MedGuideEvolve: Evolving Transferable Clinical Experience Cards from Cases under Established Guidelines

Diagnosing rare cardiovascular diseases is a complex clinical reasoning task that requires integrating clinical evidence across time and specialties and differentiating among potential etiologies underlying overlapping phenotypes. How to distill guideline-application experience that transfers across patients from multi-case clinical trajectories while remaining faithful to an established clinical guideline remains a key unresolved problem in the field. Direct case reuse relies on inter-patient phenotypic similarity and therefore struggles to determine whether phenotypic similarity implies a transferable rationale for guideline application, while experience abstraction can overfit limited cases by encoding incidental patterns and losing the original evidentiary context and applicability conditions during generalization. We propose MedGuideEvolve, which compares erroneous cases, similar correctly diagnosed cases, and hard controls under an established clinical guideline to distill conditional guideline-application experience with explicit evidence links and applicability conditions. Candidate experience bundles are retained only when they satisfy schema, provenance, guideline, applicability, audit, support, and paired-repair gates, including non-negative paired Top-1 net repair on independent patients held out from experience formation. This admission boundary limits overgeneralization from incidental patterns while leaving final diagnostic adjudication to the established clinical guideline. On 217 label-blinded cases from a temporally held-out test set, MedGuideEvolve improves Qwen3.8-27B's Top-1 accuracy over Base by 23.96 percentage points to 82.95%, demonstrating that conditional guideline-application experience distilled within established guideline constraints can transfer to unseen patients while retaining provenance.