Learning from Disagreement: Clinician Overrides as Implicit Preference Signals for Clinical AI in Value-Based Care

Abstract

We reframe clinician overrides of clinical AI recommendations as implicit preference data - the same signal structure exploited by reinforcement learning from human feedback (RLHF), but richer: the annotator is a domain expert, the alternatives carry real consequences, and downstream outcomes are observable. We present a formal framework extending standard preference learning with three contributions: a five-category override taxonomy mapping override types to distinct model update targets; a preference formulation conditioned on patient state s, organizational context c, and clinician capability kappa, where kappa decomposes into execution capability kappa-exec and alignment capability kappa-align; and a dual learning architecture that jointly trains a reward model and a capability model via alternating optimization, preventing a failure mode we term suppression bias-the systematic suppression of correct-but-difficult recommendations when clinician capability falls below the execution threshold. We argue that chronic disease management under outcome-based payment contracts produces override data with uniquely favorable properties-longitudinal density, concentrated decision space, outcome labels, and natural capability variation-and that training environments combining longitudinal outcome measurement with aligned financial incentives are a necessary condition for learning a reward model aligned with patient trajectory rather than with encounter economics. This framework emerged from operational work to improve clinician capability in a live value-based care deployment.