# CLR-voyance: Reinforcing Open-Ended Reasoning for Inpatient Clinical Decision Support with Outcome-Aware Rubrics

arXiv: https://arxiv.org/abs/2605.09584 · HTML: https://mlsanity.com/paper/2605.09584/

## Key facts

- Cited by 3 papers in the map (data through 14 Oct 2026).
- Placed in Clinical and biomedical applications, one of 17 directions in LLM reasoning.
- Builds on 34 of its 67 references that are in the map.
- First posted on arXiv 10 May 2026.

## Placed in

- LLM reasoning / [Clinical and biomedical applications](https://mlsanity.com/lr/clinical-and-biomedical-applications/)

## Builds on (most cited first, 30 of 34)

- [DeepSeekMath: Pushing the Limits of Mathematical Reasoning in Open Language Models](https://mlsanity.com/paper/2402.03300/) (2024)
- [Qwen3 Technical Report](https://mlsanity.com/paper/2505.09388/) (2025)
- [OpenAI GPT-5 System Card](https://mlsanity.com/paper/2601.03267/) (2025)
- [Language Models are Super Mario: Absorbing Abilities from Homologous Models as a Free Lunch](https://mlsanity.com/paper/2311.03099/) (2023)
- [MedGemma Technical Report](https://mlsanity.com/paper/2507.05201/) (2025)
- [HealthBench: Evaluating Large Language Models Towards Improved Human Health](https://mlsanity.com/paper/2505.08775/) (2025)
- [Rubrics as Rewards: Reinforcement Learning Beyond Verifiable Domains](https://mlsanity.com/paper/2507.17746/) (2025)
- [HuatuoGPT-o1, Towards Medical Complex Reasoning with LLMs](https://mlsanity.com/paper/2412.18925/) (2024)
- [MedXpertQA: Benchmarking Expert-Level Medical Reasoning and Understanding](https://mlsanity.com/paper/2501.18362/) (2025)
- [RM-R1: Reward Modeling as Reasoning](https://mlsanity.com/paper/2505.02387/) (2025)
- [Model Breadcrumbs: Scaling Multi-Task Model Merging with Sparse Masks](https://mlsanity.com/paper/2312.06795/) (2023)
- [Reinforcement Learning with Rubric Anchors](https://mlsanity.com/paper/2508.12790/) (2025)
- [MedReason: Eliciting Factual Medical Reasoning Steps in LLMs via Knowledge Graphs](https://mlsanity.com/paper/2504.00993/) (2025)
- [DELLA-Merging: Reducing Interference in Model Merging through Magnitude-Based Sampling](https://mlsanity.com/paper/2406.11617/) (2024)
- [Towards Conversational Diagnostic AI](https://mlsanity.com/paper/2401.05654/) (2024)
- [MedHELM: Holistic Evaluation of Large Language Models for Medical Tasks](https://mlsanity.com/paper/2505.23802/) (2025)
- [Sequential Diagnosis with Language Models](https://mlsanity.com/paper/2506.22405/) (2025)
- [GraphCare: Enhancing Healthcare Predictions with Personalized Knowledge Graphs](https://mlsanity.com/paper/2305.12788/) (2023)
- [Alternating Reinforcement Learning for Rubric-Based Reward Modeling in Non-Verifiable LLM Post-Training](https://mlsanity.com/paper/2602.01511/) (2026)
- [AdvancedIF: Rubric-Based Benchmarking and Reinforcement Learning for Advancing LLM Instruction Following](https://mlsanity.com/paper/2511.10507/) (2025)
- [Beyond Distillation: Pushing the Limits of Medical LLM Reasoning with Minimalist Rule-Based RL](https://mlsanity.com/paper/2505.17952/) (2025)
- [InfAlign: Inference-aware language model alignment](https://mlsanity.com/paper/2412.19792/) (2024)
- [Activation-Informed Merging of Large Language Models](https://mlsanity.com/paper/2502.02421/) (2025)
- [ER-Reason: A Benchmark Dataset for LLM Clinical Reasoning in the Emergency Room](https://mlsanity.com/paper/2505.22919/) (2025)
- [Text2Grad: Reinforcement Learning from Natural Language Feedback](https://mlsanity.com/paper/2505.22338/) (2025)
- [EHR-R1: A Reasoning-Enhanced Foundational Language Model for Electronic Health Record Analysis](https://mlsanity.com/paper/2510.25628/) (2025)
- [Behavior Knowledge Merge in Reinforced Agentic Models](https://mlsanity.com/paper/2601.13572/) (2026)
- [Clinical-R1: Empowering Large Language Models for Faithful and Comprehensive Reasoning with Clinical Objective Relative Policy Optimization](https://mlsanity.com/paper/2512.00601/) (2025)
- [Building a Human-Verified Clinical Reasoning Dataset via a Human LLM Hybrid Pipeline for Trustworthy Medical AI](https://mlsanity.com/paper/2505.06912/) (2025)
- [EHR-MCP: Real-world Evaluation of Clinical Information Retrieval by Large Language Models via Model Context Protocol](https://mlsanity.com/paper/2509.15957/) (2025)

## Built on by (most cited first, 3 of 3)

- [From Holistic Evaluation to Structured Criteria: Rubrics Across the Evolving LLM Landscape](https://mlsanity.com/paper/2606.08625/) (2026)
- [EarlyDx: An Admission-Anchored Benchmark for Open-Ended Generation of Evidence-Supported ED-Encounter Diagnoses](https://mlsanity.com/paper/2607.28788/) (2026)
- [Clinical Concept Centers in LLMs](https://mlsanity.com/paper/2610.02829/) (2026)

## Abstract (arXiv)

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