers in rare disease identification. Yet their utility is limited due to their lack of knowledge of common disorders and difficulty of use. In this paper, we propose RareScale to combine the knowledge LLMs with expert systems. We use jointly use an expert system and LLM to simulate rare disease chats. This data is used to train a rare disease candidate predictor model. Candidates from this smaller model are then used as additional inputs to black-box LLM to make the final differential diagnosis. Thus, RareScale allows for a balance between rare and common diagnoses. We present results on over 575 rare diseases, beginning with Abdominal Actinomycosis and ending with Wilson's Disease. Our approach significantly improves the baseline performance of black-box LLMs by over 17% in Top-5 accuracy. We also find that our candidate generation performance is high (e.g. 88.8% on gpt-4o generated chats).

Clinical diagnosis prediction models, when provided with a patient's medical history, aim to detect potential diseases early, facilitating timely intervention and improving prognostic outcomes. However, the inherent scarcity of patient data and large disease candidate space often pose challenges in developing satisfactory models for this intricate task. The exploration of leveraging Large Language Models (LLMs) for encapsulating clinical decision processes has been limited. We introduce MERA, a clinical diagnosis prediction model that bridges pertaining natural language knowledge with medical practice. We apply hierarchical contrastive learning on a disease candidate ranking list to alleviate the large decision space issue. With concept memorization through fine-tuning, we bridge the natural language clinical knowledge with medical codes. Experimental results on MIMIC-III and IV datasets show that MERA achieves the state-of-the-art diagnosis prediction performance and dramatically elevates the diagnosis prediction capabilities of generative LMs.

This study investigates GPT-4's assessment of its performance in healthcare applications. A simple prompting technique was used to prompt the LLM with questions taken from the United States Medical Licensing Examination (USMLE) questionnaire and it was tasked to evaluate its confidence score before posing the question and after asking the question. The questionnaire was categorized into two groups-questions with feedback (WF) and questions with no feedback(NF) post-question. The model was asked to provide absolute and relative confidence scores before and after each question. The experimental findings were analyzed using statistical tools to study the variability of confidence in WF and NF groups. Additionally, a sequential analysis was conducted to observe the performance variation for the WF and NF groups. Results indicate that feedback influences relative confidence but doesn't consistently increase or decrease it. Understanding the performance of LLM is paramount in exploring its utility in sensitive areas like healthcare. This study contributes to the ongoing discourse on the reliability of AI, particularly of LLMs like GPT-4, within healthcare, offering insights into how feedback mechanisms might be optimized to enhance AI-assisted medical education and decision support.

Several recent works seek to develop foundation models specifically for medical applications, adapting general-purpose large language models (LLMs) and vision-language models (VLMs) via continued pretraining on publicly available biomedical corpora. These works typically claim that such domain-adaptive pretraining (DAPT) improves performance on downstream medical tasks, such as answering medical licensing exam questions. In this paper, we compare ten public "medical" LLMs and two VLMs against their corresponding base models, arriving at a different conclusion: all medical VLMs and nearly all medical LLMs fail to consistently improve over their base models in the zero-/few-shot prompting and supervised fine-tuning regimes for medical question-answering (QA). For instance, across all tasks and model pairs we consider in the 3-shot setting, medical LLMs only outperform their base models in 22.7% of cases, reach a (statistical) tie in 36.8% of cases, and are significantly worse than their base models in the remaining 40.5% of cases. Our conclusions are based on (i) comparing each medical model head-to-head, directly against the corresponding base model; (ii) optimizing the prompts for each model separately in zero-/few-shot prompting; and (iii) accounting for statistical uncertainty in comparisons. While these basic practices are not consistently adopted in the literature, our ablations show that they substantially impact conclusions. Meanwhile, we find that after fine-tuning on specific QA tasks, medical LLMs can show performance improvements, but the benefits do not carry over to tasks based on clinical notes. Our findings suggest that state-of-the-art general-domain models may already exhibit strong medical knowledge and reasoning capabilities, and offer recommendations to strengthen the conclusions of future studies.

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.

Large language models (LLMs) have demonstrated remarkable capabilities in natural language understanding and generation across various domains, including medicine. We present a comprehensive evaluation of GPT-4, a state-of-the-art LLM, on medical competency examinations and benchmark datasets. GPT-4 is a general-purpose model that is not specialized for medical problems through training or engineered to solve clinical tasks. Our analysis covers two sets of official practice materials for the USMLE, a three-step examination program used to assess clinical competency and grant licensure in the United States. We also evaluate performance on the MultiMedQA suite of benchmark datasets. Beyond measuring model performance, experiments were conducted to investigate the influence of test questions containing both text and images on model performance, probe for memorization of content during training, and study probability calibration, which is of critical importance in high-stakes applications like medicine. Our results show that GPT-4, without any specialized prompt crafting, exceeds the passing score on USMLE by over 20 points and outperforms earlier general-purpose models (GPT-3.5) as well as models specifically fine-tuned on medical knowledge (Med-PaLM, a prompt-tuned version of Flan-PaLM 540B). In addition, GPT-4 is significantly better calibrated than GPT-3.5, demonstrating a much-improved ability to predict the likelihood that its answers are correct. We also explore the behavior of the model qualitatively through a case study that shows the ability of GPT-4 to explain medical reasoning, personalize explanations to students, and interactively craft new counterfactual scenarios around a medical case. Implications of the findings are discussed for potential uses of GPT-4 in medical education, assessment, and clinical practice, with appropriate attention to challenges of accuracy and safety.

Several recent works seek to develop foundation models specifically for medical applications, adapting general-purpose large language models (LLMs) and vision-language models (VLMs) via continued pretraining on publicly available biomedical corpora. These works typically claim that such domain-adaptive pretraining (DAPT) improves performance on downstream medical tasks, such as answering medical licensing exam questions. In this paper, we compare seven public "medical" LLMs and two VLMs against their corresponding base models, arriving at a different conclusion: all medical VLMs and nearly all medical LLMs fail to consistently improve over their base models in the zero-/few-shot prompting regime for medical question-answering (QA) tasks. For instance, across the tasks and model pairs we consider in the 3-shot setting, medical LLMs only outperform their base models in 12.1% of cases, reach a (statistical) tie in 49.8% of cases, and are significantly worse than their base models in the remaining 38.2% of cases. Our conclusions are based on (i) comparing each medical model head-to-head, directly against the corresponding base model; (ii) optimizing the prompts for each model separately; and (iii) accounting for statistical uncertainty in comparisons. While these basic practices are not consistently adopted in the literature, our ablations show that they substantially impact conclusions. Our findings suggest that state-of-the-art general-domain models may already exhibit strong medical knowledge and reasoning capabilities, and offer recommendations to strengthen the conclusions of future studies.

Clinical question answering systems have the potential to provide clinicians with relevant and timely answers to their questions. Nonetheless, despite the advances that have been made, adoption of these systems in clinical settings has been slow. One issue is a lack of question-answering datasets which reflect the real-world needs of health professionals. In this work, we present RealMedQA, a dataset of realistic clinical questions generated by humans and an LLM. We describe the process for generating and verifying the QA pairs and assess several QA models on BioASQ and RealMedQA to assess the relative difficulty of matching answers to questions. We show that the LLM is more cost-efficient for generating "ideal" QA pairs. Additionally, we achieve a lower lexical similarity between questions and answers than BioASQ which provides an additional challenge to the top two QA models, as per the results. We release our code and our dataset publicly to encourage further research.

There is a significant gap between patient needs and available mental health support today. In this paper, we aim to thoroughly examine the potential of using Large Language Models (LLMs) to assist professional psychotherapy. To this end, we propose a new benchmark, CBT-BENCH, for the systematic evaluation of cognitive behavioral therapy (CBT) assistance. We include three levels of tasks in CBT-BENCH: I: Basic CBT knowledge acquisition, with the task of multiple-choice questions; II: Cognitive model understanding, with the tasks of cognitive distortion classification, primary core belief classification, and fine-grained core belief classification; III: Therapeutic response generation, with the task of generating responses to patient speech in CBT therapy sessions. These tasks encompass key aspects of CBT that could potentially be enhanced through AI assistance, while also outlining a hierarchy of capability requirements, ranging from basic knowledge recitation to engaging in real therapeutic conversations. We evaluated representative LLMs on our benchmark. Experimental results indicate that while LLMs perform well in reciting CBT knowledge, they fall short in complex real-world scenarios requiring deep analysis of patients' cognitive structures and generating effective responses, suggesting potential future work.

The language-conditioned robotic manipulation aims to transfer natural language instructions into executable actions, from simple pick-and-place to tasks requiring intent recognition and visual reasoning. Inspired by the dual process theory in cognitive science, which suggests two parallel systems of fast and slow thinking in human decision-making, we introduce Robotics with Fast and Slow Thinking (RFST), a framework that mimics human cognitive architecture to classify tasks and makes decisions on two systems based on instruction types. Our RFST consists of two key components: 1) an instruction discriminator to determine which system should be activated based on the current user instruction, and 2) a slow-thinking system that is comprised of a fine-tuned vision language model aligned with the policy networks, which allows the robot to recognize user intention or perform reasoning tasks. To assess our methodology, we built a dataset featuring real-world trajectories, capturing actions ranging from spontaneous impulses to tasks requiring deliberate contemplation. Our results, both in simulation and real-world scenarios, confirm that our approach adeptly manages intricate tasks that demand intent recognition and reasoning. The project is available at https://jlm-z.github.io/RSFT/

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

While recent advances have boosted LM proficiency in linguistic benchmarks, LMs consistently struggle to reason correctly on complex tasks like mathematics. We turn to Reinforcement Learning from Human Feedback (RLHF) as a method with which to shape model reasoning processes. In particular, we explore two reward schemes, outcome-supervised reward models (ORMs) and process-supervised reward models (PRMs), to optimize for logical reasoning. Our results show that the fine-grained reward provided by PRM-based methods enhances accuracy on simple mathematical reasoning (GSM8K) while, unexpectedly, reducing performance in complex tasks (MATH). Furthermore, we show the critical role reward aggregation functions play in model performance. Providing promising avenues for future research, our study underscores the need for further exploration into fine-grained reward modeling for more reliable language models.

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

The integration of Artificial Intelligence (AI), especially Large Language Models (LLMs), into the clinical diagnosis process offers significant potential to improve the efficiency and accessibility of medical care. While LLMs have shown some promise in the medical domain, their application in clinical diagnosis remains underexplored, especially in real-world clinical practice, where highly sophisticated, patient-specific decisions need to be made. Current evaluations of LLMs in this field are often narrow in scope, focusing on specific diseases or specialties and employing simplified diagnostic tasks. To bridge this gap, we introduce CliBench, a novel benchmark developed from the MIMIC IV dataset, offering a comprehensive and realistic assessment of LLMs' capabilities in clinical diagnosis. This benchmark not only covers diagnoses from a diverse range of medical cases across various specialties but also incorporates tasks of clinical significance: treatment procedure identification, lab test ordering and medication prescriptions. Supported by structured output ontologies, CliBench enables a precise and multi-granular evaluation, offering an in-depth understanding of LLM's capability on diverse clinical tasks of desired granularity. We conduct a zero-shot evaluation of leading LLMs to assess their proficiency in clinical decision-making. Our preliminary results shed light on the potential and limitations of current LLMs in clinical settings, providing valuable insights for future advancements in LLM-powered healthcare.

Large language models (LLMs) have demonstrated impressive capabilities in natural language understanding and generation, but the quality bar for medical and clinical applications is high. Today, attempts to assess models' clinical knowledge typically rely on automated evaluations on limited benchmarks. There is no standard to evaluate model predictions and reasoning across a breadth of tasks. To address this, we present MultiMedQA, a benchmark combining six existing open question answering datasets spanning professional medical exams, research, and consumer queries; and HealthSearchQA, a new free-response dataset of medical questions searched online. We propose a framework for human evaluation of model answers along multiple axes including factuality, precision, possible harm, and bias. In addition, we evaluate PaLM (a 540-billion parameter LLM) and its instruction-tuned variant, Flan-PaLM, on MultiMedQA. Using a combination of prompting strategies, Flan-PaLM achieves state-of-the-art accuracy on every MultiMedQA multiple-choice dataset (MedQA, MedMCQA, PubMedQA, MMLU clinical topics), including 67.6% accuracy on MedQA (US Medical License Exam questions), surpassing prior state-of-the-art by over 17%. However, human evaluation reveals key gaps in Flan-PaLM responses. To resolve this we introduce instruction prompt tuning, a parameter-efficient approach for aligning LLMs to new domains using a few exemplars. The resulting model, Med-PaLM, performs encouragingly, but remains inferior to clinicians. We show that comprehension, recall of knowledge, and medical reasoning improve with model scale and instruction prompt tuning, suggesting the potential utility of LLMs in medicine. Our human evaluations reveal important limitations of today's models, reinforcing the importance of both evaluation frameworks and method development in creating safe, helpful LLM models for clinical applications.

A broad use case of large language models (LLMs) is in goal-directed decision-making tasks (or "agent" tasks), where an LLM needs to not just generate completions for a given prompt, but rather make intelligent decisions over a multi-turn interaction to accomplish a task (e.g., when interacting with the web, using tools, or providing customer support). Reinforcement learning (RL) provides a general paradigm to address such agent tasks, but current RL methods for LLMs largely focus on optimizing single-turn rewards. By construction, most single-turn RL methods cannot endow LLMs with the ability to intelligently seek information over multiple turns, perform credit assignment, or reason about their past actions -- all of which are critical in agent tasks. This raises the question: how can we design effective and efficient multi-turn RL algorithms for LLMs? In this paper, we develop a framework for building multi-turn RL algorithms for fine-tuning LLMs, that preserves the flexibility of existing single-turn RL methods for LLMs (e.g., proximal policy optimization), while accommodating multiple turns, long horizons, and delayed rewards effectively. To do this, our framework adopts a hierarchical RL approach and runs two RL algorithms in parallel: a high-level off-policy value-based RL algorithm to aggregate reward over utterances, and a low-level RL algorithm that utilizes this high-level value function to train a token policy within each utterance or turn. Our hierarchical framework, Actor-Critic Framework with a Hierarchical Structure (ArCHer), can also give rise to other RL methods. Empirically, we find that ArCHer significantly improves efficiency and performance on agent tasks, attaining a sample efficiency of about 100x over existing methods, while also improving with larger model capacity (upto the 7 billion scale that we tested on).

Reinforcement learning from human feedback (RLHF) has emerged as a powerful technique to make large language models (LLMs) easier to use and more effective. A core piece of the RLHF process is the training and utilization of a model of human preferences that acts as a reward function for optimization. This approach, which operates at the intersection of many stakeholders and academic disciplines, remains poorly understood. RLHF reward models are often cited as being central to achieving performance, yet very few descriptors of capabilities, evaluations, training methods, or open-source models exist. Given this lack of information, further study and transparency is needed for learned RLHF reward models. In this paper, we illustrate the complex history of optimizing preferences, and articulate lines of inquiry to understand the sociotechnical context of reward models. In particular, we highlight the ontological differences between costs, rewards, and preferences at stake in RLHF's foundations, related methodological tensions, and possible research directions to improve general understanding of how reward models function.

