MedQ-Engine: A Closed-Loop Data Engine for Evolving MLLMs in Medical Image Quality Assessment

Despite impressive performance on standard benchmarks, multimodal large language models (MLLMs) face critical challenges in real-world clinical environments where medical images inevitably suffer various quality degradations. Existing benchmarks exhibit two key limitations: (1) absence of large-scale, multidimensional assessment across medical image quality gradients and (2) no systematic confidence calibration analysis. To address these gaps, we present MedQ-Deg, a comprehensive benchmark for evaluating medical MLLMs under image quality degradations. MedQ-Deg provides multi-dimensional evaluation spanning 18 distinct degradation types, 30 fine-grained capability dimensions, and 7 imaging modalities, with 24,894 question-answer pairs. Each degradation is implemented at 3 severity degrees, calibrated by expert radiologists. We further introduce Calibration Shift metric, which quantifies the gap between a model's perceived confidence and actual performance to assess metacognitive reliability under degradation. Our comprehensive evaluation of 40 mainstream MLLMs reveals several critical findings: (1) overall model performance degrades systematically as degradation severity increases, (2) models universally exhibit the AI Dunning-Kruger Effect, maintaining inappropriately high confidence despite severe accuracy collapse, and (3) models display markedly differentiated behavioral patterns across capability dimensions, imaging modalities, and degradation types. We hope MedQ-Deg drives progress toward medical MLLMs that are robust and trustworthy in real clinical practice.

Large language models (LLMs) have demonstrated strong capabilities across diverse domains, showing considerable potential in medicine. However, their application in medical settings remains limited by the scarcity of visual question answering (VQA) datasets that capture clinical reasoning and explicit image-text alignment. Here, we leverage de-identified medical images and expert commentaries shared through clinician-oriented online resources. By combining an advanced LLM with clinician-in-the-loop verification, we established a rigorous pipeline to construct ThoughtMed-1M, a long-form medical VQA dataset containing over one million VQA pairs and designed to capture structured clinical reasoning and medical image-text alignment. To demonstrate its utility, we developed a FOundational LLM Trained on ThoughtMed-1M (FOLTMed). FOLTMed achieved state-of-the-art performance across 42 medical VQA benchmark datasets, with a macro accuracy of 85.4 percent. It also generated more clinically coherent responses on the ThoughtMed-1M test set, outperforming state-of-the-art models by 3 to 5 percent across factuality and similarity metrics, highlighting a scalable paradigm for advancing research on clinically grounded multimodal LLMs.

Multimodal large language models (MLLMs) have shown strong potential for image quality assessment (IQA) by improving consistency between quality ratings and their underlying reasoning. However, most approaches supervise reasoning through human-provided ratings and rarely examine whether it faithfully reflects image quality. Rating accuracy alone does not ensure faithful reasoning; a shared reward also obscures supervision sources and may reinforce unfaithful reasoning when a correct rating occurs by chance. To improve the faithfulness and reliability of blind IQA, we aim to (1) decouple credit assignment for reasoning and rating and (2) provide verifiable supervision for faithful reasoning. We introduce MR-IQA-2, an actor-editor-judge framework that operationalizes reasoning-editing-reflection. The actor generates quality reasoning for an input image, and the editor revises the image according to the identified quality factors. A frozen judge compares the original and edited images and provides reflective supervision for the actor's reasoning. MR-IQA-2 further uses fine-grained credit assignment to decouple reasoning and rating supervision. Judge feedback supervises reasoning, whereas human ratings supervise the predicted rating. Masked token-specific updates distinguish these signals while preserving the causal relation from reasoning to rating. Across IQA benchmarks, MR-IQA-2 achieves competitive rating alignment with humans. Visual reflection also enables richer and more faithful visual understanding beyond rating, which may inform image-quality optimization and related downstream tasks. Code is available at https://github.com/RobinY99/MR-IQA-2.