When Does RL Help Medical VLMs? Disentangling Vision, SFT, and RL Gains

Vision-language models (VLMs) are increasingly adapted through domain-specific fine-tuning, yet it remains unclear whether this improves reasoning beyond superficial visual cues, particularly in high-stakes domains like medicine. We evaluate four paired open-source VLMs (LLaVA vs. LLaVA-Med; Gemma vs. MedGemma) across four medical imaging tasks of increasing difficulty: brain tumor, pneumonia, skin cancer, and histopathology classification. We find that performance degrades toward near-random levels as task difficulty increases, indicating limited clinical reasoning. Medical fine-tuning provides no consistent advantage, and models are highly sensitive to prompt formulation, with minor changes causing large swings in accuracy and refusal rates. To test whether closed-form VQA suppresses latent knowledge, we introduce a description-based pipeline where models generate image descriptions that a text-only model (GPT-5.1) uses for diagnosis. This recovers a limited additional signal but remains bounded by task difficulty. Analysis of vision encoder embeddings further shows that failures stem from both weak visual representations and downstream reasoning. Overall, medical VLM performance is fragile, prompt-dependent, and not reliably improved by domain-specific fine-tuning.

Medical vision-language model (VLM) post-training is commonly evaluated through answer accuracy. We examine how changes in accuracy and training objectives relate to image-conditioned decisions in a controlled Qwen2.5-VL-3B study on PMC-VQA. We compare supervised fine-tuning (SFT) with low-rank adaptation (LoRA) restricted to the language model, expanded multimodal adaptation scopes, standard answer-only Group Relative Policy Optimization (GRPO), and a counterfactual evidence objective. On 2,000 clean-test questions, language model LoRA SFT changes correct-image accuracy by +1.10 percentage points (95% paired bootstrap CI:-0.85 to +3.05), while visual-benefit events decrease by 2.40 points and image sensitivity decreases by 5.60 points. Paired records reveal 155 acquired and 203 lost visual-benefit events. Broader adaptation yields lower correct-image accuracy than language-model LoRA SFT. Standard GRPO produces mixed-reward groups and parameter updates, with an uncertain clean test accuracy change. A generation audit reveals that canonical option scores can follow a different token path from generated answers. With scores taken along the greedy generation path, the evidence target improves on the training set; its gains over standard GRPO remain inconsistent on validation data at matched training doses. Sample-level analyses trace how evidence scores, decision margins, and generated answers change during post-training. This empirical and measurement audit identifies gaps between optimization activity, target acquisition, and useful held-out visual behavior.

Vision-Language Models (VLMs) frequently suffer from visual perception errors and hallucinations that compromise answer accuracy in complex reasoning tasks. Reinforcement Learning with Verifiable Rewards (RLVR) offers a promising solution by optimizing policies using answer correctness signals. Despite their effectiveness, prevailing RLVR methods face two critical limitations. First, much of the sampling budget is wasted on trajectories doomed to fail due to early visual description errors. Second, sparse rewards cannot distinguish whether failures stem from visual perception or reasoning stages. We introduce MIRL, a decoupled framework that addresses both limitations by leveraging mutual information (MI) between generated descriptions and visual inputs as a cheap pre-screening signal. This enables intelligent budget allocation toward high-potential trajectories via forking, while decoupled training provides independent MI-based rewards for visual perception optimization, resolving reward blindness. Experiments on six vision-language reasoning benchmarks demonstrate that MIRL achieves 70.22% average accuracy and successfully surpasses the performance of sampling 16 complete trajectories using only 10 pre-samples with top-6 selection (25% fewer complete trajectories). Our code is available at: https://anonymous.4open.science/r/mirl-main/.