The COVID-19 pandemic has posed a heavy burden to the healthcare system worldwide and caused huge social disruption and economic loss. Many deep learning models have been proposed to conduct clinical predictive tasks such as mortality prediction for COVID-19 patients in intensive care units using Electronic Health Record (EHR) data. Despite their initial success in certain clinical applications, there is currently a lack of benchmarking results to achieve a fair comparison so that we can select the optimal model for clinical use. Furthermore, there is a discrepancy between the formulation of traditional prediction tasks and real-world clinical practice in intensive care. To fill these gaps, we propose two clinical prediction tasks, Outcome-specific length-of-stay prediction and Early mortality prediction for COVID-19 patients in intensive care units. The two tasks are adapted from the naive length-of-stay and mortality prediction tasks to accommodate the clinical practice for COVID-19 patients. We propose fair, detailed, open-source data-preprocessing pipelines and evaluate 17 state-of-the-art predictive models on two tasks, including 5 machine learning models, 6 basic deep learning models and 6 deep learning predictive models specifically designed for EHR data. We provide benchmarking results using data from two real-world COVID-19 EHR datasets. One dataset is publicly available without needing any inquiry and another dataset can be accessed on request. We provide fair, reproducible benchmarking results for two tasks. We deploy all experiment results and models on an online platform. We also allow clinicians and researchers to upload their data to the platform and get quick prediction results using our trained models. We hope our efforts can further facilitate deep learning and machine learning research for COVID-19 predictive modeling.

Recently DeepSeek R1 demonstrated how reinforcement learning with simple rule-based incentives can enable autonomous development of complex reasoning in large language models, characterized by the "aha moment", in which the model manifest self-reflection and increased response length during training. However, attempts to extend this success to multimodal reasoning often failed to reproduce these key characteristics. In this report, we present the first successful replication of these emergent characteristics for multimodal reasoning on only a non-SFT 2B model. Starting with Qwen2-VL-2B and applying reinforcement learning directly on the SAT dataset, our model achieves 59.47% accuracy on CVBench, outperforming the base model by approximately ~30% and exceeding both SFT setting by ~2%. In addition, we share our failed attempts and insights in attempting to achieve R1-like reasoning using RL with instruct models. aiming to shed light on the challenges involved. Our key observations include: (1) applying RL on instruct model often results in trivial reasoning trajectories, and (2) naive length reward are ineffective in eliciting reasoning capabilities. The project code is available at https://github.com/turningpoint-ai/VisualThinker-R1-Zero

The global cost of drug discovery and development exceeds $200 billion annually. The main results of drug discovery and development are the outcomes of clinical trials, which directly influence the regulatory approval of new drug candidates and ultimately affect patient outcomes. Despite their significance, large-scale, high-quality clinical trial outcome data are not readily available to the public. Suppose a large clinical trial outcome dataset is provided; machine learning researchers can potentially develop accurate prediction models using past trials and outcome labels, which could help prioritize and optimize therapeutic programs, ultimately benefiting patients. This paper introduces Clinical Trial Outcome (CTO) dataset, the largest trial outcome dataset with around 479K clinical trials, aggregating outcomes from multiple sources of weakly supervised labels, minimizing the noise from individual sources, and eliminating the need for human annotation. These sources include large language model (LLM) decisions on trial-related documents, news headline sentiments, stock prices of trial sponsors, trial linkages across phases, and other signals such as patient dropout rates and adverse events. CTO's labels show unprecedented agreement with supervised clinical trial outcome labels from test split of the supervised TOP dataset, with a 91 F1.

Daily progress notes are common types in the electronic health record (EHR) where healthcare providers document the patient's daily progress and treatment plans. The EHR is designed to document all the care provided to patients, but it also enables note bloat with extraneous information that distracts from the diagnoses and treatment plans. Applications of natural language processing (NLP) in the EHR is a growing field with the majority of methods in information extraction. Few tasks use NLP methods for downstream diagnostic decision support. We introduced the 2022 National NLP Clinical Challenge (N2C2) Track 3: Progress Note Understanding - Assessment and Plan Reasoning as one step towards a new suite of tasks. The Assessment and Plan Reasoning task focuses on the most critical components of progress notes, Assessment and Plan subsections where health problems and diagnoses are contained. The goal of the task was to develop and evaluate NLP systems that automatically predict causal relations between the overall status of the patient contained in the Assessment section and its relation to each component of the Plan section which contains the diagnoses and treatment plans. The goal of the task was to identify and prioritize diagnoses as the first steps in diagnostic decision support to find the most relevant information in long documents like daily progress notes. We present the results of 2022 n2c2 Track 3 and provide a description of the data, evaluation, participation and system performance.

Large language models have the potential to be valuable in the healthcare industry, but it's crucial to verify their safety and effectiveness through rigorous evaluation. For this purpose, we comprehensively evaluated both open-source LLMs and Google's new multimodal LLM called Gemini across Medical reasoning, hallucination detection, and Medical Visual Question Answering tasks. While Gemini showed competence, it lagged behind state-of-the-art models like MedPaLM 2 and GPT-4 in diagnostic accuracy. Additionally, Gemini achieved an accuracy of 61.45\% on the medical VQA dataset, significantly lower than GPT-4V's score of 88\%. Our analysis revealed that Gemini is highly susceptible to hallucinations, overconfidence, and knowledge gaps, which indicate risks if deployed uncritically. We also performed a detailed analysis by medical subject and test type, providing actionable feedback for developers and clinicians. To mitigate risks, we applied prompting strategies that improved performance. Additionally, we facilitated future research and development by releasing a Python module for medical LLM evaluation and establishing a dedicated leaderboard on Hugging Face for medical domain LLMs. Python module can be found at https://github.com/promptslab/RosettaEval

Reinforcement learning (RL) problems can be challenging without well-shaped rewards. Prior work on provably efficient RL methods generally proposes to address this issue with dedicated exploration strategies. However, another way to tackle this challenge is to reformulate it as a multi-task RL problem, where the task space contains not only the challenging task of interest but also easier tasks that implicitly function as a curriculum. Such a reformulation opens up the possibility of running existing multi-task RL methods as a more efficient alternative to solving a single challenging task from scratch. In this work, we provide a theoretical framework that reformulates a single-task RL problem as a multi-task RL problem defined by a curriculum. Under mild regularity conditions on the curriculum, we show that sequentially solving each task in the multi-task RL problem is more computationally efficient than solving the original single-task problem, without any explicit exploration bonuses or other exploration strategies. We also show that our theoretical insights can be translated into an effective practical learning algorithm that can accelerate curriculum learning on simulated robotic tasks.

Recent advancements in large language models (LLMs) have shown promise in medical applications such as disease diagnosis and treatment planning. However, most existing medical LLMs struggle with the advanced reasoning required for complex clinical scenarios, such as differential diagnosis or personalized treatment suggestions. We proposed FineMedLM-o1, which leverages high-quality synthetic medical data and long-form reasoning data for Supervised Fine-Tuning (SFT) and Direct Preference Optimization (DPO), enabling advanced dialogue and deep reasoning capabilities. Additionally, we introduced Test-Time Training (TTT) in the medical domain for the first time, facilitating domain adaptation and ensuring reliable, accurate reasoning. Experimental results demonstrate that FineMedLM-o1 achieves a 23% average performance improvement over prior models on key medical benchmarks. Furthermore, the introduction of TTT provides an additional 14% performance boost, highlighting its effectiveness in enhancing medical reasoning capabilities. To support this process, we also proposed a novel method for synthesizing medical dialogue. Compared to other open-source datasets, our dataset stands out as superior in both quality and complexity. The project and data will be released on GitHub.

Sifting through vast textual data and summarizing key information imposes a substantial burden on how clinicians allocate their time. Although large language models (LLMs) have shown immense promise in natural language processing (NLP) tasks, their efficacy across diverse clinical summarization tasks has not yet been rigorously examined. In this work, we employ domain adaptation methods on eight LLMs, spanning six datasets and four distinct summarization tasks: radiology reports, patient questions, progress notes, and doctor-patient dialogue. Our thorough quantitative assessment reveals trade-offs between models and adaptation methods in addition to instances where recent advances in LLMs may not lead to improved results. Further, in a clinical reader study with six physicians, we depict that summaries from the best adapted LLM are preferable to human summaries in terms of completeness and correctness. Our ensuing qualitative analysis delineates mutual challenges faced by both LLMs and human experts. Lastly, we correlate traditional quantitative NLP metrics with reader study scores to enhance our understanding of how these metrics align with physician preferences. Our research marks the first evidence of LLMs outperforming human experts in clinical text summarization across multiple tasks. This implies that integrating LLMs into clinical workflows could alleviate documentation burden, empowering clinicians to focus more on personalized patient care and other irreplaceable human aspects of medicine.

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

Existing Large Reasoning Models (LRMs) have shown the potential of reinforcement learning (RL) to enhance the complex reasoning capabilities of Large Language Models~(LLMs). While they achieve remarkable performance on challenging tasks such as mathematics and coding, they often rely on their internal knowledge to solve problems, which can be inadequate for time-sensitive or knowledge-intensive questions, leading to inaccuracies and hallucinations. To address this, we propose R1-Searcher, a novel two-stage outcome-based RL approach designed to enhance the search capabilities of LLMs. This method allows LLMs to autonomously invoke external search systems to access additional knowledge during the reasoning process. Our framework relies exclusively on RL, without requiring process rewards or distillation for a cold start. % effectively generalizing to out-of-domain datasets and supporting both Base and Instruct models. Our experiments demonstrate that our method significantly outperforms previous strong RAG methods, even when compared to the closed-source GPT-4o-mini.

Reinforcement learning (RL) has been widely used in text generation to alleviate the exposure bias issue or to utilize non-parallel datasets. The reward function plays an important role in making RL training successful. However, previous reward functions are typically task-specific and sparse, restricting the use of RL. In our work, we propose a task-agnostic approach that derives a step-wise reward function directly from a model trained with teacher forcing. We additionally propose a simple modification to stabilize the RL training on non-parallel datasets with our induced reward function. Empirical results show that our method outperforms self-training and reward regression methods on several text generation tasks, confirming the effectiveness of our reward function.

Large language models (LLMs) have shown remarkable progress in encoding clinical knowledge and responding to complex medical queries with appropriate clinical reasoning. However, their applicability in subspecialist or complex medical settings remains underexplored. In this work, we probe the performance of AMIE, a research conversational diagnostic AI system, in the subspecialist domain of breast oncology care without specific fine-tuning to this challenging domain. To perform this evaluation, we curated a set of 50 synthetic breast cancer vignettes representing a range of treatment-naive and treatment-refractory cases and mirroring the key information available to a multidisciplinary tumor board for decision-making (openly released with this work). We developed a detailed clinical rubric for evaluating management plans, including axes such as the quality of case summarization, safety of the proposed care plan, and recommendations for chemotherapy, radiotherapy, surgery and hormonal therapy. To improve performance, we enhanced AMIE with the inference-time ability to perform web search retrieval to gather relevant and up-to-date clinical knowledge and refine its responses with a multi-stage self-critique pipeline. We compare response quality of AMIE with internal medicine trainees, oncology fellows, and general oncology attendings under both automated and specialist clinician evaluations. In our evaluations, AMIE outperformed trainees and fellows demonstrating the potential of the system in this challenging and important domain. We further demonstrate through qualitative examples, how systems such as AMIE might facilitate conversational interactions to assist clinicians in their decision making. However, AMIE's performance was overall inferior to attending oncologists suggesting that further research is needed prior to consideration of prospective uses.

Clinical Natural Language Processing (NLP) has become an emerging technology in healthcare that leverages a large amount of free-text data in electronic health records (EHRs) to improve patient care, support clinical decisions, and facilitate clinical and translational science research. Recently, deep learning has achieved state-of-the-art performance in many clinical NLP tasks. However, training deep learning models usually requires large annotated datasets, which are normally not publicly available and can be time-consuming to build in clinical domains. Working with smaller annotated datasets is typical in clinical NLP and therefore, ensuring that deep learning models perform well is crucial for the models to be used in real-world applications. A widely adopted approach is fine-tuning existing Pre-trained Language Models (PLMs), but these attempts fall short when the training dataset contains only a few annotated samples. Few-Shot Learning (FSL) has recently been investigated to tackle this problem. Siamese Neural Network (SNN) has been widely utilized as an FSL approach in computer vision, but has not been studied well in NLP. Furthermore, the literature on its applications in clinical domains is scarce. In this paper, we propose two SNN-based FSL approaches for clinical NLP, including Pre-Trained SNN (PT-SNN) and SNN with Second-Order Embeddings (SOE-SNN). We evaluated the proposed approaches on two clinical tasks, namely clinical text classification and clinical named entity recognition. We tested three few-shot settings including 4-shot, 8-shot, and 16-shot learning. Both clinical NLP tasks were benchmarked using three PLMs, including BERT,BioBERT, and BioClinicalBERT. The experimental results verified the effectiveness of the proposed SNN-based FSL approaches in both NLP tasks.

Background: Natural Language Processing (NLP) is widely used to extract clinical insights from Electronic Health Records (EHRs). However, the lack of annotated data, automated tools, and other challenges hinder the full utilisation of NLP for EHRs. Various Machine Learning (ML), Deep Learning (DL) and NLP techniques are studied and compared to understand the limitations and opportunities in this space comprehensively. Methodology: After screening 261 articles from 11 databases, we included 127 papers for full-text review covering seven categories of articles: 1) medical note classification, 2) clinical entity recognition, 3) text summarisation, 4) deep learning (DL) and transfer learning architecture, 5) information extraction, 6) Medical language translation and 7) other NLP applications. This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Result and Discussion: EHR was the most commonly used data type among the selected articles, and the datasets were primarily unstructured. Various ML and DL methods were used, with prediction or classification being the most common application of ML or DL. The most common use cases were: the International Classification of Diseases, Ninth Revision (ICD-9) classification, clinical note analysis, and named entity recognition (NER) for clinical descriptions and research on psychiatric disorders. Conclusion: We find that the adopted ML models were not adequately assessed. In addition, the data imbalance problem is quite important, yet we must find techniques to address this underlining problem. Future studies should address key limitations in studies, primarily identifying Lupus Nephritis, Suicide Attempts, perinatal self-harmed and ICD-9 classification.

