Clinical Reasoning Techniques and Alignment Evaluation in Large Language Models for Healthcare : A Scoping Review
Year: 2026
Type: preprint
Abstract: Large Language Models (LLMs) are increasingly used in health-care tasks, but the ways clinical reasoning is engineered (e.g., SFT, RAG, CoT, RLHF, agentic tool-use) and how clinical alignment is evaluated (e.g., clinician ratings, SCT, OSCE, LLM-as-judge, prospective trials) are not systematically mapped. This review aims to provide a comprehensive landscape of these methods and evaluation strategies. Objectives 1. To map techniques used to elicit clinical reasoning in health-care LLMs a. If possible, to summarize outcomes and evidence within and across specialties and modalities. 2. Catalogue clinical alignment evaluation strategies, reliability, instruments and validity 3. Summarize outcomes across evidence tiers (from benchmark – human – prospective / RCT) 4. Identify methodological gaps and under reporting patterns, such as missing inter-rater reliability or unvalidated LLM -as-judge metrics. Questions 1. What methods are used to engineer to trigger clinical reasoning? 2. How is clinical alignment defined, measured and validated 3. What outcomes are reported and at which evidence levels? 4. Where possible, how do these methods and outcomes vary by specialty? Eligibility Criteria Inclusion 1. Studies using or evaluating an LLM (general or domain-specific) on health-care task 2. Reporting of at least ONE reasoning technique (SFT, RAG, CoT, RLHF etc) 3. Reports at least one clinical alignment evaluation (clinician review, SCT, OSCE/SP, LLM as judge, prospective of RCT) 4. Empirical studies of any design (benchmarking, observational, prospective, RCTs) 5. From 2020-present 6. Publishes in English language Exclusion 1. Not LLM 2. Non health-care studies 3. No reasoning technique or evaluation method 4. Pure opinion or editorial Synthesis • Descriptive synthesis o Evaluation type o Specialty o Modality o Study design o Model openness o Reliability / Validity reporting summary o Narrative synthesis of prospective / RCT evidence • Evidence maps and visualisations o Reasoning Technique × Evaluation Type ; cell annotations : study counts, median κ/ICC or judge-human agreement o Timeline of evaluation methods : emergence of evaluation types o Specialty-stratified summaries and visualisations where sufficient data exist
Source: OSF Preprints (OSF Preprints)
Language: English
Subfield: Health Informatics
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7157511580