EQPO: Equitable Group Relative Policy Optimization for Clinical Reasoning

Abstract

Medical AI systems demonstrated impressive diagnostic performance, yet they routinely show uneven accuracy across demographic groups, disadvantaging underrepresented populations. Although multimodal reasoning foundation models have pushed clinical diagnosis forward, reinforcement learning-based post-training tends to absorb and magnify the biases present in majority-dominated training corpora. We propose Equitable Group Relative Policy Optimization (EQPO), a hierarchical reinforcement learning method that encourages balanced learning across heterogeneous clinical populations by adaptively reweighting samples according to subgroup representation, task difficulty, and data source. As demographic annotations are frequently missing in real-world clinical data, EQPO additionally applies unsupervised clustering to recover latent subpopulations when they are unavailable. On 7 diagnostic benchmarks covering 5 modalities (X-ray, CT, dermoscopy, mammography, ultrasound), EQPO reduces F1 standard deviation by 43.9% and the maximum cross-group F1 gap by 42.7% on QoQ-Med3-8B over vanilla GRPO, and narrows predictive parity gaps by 27.2% on MedGemma-4B over bias-mitigated RL baselines while raising F1 by 12.5% even without any demographic labels. Examining the training trajectory shows that EQPO steadily improves fairness over the course of optimization, in contrast to baseline methods whose fairness degrades as training proceeds, and the discovered implicit groups remain stable and align with masked demographic attributes. We further release EquiMedGemma-4B and EquiQoQ-Med3-8B, equitability-aware clinical VLLMs that attain state-of-the-art accuracy with markedly smaller demographic gaps.