The past few years have seen rapid progress in combining reinforcement learning (RL) with deep learning. Various breakthroughs ranging from games to robotics have spurred the interest in designing sophisticated RL algorithms and systems. However, the prevailing workflow in RL is to learn tabula rasa, which may incur computational inefficiency. This precludes continuous deployment of RL algorithms and potentially excludes researchers without large-scale computing resources. In many other areas of machine learning, the pretraining paradigm has shown to be effective in acquiring transferable knowledge, which can be utilized for a variety of downstream tasks. Recently, we saw a surge of interest in Pretraining for Deep RL with promising results. However, much of the research has been based on different experimental settings. Due to the nature of RL, pretraining in this field is faced with unique challenges and hence requires new design principles. In this survey, we seek to systematically review existing works in pretraining for deep reinforcement learning, provide a taxonomy of these methods, discuss each sub-field, and bring attention to open problems and future directions.

In many Reinforcement Learning (RL) papers, learning curves are useful indicators to measure the effectiveness of RL algorithms. However, the complete raw data of the learning curves are rarely available. As a result, it is usually necessary to reproduce the experiments from scratch, which can be time-consuming and error-prone. We present Open RL Benchmark, a set of fully tracked RL experiments, including not only the usual data such as episodic return, but also all algorithm-specific and system metrics. Open RL Benchmark is community-driven: anyone can download, use, and contribute to the data. At the time of writing, more than 25,000 runs have been tracked, for a cumulative duration of more than 8 years. Open RL Benchmark covers a wide range of RL libraries and reference implementations. Special care is taken to ensure that each experiment is precisely reproducible by providing not only the full parameters, but also the versions of the dependencies used to generate it. In addition, Open RL Benchmark comes with a command-line interface (CLI) for easy fetching and generating figures to present the results. In this document, we include two case studies to demonstrate the usefulness of Open RL Benchmark in practice. To the best of our knowledge, Open RL Benchmark is the first RL benchmark of its kind, and the authors hope that it will improve and facilitate the work of researchers in the field.

Great successes have been reported using Reinforcement Learning from Human Feedback (RLHF) to align large language models. Open-source preference datasets and reward models have enabled wider experimentation beyond generic chat settings, particularly to make systems more "helpful" for tasks like web question answering, summarization, and multi-turn dialogue. When optimizing for helpfulness, RLHF has been consistently observed to drive models to produce longer outputs. This paper demonstrates that optimizing for response length is a significant factor behind RLHF's reported improvements in these settings. First, we study the relationship between reward and length for reward models trained on three open-source preference datasets for helpfulness. Here, length correlates strongly with reward, and improvements in reward score are driven in large part by shifting the distribution over output lengths. We then explore interventions during both RL and reward model learning to see if we can achieve the same downstream improvements as RLHF without increasing length. While our interventions mitigate length increases, they aren't uniformly effective across settings. Furthermore, we find that even running RLHF with a reward based solely on length can reproduce most of the downstream improvements over the initial policy model, showing that reward models in these settings have a long way to go.

Adverse Drug Reactions (ADRs) from psychiatric medications are the leading cause of hospitalizations among mental health patients. With healthcare systems and online communities facing limitations in resolving ADR-related issues, Large Language Models (LLMs) have the potential to fill this gap. Despite the increasing capabilities of LLMs, past research has not explored their capabilities in detecting ADRs related to psychiatric medications or in providing effective harm reduction strategies. To address this, we introduce the Psych-ADR benchmark and the Adverse Drug Reaction Response Assessment (ADRA) framework to systematically evaluate LLM performance in detecting ADR expressions and delivering expert-aligned mitigation strategies. Our analyses show that LLMs struggle with understanding the nuances of ADRs and differentiating between types of ADRs. While LLMs align with experts in terms of expressed emotions and tone of the text, their responses are more complex, harder to read, and only 70.86% aligned with expert strategies. Furthermore, they provide less actionable advice by a margin of 12.32% on average. Our work provides a comprehensive benchmark and evaluation framework for assessing LLMs in strategy-driven tasks within high-risk domains.

Knowledge of the medical decision process, which can be modeled as medical decision trees (MDTs), is critical to build clinical decision support systems. However, the current MDT construction methods rely heavily on time-consuming and laborious manual annotation. In this work, we propose a novel task, Text2MDT, to explore the automatic extraction of MDTs from medical texts such as medical guidelines and textbooks. We normalize the form of the MDT and create an annotated Text-to-MDT dataset in Chinese with the participation of medical experts. We investigate two different methods for the Text2MDT tasks: (a) an end-to-end framework which only relies on a GPT style large language models (LLM) instruction tuning to generate all the node information and tree structures. (b) The pipeline framework which decomposes the Text2MDT task to three subtasks. Experiments on our Text2MDT dataset demonstrate that: (a) the end-to-end method basd on LLMs (7B parameters or larger) show promising results, and successfully outperform the pipeline methods. (b) The chain-of-thought (COT) prompting method Wei2022ChainOT can improve the performance of the fine-tuned LLMs on the Text2MDT test set. (c) the lightweight pipelined method based on encoder-based pretrained models can perform comparably with LLMs with model complexity two magnititudes smaller. Our Text2MDT dataset is open-sourced at https://tianchi.aliyun.com/dataset/95414, and the source codes are open-sourced at https://github.com/michael-wzhu/text2dt.

Although recent advances in scaling large language models (LLMs) have resulted in improvements on many NLP tasks, it remains unclear whether these models trained primarily with general web text are the right tool in highly specialized, safety critical domains such as clinical text. Recent results have suggested that LLMs encode a surprising amount of medical knowledge. This raises an important question regarding the utility of smaller domain-specific language models. With the success of general-domain LLMs, is there still a need for specialized clinical models? To investigate this question, we conduct an extensive empirical analysis of 12 language models, ranging from 220M to 175B parameters, measuring their performance on 3 different clinical tasks that test their ability to parse and reason over electronic health records. As part of our experiments, we train T5-Base and T5-Large models from scratch on clinical notes from MIMIC III and IV to directly investigate the efficiency of clinical tokens. We show that relatively small specialized clinical models substantially outperform all in-context learning approaches, even when finetuned on limited annotated data. Further, we find that pretraining on clinical tokens allows for smaller, more parameter-efficient models that either match or outperform much larger language models trained on general text. We release the code and the models used under the PhysioNet Credentialed Health Data license and data use agreement.

Codification of free-text clinical narratives have long been recognised to be beneficial for secondary uses such as funding, insurance claim processing and research. The current scenario of assigning codes is a manual process which is very expensive, time-consuming and error prone. In recent years, many researchers have studied the use of Natural Language Processing (NLP), related Machine Learning (ML) and Deep Learning (DL) methods and techniques to resolve the problem of manual coding of clinical narratives and to assist human coders to assign clinical codes more accurately and efficiently. This systematic literature review provides a comprehensive overview of automated clinical coding systems that utilises appropriate NLP, ML and DL methods and techniques to assign ICD codes to discharge summaries. We have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) guidelines and conducted a comprehensive search of publications from January, 2010 to December 2020 in four academic databases- PubMed, ScienceDirect, Association for Computing Machinery(ACM) Digital Library, and the Association for Computational Linguistics(ACL) Anthology. We reviewed 7,556 publications; 38 met the inclusion criteria. This review identified: datasets having discharge summaries; NLP techniques along with some other data extraction processes, different feature extraction and embedding techniques. To measure the performance of classification methods, different evaluation metrics are used. Lastly, future research directions are provided to scholars who are interested in automated ICD code assignment. Efforts are still required to improve ICD code prediction accuracy, availability of large-scale de-identified clinical corpora with the latest version of the classification system. This can be a platform to guide and share knowledge with the less experienced coders and researchers.

Advances in large language models (LLMs) have empowered a variety of applications. However, there is still a significant gap in research when it comes to understanding and enhancing the capabilities of LLMs in the field of mental health. In this work, we present the first comprehensive evaluation of multiple LLMs, including Alpaca, Alpaca-LoRA, FLAN-T5, GPT-3.5, and GPT-4, on various mental health prediction tasks via online text data. We conduct a broad range of experiments, covering zero-shot prompting, few-shot prompting, and instruction fine-tuning. The results indicate a promising yet limited performance of LLMs with zero-shot and few-shot prompt designs for the mental health tasks. More importantly, our experiments show that instruction finetuning can significantly boost the performance of LLMs for all tasks simultaneously. Our best-finetuned models, Mental-Alpaca and Mental-FLAN-T5, outperform the best prompt design of GPT-3.5 (25 and 15 times bigger) by 10.9% on balanced accuracy and the best of GPT-4 (250 and 150 times bigger) by 4.8%. They further perform on par with the state-of-the-art task-specific language model. We also conduct an exploratory case study on LLMs' capability on the mental health reasoning tasks, illustrating the promising capability of certain models such as GPT-4. We summarize our findings into a set of action guidelines for potential methods to enhance LLMs' capability for mental health tasks. Meanwhile, we also emphasize the important limitations before achieving deployability in real-world mental health settings, such as known racial and gender bias. We highlight the important ethical risks accompanying this line of research.

This study explores the scaling properties of Reinforcement Learning from Human Feedback (RLHF) in Large Language Models (LLMs). Although RLHF is considered an important step in post-training of LLMs, its scaling potential is still largely unknown. We systematically analyze key components in the RLHF framework--model size, data composition, and inference budget--and their impacts on performance. Our findings show that increasing data diversity and volume improves reward model performance, helping process-supervision models scale better. For policy training, more response samples per prompt boost performance initially but quickly plateau. And larger reward models offer modest gains in policy training. In addition, larger policy models benefit less from RLHF with a fixed reward model. Overall, RLHF scales less efficiently than pretraining, with diminishing returns from additional computational resources. Based on these observations, we propose strategies to optimize RLHF performance within computational limits.

In this report, we present the third technical report on the development of slow-thinking models as part of the STILL project. As the technical pathway becomes clearer, scaling RL training has become a central technique for implementing such reasoning models. We systematically experiment with and document the effects of various factors influencing RL training, conducting experiments on both base models and fine-tuned models. Specifically, we demonstrate that our RL training approach consistently improves the Qwen2.5-32B base models, enhancing both response length and test accuracy. Furthermore, we show that even when a model like DeepSeek-R1-Distill-Qwen-1.5B has already achieved a high performance level, it can be further refined through RL training, reaching an accuracy of 39.33% on AIME 2024. Beyond RL training, we also explore the use of tool manipulation, finding that it significantly boosts the reasoning performance of large reasoning models. This approach achieves a remarkable accuracy of 86.67% with greedy search on AIME 2024, underscoring its effectiveness in enhancing model capabilities. We release our resources at the STILL project website: https://github.com/RUCAIBox/Slow_Thinking_with_LLMs.

Medical language models (MLMs) have become pivotal in advancing medical natural language processing. However, prior models that rely on pre-training or supervised fine-tuning often exhibit low data efficiency and limited practicality in real-world clinical applications. While OpenAIs O1 highlights test-time scaling in mathematics, attempts to replicate this approach in medicine typically distill responses from GPT-series models to open-source models, focusing primarily on multiple-choice tasks. This strategy, though straightforward, neglects critical concerns like data privacy and realistic deployment in clinical settings. In this work, we present a deployable, small-scale medical language model, \mone, designed for long-chain reasoning in clinical tasks using a self-evolution paradigm. Starting with a seed dataset of around 8,000 instances spanning five domains and 16 datasets, we prompt a base policy model to perform Monte Carlo Tree Search (MCTS) to construct verifiable reasoning chains. Each reasoning step is assigned an evolution rollout value, allowing verified trajectories to train the policy model and the reward model. During inference, the policy model generates multiple responses, and the reward model selects the one with the highest reward score. Experiments on eleven evaluation datasets demonstrate that \mone outperforms prior open-source models by 2 points, with the addition of the reward model further boosting performance (sim13 points), surpassing GPT-4o-mini. Code and data are available at https://github.com/pixas/MedSSS.

Objective: Data unavailability has been one of the biggest barriers in clinical natural language processing. This paper is aimed at providing a large-scale and publicly available patient note dataset, named PMC-Patients, with relevant articles and similar patients annotations. The ultimate goal of PMC-Patients is to facilitate the development of retrieval-based clinical decision support systems. Materials and Methods: To collect PMC-Patients, we extract patient notes from case reports in PubMed Central by recognizing certain section patterns. Patient-article relevance and patient-patient similarity are annotated by citation relationships in PubMed. In addition, we perform three tasks with PMC-Patients to demonstrate its utility in providing clinical decision support for a given patient, including (1) classifying whether another patient is similar, (2) retrieving similar patients in PMC-Patients, and (3) retrieving relevant articles in PubMed. Results: We collect and release PMC-Patients under the CC BY-NC-SA license, which becomes the largest publicly available patient note dataset so far. PMC-Patients contains 167k patient notes that are annotated with 3.1M relevant articles and 293k similar patients. Qualitative and quantitative analyses reveal the high quality and richness of our dataset. Experiments show that classifying the similarity of patient pairs is relatively easy, but it is hard to retrieve similar patients or relevant articles for a given patient from a large set of candidates. Conclusion: We present PMC-Patients, a large-scale dataset of patient notes with high quality, easy access, diverse conditions, and rich annotations. The proposed dataset can also serve as a hard benchmark for evaluating retrieval-based clinical decision support systems.

Large Language Models (LLMs) have revolutionized natural language processing, yet aligning these models with human values and preferences using RLHF remains a significant challenge. This challenge is characterized by various instabilities, such as reward hacking and catastrophic forgetting. In this technical report, we propose two innovations to stabilize RLHF training: 1) Advantage Model, which directly models advantage score i.e., extra reward compared to the expected rewards and regulates score distributions across tasks to prevent reward hacking. 2) Selective Rehearsal, which mitigates catastrophic forgetting by strategically selecting data for PPO training and knowledge rehearsing. Our experimental analysis on public and proprietary datasets reveals that the proposed methods not only increase stability in RLHF training but also achieve higher reward scores and win rates.

Reward design in reinforcement learning (RL) is challenging since specifying human notions of desired behavior may be difficult via reward functions or require many expert demonstrations. Can we instead cheaply design rewards using a natural language interface? This paper explores how to simplify reward design by prompting a large language model (LLM) such as GPT-3 as a proxy reward function, where the user provides a textual prompt containing a few examples (few-shot) or a description (zero-shot) of the desired behavior. Our approach leverages this proxy reward function in an RL framework. Specifically, users specify a prompt once at the beginning of training. During training, the LLM evaluates an RL agent's behavior against the desired behavior described by the prompt and outputs a corresponding reward signal. The RL agent then uses this reward to update its behavior. We evaluate whether our approach can train agents aligned with user objectives in the Ultimatum Game, matrix games, and the DealOrNoDeal negotiation task. In all three tasks, we show that RL agents trained with our framework are well-aligned with the user's objectives and outperform RL agents trained with reward functions learned via supervised learning

Reinforcement Learning from Human Feedback (RLHF) has proven to be a strong method to align Pretrained Large Language Models (LLMs) with human preferences. But training models with RLHF is computationally expensive, and an overall complex process. In this work, we study RLHF where the underlying models are trained using the parameter efficient method of Low-Rank Adaptation (LoRA) introduced by Hu et al. [2021]. We investigate the setup of "Parameter Efficient Reinforcement Learning" (PERL), in which we perform reward model training and reinforcement learning using LoRA. We compare PERL to conventional fine-tuning (full-tuning) across various configurations for 7 benchmarks, including 2 novel datasets, of reward modeling and reinforcement learning. We find that PERL performs on par with the conventional RLHF setting, while training faster, and with less memory. This enables the high performance of RLHF, while reducing the computational burden that limits its adoption as an alignment technique for Large Language Models. We also release 2 novel thumbs up/down preference datasets: "Taskmaster Coffee", and "Taskmaster Ticketing" to promote research around RLHF.

