Fine-tuning large language models (LLMs) with limited data poses a practical challenge in low-resource languages, specialized domains, and constrained deployment settings. While pre-trained LLMs provide strong foundations, effective adaptation under data scarcity requires focused and efficient fine-tuning techniques. This paper presents a structured and practical survey of recent methods for fine-tuning LLMs in data-scarce scenarios. We systematically review parameter-efficient fine-tuning techniques that lower training and deployment costs, domain and cross-lingual adaptation methods for both encoder and decoder models, and model specialization strategies. We further examine preference alignment approaches that guide model behavior using limited human or synthetic feedback, emphasizing sample and compute efficiency. Throughout, we highlight empirical trade-offs, selection criteria, and best practices for choosing suitable techniques based on task constraints, including model scaling, data scaling, and the mitigation of catastrophic forgetting. The aim is to equip researchers and practitioners with actionable insights for effectively fine-tuning LLMs when data and resources are limited.

The most plausible near-term role of medical LLMs is to assist rather than replace physicians, yet current evaluations often test isolated capabilities: clinical knowledge, EHR system interaction, or patient communication. Physician assistance instead requires coordinating these capabilities within the same interaction, where physicians issue underspecified requests, patients describe symptoms ambiguously, and EHR systems demand precise tool use. We introduce PhysAssistBench, a benchmark for interactive doctor-patient-EHR assistance. Built from real MIMIC-IV cases, PhysAssistBench uses a scalable pipeline to construct agentic patients: interactive, record-grounded agents that turn static EHR records into multi-turn clinical scenarios while preserving clinical factuality. PhysAssistBench provides a curated evaluation set of 1,296 manually reviewed and physician-validated turns. Experiments with leading LLMs show that current models remain unreliable in this setting, struggling to infer physician intent, clarify vague patient descriptions, formulate grounded EHR queries, and integrate evidence across sources. These results expose a key bottleneck for clinical LLMs: reliable assistance requires coordination across knowledge, communication, and systems, not isolated gains in any of them.

LLM agents acting in structured environments fail in operational rather than conversational ways, and reliability depends on procedural knowledge of the environment. Prior self-improvement methods accumulate natural-language guidance without checking that each new item preserves previously correct behavior, so a note that fixes one trajectory can silently regress another. We introduce GRASP (Gated Regression-Aware Skill Proposer), which treats agent improvement as a sequence of edits to a bounded skill library, admitting each candidate only if it produces a net improvement on a balanced held-out probe under a hard regression budget. We evaluate GRASP across five base models (gpt-oss-120b, DeepSeek V4 Flash, Gemini 3.1 Flash Lite, GPT-4.1, GPT-5.4) on two FHIR-based clinical benchmarks. On MedAgentBench, GRASP lifts gpt-oss-120b from 40.6% to 88.8%, exceeds the strongest of five self-improvement baselines by 21.0 points, and improves every other base model by 17.2 to 40.3 points. Ablations attribute the gain to comparative proposal generation, the acceptance gate, and the hard regression budget rather than to skill writing itself, which without validation is no better than using no skills. The mechanism generalizes beyond the clinical domain, improving agents on three of four non-clinical environments and remaining flat only where the action space is open-ended. Frozen libraries transfer across models, where skills from a stronger model improve weaker executors beyond what they learn for themselves while the reverse does not, an asymmetry that no ungated baseline reproduces.

Fine-tuning Large Language Models (LLMs) on sensitive datasets carries a substantial risk of unintended memorization and leakage of Personally Identifiable Information (PII), which can violate privacy regulations and compromise individual safety. In this work, we systematically investigate a critical and underexplored vulnerability: the exposure of PII that appears only in model inputs, not in training targets. Using both synthetic and real-world datasets, we design controlled extraction probes to quantify unintended PII memorization and study how factors such as language, PII frequency, task type, and model size influence memorization behavior. We further benchmark four privacy-preserving approaches including differential privacy, machine unlearning, regularization, and preference alignment, evaluating their trade-offs between privacy and task performance. Our results show that post-training methods generally provide more consistent privacy-utility trade-offs, while differential privacy achieves strong reduction in leakage in specific settings, although it can introduce training instability. These findings highlight the persistent challenge of memorization in fine-tuned LLMs and emphasize the need for robust, scalable privacy-preserving techniques.