# The Alignment Paradox of Medical Large Language Models in Infertility Care: Decoupling Algorithmic Improvement from Clinical Decision-making Quality

arXiv: https://arxiv.org/abs/2511.18084 · HTML: https://mlsanity.com/paper/2511.18084/

## Key facts

- Cited by 1 papers in the map (data through 14 Oct 2026).
- Placed in Clinical and biomedical applications, one of 17 directions in LLM reasoning.
- Builds on 14 of its 31 references that are in the map.
- First posted on arXiv 22 Nov 2025.

## Placed in

- LLM reasoning / [Clinical and biomedical applications](https://mlsanity.com/lr/clinical-and-biomedical-applications/)
- LLM alignment / RLHF / preference optimisation / [Medical LLM alignment](https://mlsanity.com/alignment/medical-llm-alignment/)

## Builds on (most cited first, 14 of 14)

- [Proximal Policy Optimization Algorithms](https://mlsanity.com/paper/1707.06347/) (2017)
- [DeepSeekMath: Pushing the Limits of Mathematical Reasoning in Open Language Models](https://mlsanity.com/paper/2402.03300/) (2024)
- [Direct Preference Optimization: Your Language Model is Secretly a Reward Model](https://mlsanity.com/paper/2305.18290/) (2023)
- [Finetuned Language Models Are Zero-Shot Learners](https://mlsanity.com/paper/2109.01652/) (2021)
- [High-Dimensional Continuous Control Using Generalized Advantage Estimation](https://mlsanity.com/paper/1506.02438/) (2015)
- [Scaling Laws for Reward Model Overoptimization](https://mlsanity.com/paper/2210.10760/) (2022)
- [HuatuoGPT-o1, Towards Medical Complex Reasoning with LLMs](https://mlsanity.com/paper/2412.18925/) (2024)
- [Reward Model Ensembles Help Mitigate Overoptimization](https://mlsanity.com/paper/2310.02743/) (2023)
- [Lingshu: A Generalist Foundation Model for Unified Multimodal Medical Understanding and Reasoning](https://mlsanity.com/paper/2506.07044/) (2025)
- [Med-R1: Reinforcement Learning for Generalizable Medical Reasoning in Vision-Language Models](https://mlsanity.com/paper/2503.13939/) (2025)
- [Critique Fine-Tuning: Learning to Critique is More Effective than Learning to Imitate](https://mlsanity.com/paper/2501.17703/) (2025)
- [QoQ-Med: Building Multimodal Clinical Foundation Models with Domain-Aware GRPO Training](https://mlsanity.com/paper/2506.00711/) (2025)
- [AlphaMaze: Enhancing Large Language Models' Spatial Intelligence via GRPO](https://mlsanity.com/paper/2502.14669/) (2025)
- [Reliability of Large Language Model Generated Clinical Reasoning in Assisted Reproductive Technology: Blinded Comparative Evaluation Study](https://mlsanity.com/paper/2510.16095/) (2025)

## Built on by (most cited first, 1 of 1)

- [Do Mixed-Vendor Multi-Agent LLMs Improve Clinical Diagnosis?](https://mlsanity.com/paper/2603.04421/) (2026)

## Abstract (arXiv)

Large language models (LLMs) are increasingly adopted in clinical decision support, yet aligning them with the multifaceted reasoning pathways of real-world medicine remains a major challenge. Using more than 8,000 infertility treatment records, we systematically evaluate four alignment strategies: Supervised Fine-Tuning (SFT), Direct Preference Optimization (DPO), Group Relative Policy Optimization (GRPO), and In-Context Learning (ICL) through a dual-layer framework combining automatic benchmarks with blinded doctor-in-the-loop assessments. GRPO achieves the highest algorithmic accuracy across multiple decision layers, confirming the value of reinforcement-based optimization for structured prediction tasks. However, clinicians consistently prefer the SFT model, citing clearer reasoning processes (p = 0.035) and higher therapeutic feasibility (p = 0.019). In blinded pairwise comparisons, SFT attains the highest winning rate (51.2%), outperforming both GRPO (26.2%) and even physicians' original decisions (22.7%). These results reveal an alignment paradox: algorithmic improvements do not necessarily translate into higher clinical trust, and may diverge from human-centered preferences. Our findings highlight the need for alignment strategies that prioritize clinically interpretable and practically feasible reasoning, rather than solely optimizing decision-level accuracy.