DeepSeek-R1-Zero has successfully demonstrated the emergence of reasoning capabilities in LLMs purely through Reinforcement Learning (RL). Inspired by this breakthrough, we explore how RL can be utilized to enhance the reasoning capability of MLLMs. However, direct training with RL struggles to activate complex reasoning capabilities such as questioning and reflection in MLLMs, due to the absence of substantial high-quality multimodal reasoning data. To address this issue, we propose the reasoning MLLM, Vision-R1, to improve multimodal reasoning capability. Specifically, we first construct a high-quality multimodal CoT dataset without human annotations by leveraging an existing MLLM and DeepSeek-R1 through modality bridging and data filtering to obtain a 200K multimodal CoT dataset, Vision-R1-cold dataset. It serves as cold-start initialization data for Vision-R1. To mitigate the optimization challenges caused by overthinking after cold start, we propose Progressive Thinking Suppression Training (PTST) strategy and employ Group Relative Policy Optimization (GRPO) with the hard formatting result reward function to gradually refine the model's ability to learn correct and complex reasoning processes on a 10K multimodal math dataset. Comprehensive experiments show our model achieves an average improvement of sim6% across various multimodal math reasoning benchmarks. Vision-R1-7B achieves a 73.5% accuracy on the widely used MathVista benchmark, which is only 0.4% lower than the leading reasoning model, OpenAI O1. The datasets and code will be released in: https://github.com/Osilly/Vision-R1 .

Developing the required technology to assist medical experts in their everyday activities is currently a hot topic in the Artificial Intelligence research field. Thus, a number of large language models (LLMs) and automated benchmarks have recently been proposed with the aim of facilitating information extraction in Evidence-Based Medicine (EBM) using natural language as a tool for mediating in human-AI interaction. The most representative benchmarks are limited to either multiple-choice or long-form answers and are available only in English. In order to address these shortcomings, in this paper we present a new dataset which, unlike previous work: (i) includes not only explanatory arguments for the correct answer, but also arguments to reason why the incorrect answers are not correct; (ii) the explanations are written originally by medical doctors to answer questions from the Spanish Residency Medical Exams. Furthermore, this new benchmark allows us to setup a novel extractive task which consists of identifying the explanation of the correct answer written by medical doctors. An additional benefit of our setting is that we can leverage the extractive QA paradigm to automatically evaluate performance of LLMs without resorting to costly manual evaluation by medical experts. Comprehensive experimentation with language models for Spanish shows that sometimes multilingual models fare better than monolingual ones, even outperforming models which have been adapted to the medical domain. Furthermore, results across the monolingual models are mixed, with supposedly smaller and inferior models performing competitively. In any case, the obtained results show that our novel dataset and approach can be an effective technique to help medical practitioners in identifying relevant evidence-based explanations for medical questions.

The combination of Reinforcement Learning (RL) with deep learning has led to a series of impressive feats, with many believing (deep) RL provides a path towards generally capable agents. However, the success of RL agents is often highly sensitive to design choices in the training process, which may require tedious and error-prone manual tuning. This makes it challenging to use RL for new problems, while also limits its full potential. In many other areas of machine learning, AutoML has shown it is possible to automate such design choices and has also yielded promising initial results when applied to RL. However, Automated Reinforcement Learning (AutoRL) involves not only standard applications of AutoML but also includes additional challenges unique to RL, that naturally produce a different set of methods. As such, AutoRL has been emerging as an important area of research in RL, providing promise in a variety of applications from RNA design to playing games such as Go. Given the diversity of methods and environments considered in RL, much of the research has been conducted in distinct subfields, ranging from meta-learning to evolution. In this survey we seek to unify the field of AutoRL, we provide a common taxonomy, discuss each area in detail and pose open problems which would be of interest to researchers going forward.

Background: Recent advancements in large language models (LLMs) offer potential benefits in healthcare, particularly in processing extensive patient records. However, existing benchmarks do not fully assess LLMs' capability in handling real-world, lengthy clinical data. Methods: We present the LongHealth benchmark, comprising 20 detailed fictional patient cases across various diseases, with each case containing 5,090 to 6,754 words. The benchmark challenges LLMs with 400 multiple-choice questions in three categories: information extraction, negation, and sorting, challenging LLMs to extract and interpret information from large clinical documents. Results: We evaluated nine open-source LLMs with a minimum of 16,000 tokens and also included OpenAI's proprietary and cost-efficient GPT-3.5 Turbo for comparison. The highest accuracy was observed for Mixtral-8x7B-Instruct-v0.1, particularly in tasks focused on information retrieval from single and multiple patient documents. However, all models struggled significantly in tasks requiring the identification of missing information, highlighting a critical area for improvement in clinical data interpretation. Conclusion: While LLMs show considerable potential for processing long clinical documents, their current accuracy levels are insufficient for reliable clinical use, especially in scenarios requiring the identification of missing information. The LongHealth benchmark provides a more realistic assessment of LLMs in a healthcare setting and highlights the need for further model refinement for safe and effective clinical application. We make the benchmark and evaluation code publicly available.

Despite growing interest in using large language models (LLMs) in healthcare, current explorations do not assess the real-world utility and safety of LLMs in clinical settings. Our objective was to determine whether two LLMs can serve information needs submitted by physicians as questions to an informatics consultation service in a safe and concordant manner. Sixty six questions from an informatics consult service were submitted to GPT-3.5 and GPT-4 via simple prompts. 12 physicians assessed the LLM responses' possibility of patient harm and concordance with existing reports from an informatics consultation service. Physician assessments were summarized based on majority vote. For no questions did a majority of physicians deem either LLM response as harmful. For GPT-3.5, responses to 8 questions were concordant with the informatics consult report, 20 discordant, and 9 were unable to be assessed. There were 29 responses with no majority on "Agree", "Disagree", and "Unable to assess". For GPT-4, responses to 13 questions were concordant, 15 discordant, and 3 were unable to be assessed. There were 35 responses with no majority. Responses from both LLMs were largely devoid of overt harm, but less than 20% of the responses agreed with an answer from an informatics consultation service, responses contained hallucinated references, and physicians were divided on what constitutes harm. These results suggest that while general purpose LLMs are able to provide safe and credible responses, they often do not meet the specific information need of a given question. A definitive evaluation of the usefulness of LLMs in healthcare settings will likely require additional research on prompt engineering, calibration, and custom-tailoring of general purpose models.

Clinical trials are fundamental in developing new drugs, medical devices, and treatments. However, they are often time-consuming and have low success rates. Although there have been initial attempts to create large language models (LLMs) for clinical trial design and patient-trial matching, these models remain task-specific and not adaptable to diverse clinical trial tasks. To address this challenge, we propose a clinical trial foundation model named Panacea, designed to handle multiple tasks, including trial search, trial summarization, trial design, and patient-trial matching. We also assemble a large-scale dataset, named TrialAlign, of 793,279 trial documents and 1,113,207 trial-related scientific papers, to infuse clinical knowledge into the model by pre-training. We further curate TrialInstruct, which has 200,866 of instruction data for fine-tuning. These resources enable Panacea to be widely applicable for a range of clinical trial tasks based on user requirements. We evaluated Panacea on a new benchmark, named TrialPanorama, which covers eight clinical trial tasks. Our method performed the best on seven of the eight tasks compared to six cutting-edge generic or medicine-specific LLMs. Specifically, Panacea showed great potential to collaborate with human experts in crafting the design of eligibility criteria, study arms, and outcome measures, in multi-round conversations. In addition, Panacea achieved 14.42% improvement in patient-trial matching, 41.78% to 52.02% improvement in trial search, and consistently ranked at the top for five aspects of trial summarization. Our approach demonstrates the effectiveness of Panacea in clinical trials and establishes a comprehensive resource, including training data, model, and benchmark, for developing clinical trial foundation models, paving the path for AI-based clinical trial development.

Large Language Models (LLMs) have shown the potential to significantly contribute to patient care, diagnostics, and administrative processes. Emerging biomedical LLMs address healthcare-specific challenges, including privacy demands and computational constraints. However, evaluation of these models has primarily been limited to non-clinical tasks, which do not reflect the complexity of practical clinical applications. Additionally, there has been no thorough comparison between biomedical and general-domain LLMs for clinical tasks. To fill this gap, we present the Clinical Language Understanding Evaluation (CLUE), a benchmark tailored to evaluate LLMs on real-world clinical tasks. CLUE includes two novel datasets derived from MIMIC IV discharge letters and four existing tasks designed to test the practical applicability of LLMs in healthcare settings. Our evaluation covers several biomedical and general domain LLMs, providing insights into their clinical performance and applicability. CLUE represents a step towards a standardized approach to evaluating and developing LLMs in healthcare to align future model development with the real-world needs of clinical application. We publish our evaluation and data generation scripts: https://github.com/dadaamin/CLUE

Reasoning abilities, especially those for solving complex math problems, are crucial components of general intelligence. Recent advances by proprietary companies, such as o-series models of OpenAI, have made remarkable progress on reasoning tasks. However, the complete technical details remain unrevealed, and the techniques that are believed certainly to be adopted are only reinforcement learning (RL) and the long chain of thoughts. This paper proposes a new RL framework, termed OREAL, to pursue the performance limit that can be achieved through Outcome REwArd-based reinforcement Learning for mathematical reasoning tasks, where only binary outcome rewards are easily accessible. We theoretically prove that behavior cloning on positive trajectories from best-of-N (BoN) sampling is sufficient to learn the KL-regularized optimal policy in binary feedback environments. This formulation further implies that the rewards of negative samples should be reshaped to ensure the gradient consistency between positive and negative samples. To alleviate the long-existing difficulties brought by sparse rewards in RL, which are even exacerbated by the partial correctness of the long chain of thought for reasoning tasks, we further apply a token-level reward model to sample important tokens in reasoning trajectories for learning. With OREAL, for the first time, a 7B model can obtain 94.0 pass@1 accuracy on MATH-500 through RL, being on par with 32B models. OREAL-32B also surpasses previous 32B models trained by distillation with 95.0 pass@1 accuracy on MATH-500. Our investigation also indicates the importance of initial policy models and training queries for RL. Code, models, and data will be released to benefit future researchhttps://github.com/InternLM/OREAL.

Large Language Models (LLMs) have made substantial strides in structured tasks through Reinforcement Learning (RL), demonstrating proficiency in mathematical reasoning and code generation. However, applying RL in broader domains like chatbots and content generation -- through the process known as Reinforcement Learning from Human Feedback (RLHF) -- presents unique challenges. Reward models in RLHF are critical, acting as proxies that evaluate the alignment of LLM outputs with human intent. Despite advancements, the development of reward models is hindered by challenges such as computational heavy training, costly evaluation, and therefore poor reproducibility. We advocate for using embedding-based input in reward model research as an accelerated solution to those challenges. By leveraging embeddings for reward modeling, we can enhance reproducibility, reduce computational demands on hardware, improve training stability, and significantly reduce training and evaluation costs, hence facilitating fair and efficient comparisons in this active research area. We then show a case study of reproducing existing reward model ensemble research using embedding-based reward models. We discussed future avenues for research, aiming to contribute to safer and more effective LLM deployments.

Large language models (LLMs) have formulated a blueprint for the advancement of artificial general intelligence. Its primary objective is to function as a human-centric (helpful, honest, and harmless) assistant. Alignment with humans assumes paramount significance, and reinforcement learning with human feedback (RLHF) emerges as the pivotal technological paradigm underpinning this pursuit. Current technical routes usually include reward models to measure human preferences, Proximal Policy Optimization (PPO) to optimize policy model outputs, and process supervision to improve step-by-step reasoning capabilities. However, due to the challenges of reward design, environment interaction, and agent training, coupled with huge trial and error cost of large language models, there is a significant barrier for AI researchers to motivate the development of technical alignment and safe landing of LLMs. The stable training of RLHF has still been a puzzle. In the first report, we dissect the framework of RLHF, re-evaluate the inner workings of PPO, and explore how the parts comprising PPO algorithms impact policy agent training. We identify policy constraints being the key factor for the effective implementation of the PPO algorithm. Therefore, we explore the PPO-max, an advanced version of PPO algorithm, to efficiently improve the training stability of the policy model. Based on our main results, we perform a comprehensive analysis of RLHF abilities compared with SFT models and ChatGPT. The absence of open-source implementations has posed significant challenges to the investigation of LLMs alignment. Therefore, we are eager to release technical reports, reward models and PPO codes

Recent AI advancements, such as OpenAI's new models, are transforming LLMs into LRMs (Large Reasoning Models) that perform reasoning during inference, taking extra time and compute for higher-quality outputs. We aim to uncover the algorithmic framework for training LRMs. Methods like self-consistency, PRM, and AlphaZero suggest reasoning as guided search. We ask: what is the simplest, most scalable way to enable search in LLMs? We propose a post-training framework called Reinforcement Learning via Self-Play (RLSP). RLSP involves three steps: (1) supervised fine-tuning with human or synthetic demonstrations of the reasoning process, (2) using an exploration reward signal to encourage diverse and efficient reasoning behaviors, and (3) RL training with an outcome verifier to ensure correctness while preventing reward hacking. Our key innovation is to decouple exploration and correctness signals during PPO training, carefully balancing them to improve performance and efficiency. Empirical studies in the math domain show that RLSP improves reasoning. On the Llama-3.1-8B-Instruct model, RLSP can boost performance by 23% in MATH-500 test set; On AIME 2024 math problems, Qwen2.5-32B-Instruct improved by 10% due to RLSP. However, a more important finding of this work is that the models trained using RLSP, even with the simplest exploration reward that encourages the model to take more intermediate steps, showed several emergent behaviors such as backtracking, exploration of ideas, and verification. These findings demonstrate that RLSP framework might be enough to enable emergence of complex reasoning abilities in LLMs when scaled. Lastly, we propose a theory as to why RLSP search strategy is more suitable for LLMs inspired by a remarkable result that says CoT provably increases computational power of LLMs, which grows as the number of steps in CoT li2024chain,merrill2023expresssive.

