Instruction-Free Tuning of Large Vision Language Models for Medical Instruction Following

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.

The advancement of general medical Multimodal Large Language Models (MLLMs) has shown great potential for building conversational assistants to support clinical diagnosis. However, their adaptation to highly specialized domains such as ophthalmology remains underexplored, primarily due to the scarcity of large-scale, domain-specific instruction-tuning data. Existing ophthalmic datasets for conversational agents are often limited in scale and largely rely on images from established public benchmarks, limiting the scalability of ophthalmic MLLMs and their ability to capture real-world clinical complexity. To address this gap, we propose $\textbf{OphIn-Engine}$, an ophthalmology-specific instruction data curation pipeline that constructs high-quality instruction data from open-access ophthalmology web-scale videos. The pipeline integrates multimodal transcription for extracting image-transcript pairs, visual cue separation and scoring for identifying clinically relevant visual descriptions, and instruction synthesis with quality control for generating accurate and diverse clinical dialogues. Using this engine, we introduce $\textbf{OphIn-500K}$, a large-scale multimodal ophthalmology instruction-tuning dataset containing over 500,000 instruction instances and more than 151,000 unique images from over 29,000 video clips, formatted as visual question answering (VQA), multi-turn conversational interactions, and chain-of-thought (CoT) reasoning. Built upon this dataset, we further develop $\textbf{OphIn-VL}$, an ophthalmology-specific MLLM with advanced visual understanding and conversational capabilities. Comprehensive experiments and case studies demonstrate that OphIn-VL achieves superior performance compared with state-of-the-art general medical and domain-specific MLLMs.

Multimodal large language models (MLLMs) perform well on many vision-language tasks but often struggle with vision-centric problems that require fine-grained visual reasoning. Recent evidence suggests that this limitation arises not from weak visual representations, but from under-utilization of visual information during instruction tuning, where many tasks can be partially solved using language priors alone. We propose a simple and lightweight approach that augments visual instruction tuning with a small number of visually grounded self-supervised tasks expressed as natural language instructions. By reformulating classical self-supervised pretext tasks, such as rotation prediction, color matching, and cross-view correspondence, as image-instruction-response triplets, we introduce supervision that cannot be solved without relying on visual evidence. Our approach requires no human annotations, no architectural modifications, and no additional training stages. Across multiple models, training regimes, and benchmarks, injecting only a small fraction (3-10%) of such visually grounded instructions consistently improves performance on vision-centric evaluations. Our findings highlight instruction tuning with visually grounded SSL tasks as a powerful lever for improving visual reasoning in MLLMs through simple adjustments to the training data distribution. Code available at: https://github.com/sirkosophia/V-GIFT