TrustMed-RL: Long-Horizon Reinforcement Learning for Evidence-Grounded Clinical Diagnosis

Abstract

Medical language models can produce correct diagnoses despite incomplete investigations and unsupported reasoning. To support long-horizon, evidence-grounded diagnosis, we introduce \textbf{TrustMed-RL}. Built from PubMed rare-disease cases and over 24,000 manually annotated image panels, it integrates interviews, examinations, testing, specialist consultation, and literature search through state-dependent actions. Our 8B vision--language policy, trained with clinically adapted GiGPO and coverage-adjusted diagnostic rewards, achieves 37.1\% diagnostic accuracy on 2,500 evaluation cases, outperforming all evaluated open-weight baselines and improving over supervised fine-tuning by 12.4 percentage points.. When success additionally requires acquiring at least 50\% of supporting test evidence, TrustMed-RL achieves 32.5\%, exceeding GPT-4o by 6.8 percentage points. Furthermore, it surpasses all evaluated baselines on MTMedDialog and multiple larger 27--32B models on AgentClinic. In physician review of 200 diagnostically accepted test-set trajectories, 83.0\% receive evidential-grounding scores of 4--5 out of 5. Physicians'assessments suggest that these diagnostic trajectories are trustworthy and aligned with human diagnostic reasoning.