Large language models (LLMs) have demonstrated remarkable capabilities across a range of text-generation tasks. However, LLMs still struggle with problems requiring multi-step decision-making and environmental feedback, such as online shopping, scientific reasoning, and mathematical problem-solving. Unlike pure text data, collecting large-scale decision-making data is challenging. Moreover, many powerful LLMs are only accessible through APIs, which hinders their fine-tuning for agent tasks due to cost and complexity. To address LLM agents' limitations, we propose a framework that can automatically learn a reward model from the environment without human annotations. This model can be used to evaluate the action trajectories of LLM agents and provide heuristics for task planning. Specifically, our approach involves employing one LLM-based agent to navigate an environment randomly, generating diverse action trajectories. Subsequently, a separate LLM is leveraged to assign a task intent and synthesize a negative response alongside the correct response for each trajectory. These triplets (task intent, positive response, and negative response) are then utilized as training data to optimize a reward model capable of scoring action trajectories. The effectiveness and generalizability of our framework are demonstrated through evaluations conducted on different agent benchmarks. In conclusion, our proposed framework represents a significant advancement in enhancing LLM agents' decision-making capabilities. By automating the learning of reward models, we overcome the challenges of data scarcity and API limitations, potentially revolutionizing the application of LLMs in complex and interactive environments. This research paves the way for more sophisticated AI agents capable of tackling a wide range of real-world problems requiring multi-step decision-making.

Large language models (LLMs) provide excellent text-generation capabilities, but standard prompting and generation methods generally do not lead to intentional or goal-directed agents and might necessitate considerable prompt tuning. This becomes particularly apparent in multi-turn conversations: even the best current LLMs rarely ask clarifying questions, engage in explicit information gathering, or take actions now that lead to better decisions after multiple turns. Reinforcement learning has the potential to leverage the powerful modeling capabilities of LLMs, as well as their internal representation of textual interactions, to create capable goal-directed language agents. This can enable intentional and temporally extended interactions, such as with humans, through coordinated persuasion and carefully crafted questions, or in goal-directed play through text games to bring about desired final outcomes. However, enabling this requires the community to develop stable and reliable reinforcement learning algorithms that can effectively train LLMs. Developing such algorithms requires tasks that can gauge progress on algorithm design, provide accessible and reproducible evaluations for multi-turn interactions, and cover a range of task properties and challenges in improving reinforcement learning algorithms. Our paper introduces the LMRL-Gym benchmark for evaluating multi-turn RL for LLMs, together with an open-source research framework containing a basic toolkit for getting started on multi-turn RL with offline value-based and policy-based RL methods. Our benchmark consists of 8 different language tasks, which require multiple rounds of language interaction and cover a range of tasks in open-ended dialogue and text games.

Recent advances in large language models have led to renewed interest in natural language processing in healthcare using the free text of clinical notes. One distinguishing characteristic of clinical notes is their long time span over multiple long documents. The unique structure of clinical notes creates a new design choice: when the context length for a language model predictor is limited, which part of clinical notes should we choose as the input? Existing studies either choose the inputs with domain knowledge or simply truncate them. We propose a framework to analyze the sections with high predictive power. Using MIMIC-III, we show that: 1) predictive power distribution is different between nursing notes and discharge notes and 2) combining different types of notes could improve performance when the context length is large. Our findings suggest that a carefully selected sampling function could enable more efficient information extraction from clinical notes.

Reinforcement learning from human feedback (RLHF) is a technique for training AI systems to align with human goals. RLHF has emerged as the central method used to finetune state-of-the-art large language models (LLMs). Despite this popularity, there has been relatively little public work systematizing its flaws. In this paper, we (1) survey open problems and fundamental limitations of RLHF and related methods; (2) overview techniques to understand, improve, and complement RLHF in practice; and (3) propose auditing and disclosure standards to improve societal oversight of RLHF systems. Our work emphasizes the limitations of RLHF and highlights the importance of a multi-faceted approach to the development of safer AI systems.

Recent advances in Large Language Models (LLMs) have achieved remarkable breakthroughs in understanding and responding to user intents. However, their performance lag behind general use cases in some expertise domains, such as Chinese medicine. Existing efforts to incorporate Chinese medicine into LLMs rely on Supervised Fine-Tuning (SFT) with single-turn and distilled dialogue data. These models lack the ability for doctor-like proactive inquiry and multi-turn comprehension and cannot align responses with experts' intentions. In this work, we introduce Zhongjing, the first Chinese medical LLaMA-based LLM that implements an entire training pipeline from continuous pre-training, SFT, to Reinforcement Learning from Human Feedback (RLHF). Additionally, we construct a Chinese multi-turn medical dialogue dataset of 70,000 authentic doctor-patient dialogues, CMtMedQA, which significantly enhances the model's capability for complex dialogue and proactive inquiry initiation. We also define a refined annotation rule and evaluation criteria given the unique characteristics of the biomedical domain. Extensive experimental results show that Zhongjing outperforms baselines in various capacities and matches the performance of ChatGPT in some abilities, despite the 100x parameters. Ablation studies also demonstrate the contributions of each component: pre-training enhances medical knowledge, and RLHF further improves instruction-following ability and safety. Our code, datasets, and models are available at https://github.com/SupritYoung/Zhongjing.

Step-level reward models (SRMs) can significantly enhance mathematical reasoning performance through process supervision or step-level preference alignment based on reinforcement learning. The performance of SRMs is pivotal, as they serve as critical guidelines, ensuring that each step in the reasoning process is aligned with desired outcomes. Recently, AlphaZero-like methods, where Monte Carlo Tree Search (MCTS) is employed for automatic step-level preference annotation, have proven particularly effective. However, the precise mechanisms behind the success of SRMs remain largely unexplored. To address this gap, this study delves into the counterintuitive aspects of SRMs, particularly focusing on MCTS-based approaches. Our findings reveal that the removal of natural language descriptions of thought processes has minimal impact on the efficacy of SRMs. Furthermore, we demonstrate that SRMs are adept at assessing the complex logical coherence present in mathematical language while having difficulty in natural language. These insights provide a nuanced understanding of the core elements that drive effective step-level reward modeling in mathematical reasoning. By shedding light on these mechanisms, this study offers valuable guidance for developing more efficient and streamlined SRMs, which can be achieved by focusing on the crucial parts of mathematical reasoning.

In recent years, the application of Large Language Models (LLMs) in healthcare has shown significant promise in improving the accessibility and dissemination of medical knowledge. This paper presents a detailed study of various LLMs trained on the MedQuAD medical question-answering dataset, with a focus on identifying the most effective model for providing accurate medical information. Among the models tested, the Sentence-t5 combined with Mistral 7B demonstrated superior performance, achieving a precision score of 0.762. This model's enhanced capabilities are attributed to its advanced pretraining techniques, robust architecture, and effective prompt construction methodologies. By leveraging these strengths, the Sentence-t5 + Mistral 7B model excels in understanding and generating precise medical answers. Our findings highlight the potential of integrating sophisticated LLMs in medical contexts to facilitate efficient and accurate medical knowledge retrieval, thus significantly enhancing patient education and support.

To align conditional text generation model outputs with desired behaviors, there has been an increasing focus on training the model using reinforcement learning (RL) with reward functions learned from human annotations. Under this framework, we identify three common cases where high rewards are incorrectly assigned to undesirable patterns: noise-induced spurious correlation, naturally occurring spurious correlation, and covariate shift. We show that even though learned metrics achieve high performance on the distribution of the data used to train the reward function, the undesirable patterns may be amplified during RL training of the text generation model. While there has been discussion about reward gaming in the RL or safety community, in this discussion piece, we would like to highlight reward gaming in the natural language generation (NLG) community using concrete conditional text generation examples and discuss potential fixes and areas for future work.

Recent advances in generative models, including large language models (LLMs), vision language models (VLMs), and diffusion models, have accelerated the field of natural language and image processing in medicine and marked a significant paradigm shift in how biomedical models can be developed and deployed. While these models are highly adaptable to new tasks, scaling and evaluating their usage presents new challenges not addressed in previous frameworks. In particular, the ability of these models to produce useful outputs with little to no specialized training data ("zero-" or "few-shot" approaches), as well as the open-ended nature of their outputs, necessitate the development of new guidelines for robust reporting of clinical generative model research. In response to gaps in standards and best practices for the development of clinical AI tools identified by US Executive Order 141103 and several emerging national networks for clinical AI evaluation, we begin to formalize some of these guidelines by building on the original MI-CLAIM checklist. The new checklist, MI-CLAIM-GEN (Table 1), aims to address differences in training, evaluation, interpretability, and reproducibility of new generative models compared to non-generative ("predictive") AI models. This MI-CLAIM-GEN checklist also seeks to clarify cohort selection reporting with unstructured clinical data and adds additional items on alignment with ethical standards for clinical AI research.

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.

Reinforcement learning from human feedback (RLHF) is one of the key techniques that helps large language models (LLMs) to follow instructions and provide helpful and harmless responses. While direct policy optimization methods exist, state-of-the-art LLMs adopt RL-based methods (usually PPO) in RLHF to train the policy to generate good responses guided by a reward model learned from preference data. The main challenge of these methods is the inaccuracy of the intermediate reward model, especially in code generation tasks that require long and complex reasoning to score a response. We find that the reliability of the reward model varies across responses assigned with different rewards. This motivates us to filter the samples whose rewards may be unreliable to improve signal-to-noise ratio during policy learning, resulting in Policy Filtration for Proximal Policy Optimization (PF-PPO). To choose a proper policy filtration strategy for a given reward model, the coefficient of determination (R^2) between rewards and actual scores on filtered samples serves as a good metrics and helps us find several promising strategies. We provide extensive experiments to validate the effectiveness of PF-PPO in code generation tasks, and find that some variants of PF-PPO are highly effective and achieve new state-of-the-art performance across 7-billion-parameter models on HumanEval, MBPP, and a new and more challenging LeetCode Contest benchmark.

Clinical trial matching is a key process in health delivery and discovery. In practice, it is plagued by overwhelming unstructured data and unscalable manual processing. In this paper, we conduct a systematic study on scaling clinical trial matching using large language models (LLMs), with oncology as the focus area. Our study is grounded in a clinical trial matching system currently in test deployment at a large U.S. health network. Initial findings are promising: out of box, cutting-edge LLMs, such as GPT-4, can already structure elaborate eligibility criteria of clinical trials and extract complex matching logic (e.g., nested AND/OR/NOT). While still far from perfect, LLMs substantially outperform prior strong baselines and may serve as a preliminary solution to help triage patient-trial candidates with humans in the loop. Our study also reveals a few significant growth areas for applying LLMs to end-to-end clinical trial matching, such as context limitation and accuracy, especially in structuring patient information from longitudinal medical records.

Large language models (LLMs) trained with Reinforcement Learning from Human Feedback (RLHF) have demonstrated remarkable capabilities, but their underlying reward functions and decision-making processes remain opaque. This paper introduces a novel approach to interpreting LLMs by applying inverse reinforcement learning (IRL) to recover their implicit reward functions. We conduct experiments on toxicity-aligned LLMs of varying sizes, extracting reward models that achieve up to 80.40% accuracy in predicting human preferences. Our analysis reveals key insights into the non-identifiability of reward functions, the relationship between model size and interpretability, and potential pitfalls in the RLHF process. We demonstrate that IRL-derived reward models can be used to fine-tune new LLMs, resulting in comparable or improved performance on toxicity benchmarks. This work provides a new lens for understanding and improving LLM alignment, with implications for the responsible development and deployment of these powerful systems.

Clinical natural language processing requires methods that can address domain-specific challenges, such as complex medical terminology and clinical contexts. Recently, large language models (LLMs) have shown promise in this domain. Yet, their direct deployment can lead to privacy issues and are constrained by resources. To address this challenge, we delve into synthetic clinical text generation using LLMs for clinical NLP tasks. We propose an innovative, resource-efficient approach, ClinGen, which infuses knowledge into the process. Our model involves clinical knowledge extraction and context-informed LLM prompting. Both clinical topics and writing styles are drawn from external domain-specific knowledge graphs and LLMs to guide data generation. Our extensive empirical study across 7 clinical NLP tasks and 16 datasets reveals that ClinGen consistently enhances performance across various tasks, effectively aligning the distribution of real datasets and significantly enriching the diversity of generated training instances. We will publish our code and all the generated data in https://github.com/ritaranx/ClinGen.

Recent advances in Natural Language Processing (NLP), and specifically automated Question Answering (QA) systems, have demonstrated both impressive linguistic fluency and a pernicious tendency to reflect social biases. In this study, we introduce Q-Pain, a dataset for assessing bias in medical QA in the context of pain management, one of the most challenging forms of clinical decision-making. Along with the dataset, we propose a new, rigorous framework, including a sample experimental design, to measure the potential biases present when making treatment decisions. We demonstrate its use by assessing two reference Question-Answering systems, GPT-2 and GPT-3, and find statistically significant differences in treatment between intersectional race-gender subgroups, thus reaffirming the risks posed by AI in medical settings, and the need for datasets like ours to ensure safety before medical AI applications are deployed.

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.

Despite the promise of RLHF in aligning LLMs with human preferences, it often leads to superficial alignment, prioritizing stylistic changes over improving downstream performance of LLMs. Underspecified preferences could obscure directions to align the models. Lacking exploration restricts identification of desirable outputs to improve the models. To overcome these challenges, we propose a novel framework: Reinforcement Learning from Reflective Feedback (RLRF), which leverages fine-grained feedback based on detailed criteria to improve the core capabilities of LLMs. RLRF employs a self-reflection mechanism to systematically explore and refine LLM responses, then fine-tuning the models via a RL algorithm along with promising responses. Our experiments across Just-Eval, Factuality, and Mathematical Reasoning demonstrate the efficacy and transformative potential of RLRF beyond superficial surface-level adjustment.

As mental health care systems worldwide struggle to meet demand, there is increasing focus on using language models to infer neuropsychiatric conditions or psychopathological traits from language production. Yet, so far, this research has only delivered solutions with limited clinical applicability, due to insufficient consideration of ethical questions crucial to ensuring the synergy between possible applications and model design. To accelerate progress towards clinically applicable models, our paper charts the ethical landscape of research on language-based inference of psychopathology and provides a practical tool for researchers to navigate it. We identify seven core ethical principles that should guide model development and deployment in this domain, translate them into ELLIPS, an ethical toolkit operationalizing these principles into questions that can guide researchers' choices with respect to data selection, architectures, evaluation, and model deployment, and provide a case study exemplifying its use. With this, we aim to facilitate the emergence of model technology with concrete potential for real-world applicability.

An accurate differential diagnosis (DDx) is a cornerstone of medical care, often reached through an iterative process of interpretation that combines clinical history, physical examination, investigations and procedures. Interactive interfaces powered by Large Language Models (LLMs) present new opportunities to both assist and automate aspects of this process. In this study, we introduce an LLM optimized for diagnostic reasoning, and evaluate its ability to generate a DDx alone or as an aid to clinicians. 20 clinicians evaluated 302 challenging, real-world medical cases sourced from the New England Journal of Medicine (NEJM) case reports. Each case report was read by two clinicians, who were randomized to one of two assistive conditions: either assistance from search engines and standard medical resources, or LLM assistance in addition to these tools. All clinicians provided a baseline, unassisted DDx prior to using the respective assistive tools. Our LLM for DDx exhibited standalone performance that exceeded that of unassisted clinicians (top-10 accuracy 59.1% vs 33.6%, [p = 0.04]). Comparing the two assisted study arms, the DDx quality score was higher for clinicians assisted by our LLM (top-10 accuracy 51.7%) compared to clinicians without its assistance (36.1%) (McNemar's Test: 45.7, p < 0.01) and clinicians with search (44.4%) (4.75, p = 0.03). Further, clinicians assisted by our LLM arrived at more comprehensive differential lists than those without its assistance. Our study suggests that our LLM for DDx has potential to improve clinicians' diagnostic reasoning and accuracy in challenging cases, meriting further real-world evaluation for its ability to empower physicians and widen patients' access to specialist-level expertise.

We propose DISC-MedLLM, a comprehensive solution that leverages Large Language Models (LLMs) to provide accurate and truthful medical response in end-to-end conversational healthcare services. To construct high-quality Supervised Fine-Tuning (SFT) datasets, we employ three strategies: utilizing medical knowledge-graphs, reconstructing real-world dialogues, and incorporating human-guided preference rephrasing. These datasets are instrumental in training DISC-MedLLM, surpassing existing medical LLMs in both single-turn and multi-turn consultation scenarios. Extensive experimental results demonstrate the effectiveness of the proposed model in bridging the gap between general language models and real-world medical consultation. Additionally, we release the constructed dataset and model weights to further contribute to research and development. Further details and resources can be found at https://github.com/FudanDISC/DISC-MedLLM

Knowing when to answer or refuse is crucial for safe and reliable decision-making language agents. Although prior work has introduced refusal strategies to boost LMs' reliability, how these models adapt their decisions to different risk levels remains underexplored. We formalize the task of risk-aware decision-making, expose critical weaknesses in existing LMs, and propose skill-decomposition solutions to mitigate them. Our findings show that even cutting-edge LMs--both regular and reasoning models--still require explicit prompt chaining to handle the task effectively, revealing the challenges that must be overcome to achieve truly autonomous decision-making agents.

In this study, we present MedS-Bench, a comprehensive benchmark designed to evaluate the performance of large language models (LLMs) in clinical contexts. Unlike existing benchmarks that focus on multiple-choice question answering, MedS-Bench spans 11 high-level clinical tasks, including clinical report summarization, treatment recommendations, diagnosis, named entity recognition, and medical concept explanation, among others. We evaluated six leading LLMs, e.g., MEDITRON, Mistral, InternLM 2, Llama 3, GPT-4, and Claude-3.5 using few-shot prompting, and found that even the most sophisticated models struggle with these complex tasks. To address these limitations, we developed MedS-Ins, a large-scale instruction tuning dataset for medicine. MedS-Ins comprises 58 medically oriented language corpora, totaling 13.5 million samples across 122 tasks. To demonstrate the dataset's utility, we conducted a proof-of-concept experiment by performing instruction tuning on a lightweight, open-source medical language model. The resulting model, MMedIns-Llama 3, significantly outperformed existing models across nearly all clinical tasks. To promote further advancements in the application of LLMs to clinical challenges, we have made the MedS-Ins dataset fully accessible and invite the research community to contribute to its expansion.Additionally, we have launched a dynamic leaderboard for MedS-Bench, which we plan to regularly update the test set to track progress and enhance the adaptation of general LLMs to the medical domain. Leaderboard: https://henrychur.github.io/MedS-Bench/. Github: https://github.com/MAGIC-AI4Med/MedS-Ins.

We tackle the problem of aligning pre-trained large language models (LMs) with human preferences. If we view text generation as a sequential decision-making problem, reinforcement learning (RL) appears to be a natural conceptual framework. However, using RL for LM-based generation faces empirical challenges, including training instability due to the combinatorial action space, as well as a lack of open-source libraries and benchmarks customized for LM alignment. Thus, a question rises in the research community: is RL a practical paradigm for NLP? To help answer this, we first introduce an open-source modular library, RL4LMs (Reinforcement Learning for Language Models), for optimizing language generators with RL. The library consists of on-policy RL algorithms that can be used to train any encoder or encoder-decoder LM in the HuggingFace library (Wolf et al. 2020) with an arbitrary reward function. Next, we present the GRUE (General Reinforced-language Understanding Evaluation) benchmark, a set of 6 language generation tasks which are supervised not by target strings, but by reward functions which capture automated measures of human preference.GRUE is the first leaderboard-style evaluation of RL algorithms for NLP tasks. Finally, we introduce an easy-to-use, performant RL algorithm, NLPO (Natural Language Policy Optimization)} that learns to effectively reduce the combinatorial action space in language generation. We show 1) that RL techniques are generally better than supervised methods at aligning LMs to human preferences; and 2) that NLPO exhibits greater stability and performance than previous policy gradient methods (e.g., PPO (Schulman et al. 2017)), based on both automatic and human evaluations.

With the introduction of ChatGPT, Large Language Models (LLMs) have received enormous attention in healthcare. Despite their potential benefits, researchers have underscored various ethical implications. While individual instances have drawn much attention, the debate lacks a systematic overview of practical applications currently researched and ethical issues connected to them. Against this background, this work aims to map the ethical landscape surrounding the current stage of deployment of LLMs in medicine and healthcare. Electronic databases and preprint servers were queried using a comprehensive search strategy. Studies were screened and extracted following a modified rapid review approach. Methodological quality was assessed using a hybrid approach. For 53 records, a meta-aggregative synthesis was performed. Four fields of applications emerged and testify to a vivid exploration phase. Advantages of using LLMs are attributed to their capacity in data analysis, personalized information provisioning, support in decision-making, mitigating information loss and enhancing information accessibility. However, we also identifies recurrent ethical concerns connected to fairness, bias, non-maleficence, transparency, and privacy. A distinctive concern is the tendency to produce harmful misinformation or convincingly but inaccurate content. A recurrent plea for ethical guidance and human oversight is evident. Given the variety of use cases, it is suggested that the ethical guidance debate be reframed to focus on defining what constitutes acceptable human oversight across the spectrum of applications. This involves considering diverse settings, varying potentials for harm, and different acceptable thresholds for performance and certainty in healthcare. In addition, a critical inquiry is necessary to determine the extent to which the current experimental use of LLMs is necessary and justified.

This paper proposes a novel reinforcement learning (RL) framework for credit underwriting that tackles ungeneralizable contextual challenges. We adapt RL principles for credit scoring, incorporating action space renewal and multi-choice actions. Our work demonstrates that the traditional underwriting approach aligns with the RL greedy strategy. We introduce two new RL-based credit underwriting algorithms to enable more informed decision-making. Simulations show these new approaches outperform the traditional method in scenarios where the data aligns with the model. However, complex situations highlight model limitations, emphasizing the importance of powerful machine learning models for optimal performance. Future research directions include exploring more sophisticated models alongside efficient exploration mechanisms.

Automatically summarizing patients' main problems from daily progress notes using natural language processing methods helps to battle against information and cognitive overload in hospital settings and potentially assists providers with computerized diagnostic decision support. Problem list summarization requires a model to understand, abstract, and generate clinical documentation. In this work, we propose a new NLP task that aims to generate a list of problems in a patient's daily care plan using input from the provider's progress notes during hospitalization. We investigate the performance of T5 and BART, two state-of-the-art seq2seq transformer architectures, in solving this problem. We provide a corpus built on top of progress notes from publicly available electronic health record progress notes in the Medical Information Mart for Intensive Care (MIMIC)-III. T5 and BART are trained on general domain text, and we experiment with a data augmentation method and a domain adaptation pre-training method to increase exposure to medical vocabulary and knowledge. Evaluation methods include ROUGE, BERTScore, cosine similarity on sentence embedding, and F-score on medical concepts. Results show that T5 with domain adaptive pre-training achieves significant performance gains compared to a rule-based system and general domain pre-trained language models, indicating a promising direction for tackling the problem summarization task.

Recent artificial intelligence (AI) systems have reached milestones in "grand challenges" ranging from Go to protein-folding. The capability to retrieve medical knowledge, reason over it, and answer medical questions comparably to physicians has long been viewed as one such grand challenge. Large language models (LLMs) have catalyzed significant progress in medical question answering; Med-PaLM was the first model to exceed a "passing" score in US Medical Licensing Examination (USMLE) style questions with a score of 67.2% on the MedQA dataset. However, this and other prior work suggested significant room for improvement, especially when models' answers were compared to clinicians' answers. Here we present Med-PaLM 2, which bridges these gaps by leveraging a combination of base LLM improvements (PaLM 2), medical domain finetuning, and prompting strategies including a novel ensemble refinement approach. Med-PaLM 2 scored up to 86.5% on the MedQA dataset, improving upon Med-PaLM by over 19% and setting a new state-of-the-art. We also observed performance approaching or exceeding state-of-the-art across MedMCQA, PubMedQA, and MMLU clinical topics datasets. We performed detailed human evaluations on long-form questions along multiple axes relevant to clinical applications. In pairwise comparative ranking of 1066 consumer medical questions, physicians preferred Med-PaLM 2 answers to those produced by physicians on eight of nine axes pertaining to clinical utility (p < 0.001). We also observed significant improvements compared to Med-PaLM on every evaluation axis (p < 0.001) on newly introduced datasets of 240 long-form "adversarial" questions to probe LLM limitations. While further studies are necessary to validate the efficacy of these models in real-world settings, these results highlight rapid progress towards physician-level performance in medical question answering.

Human intelligence involves metacognitive abilities like self-regulation, recognizing limitations, and seeking assistance only when needed. While LLM Agents excel in many domains, they often lack this awareness. Overconfident agents risk catastrophic failures, while those that seek help excessively hinder efficiency. A key challenge is enabling agents with a limited intervention budget C is to decide when to request assistance. In this paper, we propose an offline framework that trains a "helper" policy to request interventions, such as more powerful models or test-time compute, by combining LLM-based process reward models (PRMs) with tabular reinforcement learning. Using state transitions collected offline, we score optimal intervention timing with PRMs and train the helper model on these labeled trajectories. This offline approach significantly reduces costly intervention calls during training. Furthermore, the integration of PRMs with tabular RL enhances robustness to off-policy data while avoiding the inefficiencies of deep RL. We empirically find that our method delivers optimal helper behavior.

Documentation burden is a major contributor to clinician burnout, which is rising nationally and is an urgent threat to our ability to care for patients. Artificial intelligence (AI) chatbots, such as ChatGPT, could reduce clinician burden by assisting with documentation. Although many hospitals are actively integrating such systems into electronic medical record systems, AI chatbots utility and impact on clinical decision-making have not been studied for this intended use. We are the first to examine the utility of large language models in assisting clinicians draft responses to patient questions. In our two-stage cross-sectional study, 6 oncologists responded to 100 realistic synthetic cancer patient scenarios and portal messages developed to reflect common medical situations, first manually, then with AI assistance. We find AI-assisted responses were longer, less readable, but provided acceptable drafts without edits 58% of time. AI assistance improved efficiency 77% of time, with low harm risk (82% safe). However, 7.7% unedited AI responses could severely harm. In 31% cases, physicians thought AI drafts were human-written. AI assistance led to more patient education recommendations, fewer clinical actions than manual responses. Results show promise for AI to improve clinician efficiency and patient care through assisting documentation, if used judiciously. Monitoring model outputs and human-AI interaction remains crucial for safe implementation.

Background: Large language models (LLMs) are trained to follow directions, but this introduces a vulnerability to blindly comply with user requests even if they generate wrong information. In medicine, this could accelerate the generation of misinformation that impacts human well-being. Objectives/Methods: We analyzed compliance to requests to generate misleading content about medications in settings where models know the request is illogical. We investigated whether in-context directions and instruction-tuning of LLMs to prioritize logical reasoning over compliance reduced misinformation risk. Results: While all frontier LLMs complied with misinformation requests, both prompt-based and parameter-based approaches can improve the detection of logic flaws in requests and prevent the dissemination of medical misinformation. Conclusion: Shifting LLMs to prioritize logic over compliance could reduce risks of exploitation for medical misinformation.

The observed similarities in the behavior of humans and Large Language Models (LLMs) have prompted researchers to consider the potential of using LLMs as models of human cognition. However, several significant challenges must be addressed before LLMs can be legitimately regarded as cognitive models. For instance, LLMs are trained on far more data than humans typically encounter, and may have been directly trained on human data in specific cognitive tasks or aligned with human preferences. Consequently, the origins of these behavioral similarities are not well understood. In this paper, we propose a novel way to enhance the utility of LLMs as cognitive models. This approach involves (i) leveraging computationally equivalent tasks that both an LLM and a rational agent need to master for solving a cognitive problem and (ii) examining the specific task distributions required for an LLM to exhibit human-like behaviors. We apply this approach to decision-making -- specifically risky and intertemporal choice -- where the key computationally equivalent task is the arithmetic of expected value calculations. We show that an LLM pretrained on an ecologically valid arithmetic dataset, which we call Arithmetic-GPT, predicts human behavior better than many traditional cognitive models. Pretraining LLMs on ecologically valid arithmetic datasets is sufficient to produce a strong correspondence between these models and human decision-making. Our results also suggest that LLMs used as cognitive models should be carefully investigated via ablation studies of the pretraining data.

There is enormous enthusiasm and concerns in using large language models (LLMs) in healthcare, yet current assumptions are all based on general-purpose LLMs such as ChatGPT. This study develops a clinical generative LLM, GatorTronGPT, using 277 billion words of mixed clinical and English text with a GPT-3 architecture of 20 billion parameters. GatorTronGPT improves biomedical natural language processing for medical research. Synthetic NLP models trained using GatorTronGPT generated text outperform NLP models trained using real-world clinical text. Physicians Turing test using 1 (worst) to 9 (best) scale shows that there is no significant difference in linguistic readability (p = 0.22; 6.57 of GatorTronGPT compared with 6.93 of human) and clinical relevance (p = 0.91; 7.0 of GatorTronGPT compared with 6.97 of human) and that physicians cannot differentiate them (p < 0.001). This study provides insights on the opportunities and challenges of LLMs for medical research and healthcare.

Developing clinical prediction models (e.g., mortality prediction) based on electronic health records (EHRs) typically relies on expert opinion for feature selection and adjusting observation window size. This burdens experts and creates a bottleneck in the development process. We propose Retrieval-Enhanced Medical prediction model (REMed) to address such challenges. REMed can essentially evaluate an unlimited number of clinical events, select the relevant ones, and make predictions. This approach effectively eliminates the need for manual feature selection and enables an unrestricted observation window. We verified these properties through experiments on 27 clinical tasks and two independent cohorts from publicly available EHR datasets, where REMed outperformed other contemporary architectures that aim to handle as many events as possible. Notably, we found that the preferences of REMed align closely with those of medical experts. We expect our approach to significantly expedite the development of EHR prediction models by minimizing clinicians' need for manual involvement.

Large language models have exhibited exceptional performance on various Natural Language Processing (NLP) tasks, leveraging techniques such as the pre-training, and instruction fine-tuning. Despite these advances, their effectiveness in medical applications is limited, due to challenges such as factual inaccuracies, reasoning abilities, and lack grounding in real-world experience. In this study, we present ClinicalGPT, a language model explicitly designed and optimized for clinical scenarios. By incorporating extensive and diverse real-world data, such as medical records, domain-specific knowledge, and multi-round dialogue consultations in the training process, ClinicalGPT is better prepared to handle multiple clinical task. Furthermore, we introduce a comprehensive evaluation framework that includes medical knowledge question-answering, medical exams, patient consultations, and diagnostic analysis of medical records. Our results demonstrate that ClinicalGPT significantly outperforms other models in these tasks, highlighting the effectiveness of our approach in adapting large language models to the critical domain of healthcare.

We introduce a new benchmark for reward models that quantifies their ability to produce strong language models through RLHF (Reinforcement Learning from Human Feedback). The gold-standard approach is to run a full RLHF training pipeline and directly probe downstream LLM performance. However, this process is prohibitively expensive. To address this, we build a predictive model of downstream LLM performance by evaluating the reward model on proxy tasks. These proxy tasks consist of a large-scale human preference and a verifiable correctness preference dataset, in which we measure 12 metrics across 12 domains. To investigate which reward model metrics are most correlated to gold-standard RLHF outcomes, we launch an end-to-end RLHF experiment on a large-scale crowdsourced human preference platform to view real reward model downstream performance as ground truth. Ultimately, we compile our data and findings into Preference Proxy Evaluations (PPE), the first reward model benchmark explicitly linked to post-RLHF real-world human preference performance, which we open-source for public use and further development. Our code and evaluations can be found at https://github.com/lmarena/PPE .

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.

We apply preference modeling and reinforcement learning from human feedback (RLHF) to finetune language models to act as helpful and harmless assistants. We find this alignment training improves performance on almost all NLP evaluations, and is fully compatible with training for specialized skills such as python coding and summarization. We explore an iterated online mode of training, where preference models and RL policies are updated on a weekly cadence with fresh human feedback data, efficiently improving our datasets and models. Finally, we investigate the robustness of RLHF training, and identify a roughly linear relation between the RL reward and the square root of the KL divergence between the policy and its initialization. Alongside our main results, we perform peripheral analyses on calibration, competing objectives, and the use of OOD detection, compare our models with human writers, and provide samples from our models using prompts appearing in recent related work.

Reinforcement Learning from Human Feedback (RLHF) is a pivotal technique that aligns language models closely with human-centric values. The initial phase of RLHF involves learning human values using a reward model from ranking data. It is observed that the performance of the reward model degrades after one epoch of training, and optimizing too much against the learned reward model eventually hinders the true objective. This paper delves into these issues, leveraging the theoretical insights to design improved reward learning algorithm termed 'Iterative Data Smoothing' (IDS). The core idea is that during each training epoch, we not only update the model with the data, but also update the date using the model, replacing hard labels with soft labels. Our empirical findings highlight the superior performance of this approach over the traditional methods.

As Large Language Models (LLMs) become more prevalent, concerns about their safety, ethics, and potential biases have risen. Systematically evaluating LLMs' risk decision-making tendencies and attitudes, particularly in the ethical domain, has become crucial. This study innovatively applies the Domain-Specific Risk-Taking (DOSPERT) scale from cognitive science to LLMs and proposes a novel Ethical Decision-Making Risk Attitude Scale (EDRAS) to assess LLMs' ethical risk attitudes in depth. We further propose a novel approach integrating risk scales and role-playing to quantitatively evaluate systematic biases in LLMs. Through systematic evaluation and analysis of multiple mainstream LLMs, we assessed the "risk personalities" of LLMs across multiple domains, with a particular focus on the ethical domain, and revealed and quantified LLMs' systematic biases towards different groups. This research helps understand LLMs' risk decision-making and ensure their safe and reliable application. Our approach provides a tool for identifying and mitigating biases, contributing to fairer and more trustworthy AI systems. The code and data are available.

The Mental Health Question Answer (MHQA) task requires the seeker and supporter to complete the support process in one-turn dialogue. Given the richness of help-seeker posts, supporters must thoroughly understand the content and provide logical, comprehensive, and well-structured responses. Previous works in MHQA mostly focus on single-agent approaches based on the cognitive element of Cognitive Behavioral Therapy (CBT), but they overlook the interactions among various CBT elements, such as emotion and cognition. This limitation hinders the models' ability to thoroughly understand the distress of help-seekers. To address this, we propose a framework named Multi-Agent Deductive Planning (MADP), which is based on the interactions between the various psychological elements of CBT. This method guides Large Language Models (LLMs) to achieve a deeper understanding of the seeker's context and provide more personalized assistance based on individual circumstances. Furthermore, we construct a new dataset based on the MADP framework and use it to fine-tune LLMs, resulting in a specialized model named MADP-LLM. We conduct extensive experiments, including comparisons with multiple LLMs, human evaluations, and automatic evaluations, to validate the effectiveness of the MADP framework and MADP-LLM.

Language models (LMs) can produce errors that are hard to detect for humans, especially when the task is complex. RLHF, the most popular post-training method, may exacerbate this problem: to achieve higher rewards, LMs might get better at convincing humans that they are right even when they are wrong. We study this phenomenon under a standard RLHF pipeline, calling it "U-SOPHISTRY" since it is Unintended by model developers. Specifically, we ask time-constrained (e.g., 3-10 minutes) human subjects to evaluate the correctness of model outputs and calculate humans' accuracy against gold labels. On a question-answering task (QuALITY) and programming task (APPS), RLHF makes LMs better at convincing our subjects but not at completing the task correctly. RLHF also makes the model harder to evaluate: our subjects' false positive rate increases by 24.1% on QuALITY and 18.3% on APPS. Finally, we show that probing, a state-of-the-art approach for detecting Intended Sophistry (e.g. backdoored LMs), does not generalize to U-SOPHISTRY. Our results highlight an important failure mode of RLHF and call for more research in assisting humans to align them.

Background: Rapid advancements in natural language processing have led to the development of large language models with the potential to revolutionize mental health care. These models have shown promise in assisting clinicians and providing support to individuals experiencing various psychological challenges. Objective: This study aims to compare the performance of two large language models, GPT-4 and Chat-GPT, in responding to a set of 18 psychological prompts, to assess their potential applicability in mental health care settings. Methods: A blind methodology was employed, with a clinical psychologist evaluating the models' responses without knowledge of their origins. The prompts encompassed a diverse range of mental health topics, including depression, anxiety, and trauma, to ensure a comprehensive assessment. Results: The results demonstrated a significant difference in performance between the two models (p > 0.05). GPT-4 achieved an average rating of 8.29 out of 10, while Chat-GPT received an average rating of 6.52. The clinical psychologist's evaluation suggested that GPT-4 was more effective at generating clinically relevant and empathetic responses, thereby providing better support and guidance to potential users. Conclusions: This study contributes to the growing body of literature on the applicability of large language models in mental health care settings. The findings underscore the importance of continued research and development in the field to optimize these models for clinical use. Further investigation is necessary to understand the specific factors underlying the performance differences between the two models and to explore their generalizability across various populations and mental health conditions.

Reinforcement learning has been applied in operation research and has shown promise in solving large combinatorial optimization problems. However, existing works focus on developing neural network architectures for certain problems. These works lack the flexibility to incorporate recent advances in reinforcement learning, as well as the flexibility of customizing model architectures for operation research problems. In this work, we analyze the end-to-end autoregressive models for vehicle routing problems and show that these models can benefit from the recent advances in reinforcement learning with a careful re-implementation of the model architecture. In particular, we re-implemented the Attention Model and trained it with Proximal Policy Optimization (PPO) in CleanRL, showing at least 8 times speed up in training time. We hereby introduce RLOR, a flexible framework for Deep Reinforcement Learning for Operation Research. We believe that a flexible framework is key to developing deep reinforcement learning models for operation research problems. The code of our work is publicly available at https://github.com/cpwan/RLOR.

Clinicians spend a significant amount of time reviewing medical images and transcribing their findings regarding patient diagnosis, referral and treatment in text form. Vision-language models (VLMs), which automatically interpret images and summarize their findings as text, have enormous potential to alleviate clinical workloads and increase patient access to high-quality medical care. While foundational models have stirred considerable interest in the medical community, it is unclear whether their general capabilities translate to real-world clinical utility. In this work, we show that foundation VLMs markedly underperform compared to practicing ophthalmologists on specialist tasks crucial to the care of patients with age-related macular degeneration (AMD). To address this, we initially identified the essential capabilities required for image-based clinical decision-making, and then developed a curriculum to selectively train VLMs in these skills. The resulting model, RetinaVLM, can be instructed to write reports that significantly outperform those written by leading foundation medical VLMs in disease staging (F1 score of 0.63 vs. 0.11) and patient referral (0.67 vs. 0.39), and approaches the diagnostic performance of junior ophthalmologists (who achieve 0.77 and 0.78 on the respective tasks). Furthermore, in a reader study involving two senior ophthalmologists with up to 32 years of experience, RetinaVLM's reports were found to be similarly correct (78.6% vs. 82.1%) and complete (both 78.6%) as reports written by junior ophthalmologists with up to 10 years of experience. These results demonstrate that our curriculum-based approach provides a blueprint for specializing generalist foundation medical VLMs to handle real-world clinical tasks.

Advances in large language models (LLMs) provide new opportunities in healthcare for improved patient care, clinical decision-making, and enhancement of physician and administrator workflows. However, the potential of these models importantly depends on their ability to generalize effectively across clinical environments and populations, a challenge often underestimated in early development. To better understand reasons for these challenges and inform mitigation approaches, we evaluated ClinicLLM, an LLM trained on [HOSPITAL]'s clinical notes, analyzing its performance on 30-day all-cause readmission prediction focusing on variability across hospitals and patient characteristics. We found poorer generalization particularly in hospitals with fewer samples, among patients with government and unspecified insurance, the elderly, and those with high comorbidities. To understand reasons for lack of generalization, we investigated sample sizes for fine-tuning, note content (number of words per note), patient characteristics (comorbidity level, age, insurance type, borough), and health system aspects (hospital, all-cause 30-day readmission, and mortality rates). We used descriptive statistics and supervised classification to identify features. We found that, along with sample size, patient age, number of comorbidities, and the number of words in notes are all important factors related to generalization. Finally, we compared local fine-tuning (hospital specific), instance-based augmented fine-tuning and cluster-based fine-tuning for improving generalization. Among these, local fine-tuning proved most effective, increasing AUC by 0.25% to 11.74% (most helpful in settings with limited data). Overall, this study provides new insights for enhancing the deployment of large language models in the societally important domain of healthcare, and improving their performance for broader populations.

In recent years, there have been significant breakthroughs in the field of natural language processing, particularly with the development of large language models (LLMs). These LLMs have showcased remarkable capabilities on various benchmarks. In the healthcare field, the exact role LLMs and other future AI models will play remains unclear. There is a potential for these models in the future to be used as part of adaptive physician training, medical co-pilot applications, and digital patient interaction scenarios. The ability of AI models to participate in medical training and patient care will depend in part on their mastery of the knowledge content of specific medical fields. This study investigated the medical knowledge capability of LLMs, specifically in the context of internal medicine subspecialty multiple-choice test-taking ability. We compared the performance of several open-source LLMs (Koala 7B, Falcon 7B, Stable-Vicuna 13B, and Orca Mini 13B), to GPT-4 and Claude 2 on multiple-choice questions in the field of Nephrology. Nephrology was chosen as an example of a particularly conceptually complex subspecialty field within internal medicine. The study was conducted to evaluate the ability of LLM models to provide correct answers to nephSAP (Nephrology Self-Assessment Program) multiple-choice questions. The overall success of open-sourced LLMs in answering the 858 nephSAP multiple-choice questions correctly was 17.1% - 25.5%. In contrast, Claude 2 answered 54.4% of the questions correctly, whereas GPT-4 achieved a score of 73.3%. We show that current widely used open-sourced LLMs do poorly in their ability for zero-shot reasoning when compared to GPT-4 and Claude 2. The findings of this study potentially have significant implications for the future of subspecialty medical training and patient care.

Brief hospital course (BHC) summaries are common clinical documents generated by summarizing clinical notes. While large language models (LLMs) depict remarkable capabilities in automating real-world tasks, their capabilities for healthcare applications such as BHC synthesis have not been shown. To enable the adaptation of LLMs for BHC synthesis, we introduce a novel benchmark consisting of a pre-processed dataset extracted from MIMIC-IV notes, encapsulating clinical note, and brief hospital course (BHC) pairs. We assess the performance of two general-purpose LLMs and three healthcare-adapted LLMs to improve BHC synthesis from clinical notes. Using clinical notes as input for generating BHCs, we apply prompting-based (using in-context learning) and fine-tuning-based adaptation strategies to three open-source LLMs (Clinical-T5-Large, Llama2-13B, FLAN-UL2) and two proprietary LLMs (GPT-3.5, GPT-4). We quantitatively evaluate the performance of these LLMs across varying context-length inputs using conventional natural language similarity metrics. We further perform a qualitative study where five diverse clinicians blindly compare clinician-written BHCs and two LLM-generated BHCs for 30 samples across metrics of comprehensiveness, conciseness, factual correctness, and fluency. Overall, we present a new benchmark and pre-processed dataset for using LLMs in BHC synthesis from clinical notes. We observe high-quality summarization performance for both in-context proprietary and fine-tuned open-source LLMs using both quantitative metrics and a qualitative clinical reader study. We propose our work as a benchmark to motivate future works to adapt and assess the performance of LLMs in BHC synthesis.

Real-world sequential decision making is characterized by sparse rewards and large decision spaces, posing significant difficulty for experiential learning systems like tabula rasa reinforcement learning (RL) agents. Large Language Models (LLMs), with a wealth of world knowledge, can help RL agents learn quickly and adapt to distribution shifts. In this work, we introduce Language Guided Exploration (LGE) framework, which uses a pre-trained language model (called GUIDE ) to provide decision-level guidance to an RL agent (called EXPLORER). We observe that on ScienceWorld (Wang et al.,2022), a challenging text environment, LGE outperforms vanilla RL agents significantly and also outperforms other sophisticated methods like Behaviour Cloning and Text Decision Transformer.

The ability to predict upcoming events has been hypothesized to comprise a key aspect of natural and machine cognition. This is supported by trends in deep reinforcement learning (RL), where self-supervised auxiliary objectives such as prediction are widely used to support representation learning and improve task performance. Here, we study the effects predictive auxiliary objectives have on representation learning across different modules of an RL system and how these mimic representational changes observed in the brain. We find that predictive objectives improve and stabilize learning particularly in resource-limited architectures, and we identify settings where longer predictive horizons better support representational transfer. Furthermore, we find that representational changes in this RL system bear a striking resemblance to changes in neural activity observed in the brain across various experiments. Specifically, we draw a connection between the auxiliary predictive model of the RL system and hippocampus, an area thought to learn a predictive model to support memory-guided behavior. We also connect the encoder network and the value learning network of the RL system to visual cortex and striatum in the brain, respectively. This work demonstrates how representation learning in deep RL systems can provide an interpretable framework for modeling multi-region interactions in the brain. The deep RL perspective taken here also suggests an additional role of the hippocampus in the brain -- that of an auxiliary learning system that benefits representation learning in other regions.

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

Large Language Models (LLMs) have shown impressive performance on existing medical question-answering benchmarks. This high performance makes it increasingly difficult to meaningfully evaluate and differentiate advanced methods. We present MedAgentsBench, a benchmark that focuses on challenging medical questions requiring multi-step clinical reasoning, diagnosis formulation, and treatment planning-scenarios where current models still struggle despite their strong performance on standard tests. Drawing from seven established medical datasets, our benchmark addresses three key limitations in existing evaluations: (1) the prevalence of straightforward questions where even base models achieve high performance, (2) inconsistent sampling and evaluation protocols across studies, and (3) lack of systematic analysis of the interplay between performance, cost, and inference time. Through experiments with various base models and reasoning methods, we demonstrate that the latest thinking models, DeepSeek R1 and OpenAI o3, exhibit exceptional performance in complex medical reasoning tasks. Additionally, advanced search-based agent methods offer promising performance-to-cost ratios compared to traditional approaches. Our analysis reveals substantial performance gaps between model families on complex questions and identifies optimal model selections for different computational constraints. Our benchmark and evaluation framework are publicly available at https://github.com/gersteinlab/medagents-benchmark.

Abstract Language Models (LMs) achieve substantial language capabilities when finetuned using Reinforcement Learning with Human Feedback (RLHF). However, RLHF is an unstable and data-hungry process that continually requires new high-quality LM-generated data for finetuning. We introduce Advantage-Leftover Lunch RL (A-LoL), a new class of offline policy gradient algorithms that enable RL training on any pre-existing data. By assuming the entire LM output sequence as a single action, A-LoL allows incorporating sequence-level classifiers or human-designed scoring functions as rewards. Subsequently, by using LM's internal sequence-level value estimate, A-LoL filters negative advantage (low-quality) data points during training, making it resilient to noise. Overall, A-LoL is an easy-to-implement LM training recipe that is sample-efficient and stable. We demonstrate the effectiveness of A-LoL and its variants with a set of four different language generation tasks. We compare against both online RL (PPO) and recent preference-based (DPO, PRO) and reward-based (GOLD) offline RL baselines. On the commonly-used RLHF benchmark, Helpful and Harmless Assistant (HHA), LMs trained with A-LoL methods achieve the highest diversity while also being rated more safe and helpful than baselines according to humans. Additionally, in the remaining three tasks, A-LoL could optimize multiple distinct reward functions even when using noisy or suboptimal training data. We also release our experimental code. https://github.com/abaheti95/LoL-RL

Clinical trial matching is the task of identifying trials for which patients may be potentially eligible. Typically, this task is labor-intensive and requires detailed verification of patient electronic health records (EHRs) against the stringent inclusion and exclusion criteria of clinical trials. This process is manual, time-intensive, and challenging to scale up, resulting in many patients missing out on potential therapeutic options. Recent advancements in Large Language Models (LLMs) have made automating patient-trial matching possible, as shown in multiple concurrent research studies. However, the current approaches are confined to constrained, often synthetic datasets that do not adequately mirror the complexities encountered in real-world medical data. In this study, we present the first, end-to-end large-scale empirical evaluation of clinical trial matching using real-world EHRs. Our study showcases the capability of LLMs to accurately match patients with appropriate clinical trials. We perform experiments with proprietary LLMs, including GPT-4 and GPT-3.5, as well as our custom fine-tuned model called OncoLLM and show that OncoLLM, despite its significantly smaller size, not only outperforms GPT-3.5 but also matches the performance of qualified medical doctors. All experiments were carried out on real-world EHRs that include clinical notes and available clinical trials from a single cancer center in the United States.

We present a corpus of 5,000 richly annotated abstracts of medical articles describing clinical randomized controlled trials. Annotations include demarcations of text spans that describe the Patient population enrolled, the Interventions studied and to what they were Compared, and the Outcomes measured (the `PICO' elements). These spans are further annotated at a more granular level, e.g., individual interventions within them are marked and mapped onto a structured medical vocabulary. We acquired annotations from a diverse set of workers with varying levels of expertise and cost. We describe our data collection process and the corpus itself in detail. We then outline a set of challenging NLP tasks that would aid searching of the medical literature and the practice of evidence-based medicine.

Recently, both closed-source LLMs and open-source communities have made significant strides, outperforming humans in various general domains. However, their performance in specific professional fields such as medicine, especially within the open-source community, remains suboptimal due to the complexity of medical knowledge. We propose Aquila-Med, a bilingual medical LLM based on Aquila, addressing these challenges through continue pre-training, supervised fine-tuning (SFT), and reinforcement learning from human feedback (RLHF). We construct a large-scale Chinese and English medical dataset for continue pre-training and a high-quality SFT dataset, covering extensive medical specialties. Additionally, we develop a high-quality Direct Preference Optimization (DPO) dataset for further alignment. Aquila-Med achieves notable results across single-turn, multi-turn dialogues, and medical multiple-choice questions, demonstrating the effectiveness of our approach. We open-source the datasets and the entire training process, contributing valuable resources to the research community. Our models and datasets will released at https://huggingface.co/BAAI/AquilaMed-RL.

Deep Reinforcement Learning approaches to Online Portfolio Selection have grown in popularity in recent years. The sensitive nature of training Reinforcement Learning agents implies a need for extensive efforts in market representation, behavior objectives, and training processes, which have often been lacking in previous works. We propose a training and evaluation process to assess the performance of classical DRL algorithms for portfolio management. We found that most Deep Reinforcement Learning algorithms were not robust, with strategies generalizing poorly and degrading quickly during backtesting.

Patient recruitment is challenging for clinical trials. We introduce TrialGPT, an end-to-end framework for zero-shot patient-to-trial matching with large language models. TrialGPT comprises three modules: it first performs large-scale filtering to retrieve candidate trials (TrialGPT-Retrieval); then predicts criterion-level patient eligibility (TrialGPT-Matching); and finally generates trial-level scores (TrialGPT-Ranking). We evaluate TrialGPT on three cohorts of 183 synthetic patients with over 75,000 trial annotations. TrialGPT-Retrieval can recall over 90% of relevant trials using less than 6% of the initial collection. Manual evaluations on 1,015 patient-criterion pairs show that TrialGPT-Matching achieves an accuracy of 87.3% with faithful explanations, close to the expert performance. The TrialGPT-Ranking scores are highly correlated with human judgments and outperform the best-competing models by 43.8% in ranking and excluding trials. Furthermore, our user study reveals that TrialGPT can reduce the screening time by 42.6% in patient recruitment. Overall, these results have demonstrated promising opportunities for patient-to-trial matching with TrialGPT.

Data quality or data evaluation is sometimes a task as important as collecting a large volume of data when it comes to generating accurate artificial intelligence models. In fact, being able to evaluate the data can lead to a larger database that is better suited to a particular problem because we have the ability to filter out data obtained automatically of dubious quality. In this paper we present RLBoost, an algorithm that uses deep reinforcement learning strategies to evaluate a particular dataset and obtain a model capable of estimating the quality of any new data in order to improve the final predictive quality of a supervised learning model. This solution has the advantage that of being agnostic regarding the supervised model used and, through multi-attention strategies, takes into account the data in its context and not only individually. The results of the article show that this model obtains better and more stable results than other state-of-the-art algorithms such as LOO, DataShapley or DVRL.

Reinforcement learning (RL) has been widely used in training large language models~(LLMs) for preventing unexpected outputs, \eg reducing harmfulness and errors. However, existing RL methods mostly adopt the instance-level reward, which is unable to provide fine-grained supervision for complex reasoning tasks, and can not focus on the few key tokens that lead to the incorrectness. To address it, we propose a new RL method named RLMEC that incorporates a generative model as the reward model, which is trained by the erroneous solution rewriting task under the minimum editing constraint, and can produce token-level rewards for RL training. Based on the generative reward model, we design the token-level RL objective for training and an imitation-based regularization for stabilizing RL process. And the both objectives focus on the learning of the key tokens for the erroneous solution, reducing the effect of other unimportant tokens. The experiment results on mathematical tasks and question-answering tasks have demonstrated the effectiveness of our approach. Our code and data are available at https://github.com/RUCAIBox/RLMEC.

Reinforcement learning (RL) has achieved tremendous success in many complex decision making tasks. When it comes to deploying RL in the real world, safety concerns are usually raised, leading to a growing demand for safe RL algorithms, such as in autonomous driving and robotics scenarios. While safety control has a long history, the study of safe RL algorithms is still in the early stages. To establish a good foundation for future research in this thread, in this paper, we provide a review for safe RL from the perspectives of methods, theory and applications. Firstly, we review the progress of safe RL from five dimensions and come up with five problems that are crucial for safe RL being deployed in real-world applications, coined as "2H3W". Secondly, we analyze the theory and algorithm progress from the perspectives of answering the "2H3W" problems. Then, the sample complexity of safe RL methods is reviewed and discussed, followed by an introduction of the applications and benchmarks of safe RL algorithms. Finally, we open the discussion of the challenging problems in safe RL, hoping to inspire more future research on this thread. To advance the study of safe RL algorithms, we release a benchmark suite, an open-sourced repository containing the implementations of major safe RL algorithms, along with tutorials at the link: https://github.com/chauncygu/Safe-Reinforcement-Learning-Baselines.git.

Large Language Models (LLMs) like ChatGPT demonstrate significant potential in the medical field, often evaluated using multiple-choice questions (MCQs) similar to those found on the USMLE. Despite their prevalence in medical education, MCQs have limitations that might be exacerbated when assessing LLMs. To evaluate the effectiveness of MCQs in assessing the performance of LLMs, we developed a fictional medical benchmark focused on a non-existent gland, the Glianorex. This approach allowed us to isolate the knowledge of the LLM from its test-taking abilities. We used GPT-4 to generate a comprehensive textbook on the Glianorex in both English and French and developed corresponding multiple-choice questions in both languages. We evaluated various open-source, proprietary, and domain-specific LLMs using these questions in a zero-shot setting. The models achieved average scores around 67%, with minor performance differences between larger and smaller models. Performance was slightly higher in English than in French. Fine-tuned medical models showed some improvement over their base versions in English but not in French. The uniformly high performance across models suggests that traditional MCQ-based benchmarks may not accurately measure LLMs' clinical knowledge and reasoning abilities, instead highlighting their pattern recognition skills. This study underscores the need for more robust evaluation methods to better assess the true capabilities of LLMs in medical contexts.

We introduce MedXpertQA, a highly challenging and comprehensive benchmark to evaluate expert-level medical knowledge and advanced reasoning. MedXpertQA includes 4,460 questions spanning 17 specialties and 11 body systems. It includes two subsets, Text for text evaluation and MM for multimodal evaluation. Notably, MM introduces expert-level exam questions with diverse images and rich clinical information, including patient records and examination results, setting it apart from traditional medical multimodal benchmarks with simple QA pairs generated from image captions. MedXpertQA applies rigorous filtering and augmentation to address the insufficient difficulty of existing benchmarks like MedQA, and incorporates specialty board questions to improve clinical relevance and comprehensiveness. We perform data synthesis to mitigate data leakage risk and conduct multiple rounds of expert reviews to ensure accuracy and reliability. We evaluate 16 leading models on MedXpertQA. Moreover, medicine is deeply connected to real-world decision-making, providing a rich and representative setting for assessing reasoning abilities beyond mathematics and code. To this end, we develop a reasoning-oriented subset to facilitate the assessment of o1-like models.

Offline reinforcement learning algorithms hold the promise of enabling data-driven RL methods that do not require costly or dangerous real-world exploration and benefit from large pre-collected datasets. This in turn can facilitate real-world applications, as well as a more standardized approach to RL research. Furthermore, offline RL methods can provide effective initializations for online finetuning to overcome challenges with exploration. However, evaluating progress on offline RL algorithms requires effective and challenging benchmarks that capture properties of real-world tasks, provide a range of task difficulties, and cover a range of challenges both in terms of the parameters of the domain (e.g., length of the horizon, sparsity of rewards) and the parameters of the data (e.g., narrow demonstration data or broad exploratory data). While considerable progress in offline RL in recent years has been enabled by simpler benchmark tasks, the most widely used datasets are increasingly saturating in performance and may fail to reflect properties of realistic tasks. We propose a new benchmark for offline RL that focuses on realistic simulations of robotic manipulation and locomotion environments, based on models of real-world robotic systems, and comprising a variety of data sources, including scripted data, play-style data collected by human teleoperators, and other data sources. Our proposed benchmark covers state-based and image-based domains, and supports both offline RL and online fine-tuning evaluation, with some of the tasks specifically designed to require both pre-training and fine-tuning. We hope that our proposed benchmark will facilitate further progress on both offline RL and fine-tuning algorithms. Website with code, examples, tasks, and data is available at https://sites.google.com/view/d5rl/

Multimodal large language models (MLLMs) hold significant potential in the medical field, but their capabilities are often limited by insufficient data in certain medical domains, highlighting the need for understanding what kinds of images can be used by MLLMs for generalization. Current research suggests that multi-task training outperforms single-task as different tasks can benefit each other, but they often overlook the internal relationships within these tasks, providing limited guidance on selecting datasets to enhance specific tasks. To analyze this phenomenon, we attempted to employ compositional generalization (CG)-the ability of models to understand novel combinations by recombining learned elements-as a guiding framework. Since medical images can be precisely defined by Modality, Anatomical area, and Task, naturally providing an environment for exploring CG. Therefore, we assembled 106 medical datasets to create Med-MAT for comprehensive experiments. The experiments confirmed that MLLMs can use CG to understand unseen medical images and identified CG as one of the main drivers of the generalization observed in multi-task training. Additionally, further studies demonstrated that CG effectively supports datasets with limited data and delivers consistent performance across different backbones, highlighting its versatility and broad applicability. Med-MAT is publicly available at https://github.com/FreedomIntelligence/Med-MAT.