Dialectic-Med: Mitigating Diagnostic Hallucinations via Counterfactual Adversarial Multi-Agent Debate

Clinical diagnosis is a complex reasoning process in which clinicians gather evidence, form hypotheses, and test them against alternative explanations. In medical training, this reasoning is explicitly developed through counterfactual questioning--e.g., asking how a diagnosis would change if a key symptom were absent or altered--to strengthen differential diagnosis skills. As large language model (LLM)-based systems are increasingly used for diagnostic support, ensuring the interpretability of their recommendations becomes critical. However, most existing LLM-based diagnostic agents reason over fixed clinical evidence without explicitly testing how individual findings support or weaken competing diagnoses. In this work, we propose a counterfactual multi-agent diagnostic framework inspired by clinician training that makes hypothesis testing explicit and evidence-grounded. Our framework introduces counterfactual case editing to modify clinical findings and evaluate how these changes affect competing diagnoses. We further define the Counterfactual Probability Gap, a method that quantifies how strongly individual findings support a diagnosis by measuring confidence shifts under these edits. These counterfactual signals guide multi-round specialist discussions, enabling agents to challenge unsupported hypotheses, refine differential diagnoses, and produce more interpretable reasoning trajectories. Across three diagnostic benchmarks and seven LLMs, our method consistently improves diagnostic accuracy over prompting and prior multi-agent baselines, with the largest gains observed in complex and ambiguous cases. Human evaluation further indicates that our framework produces more clinically useful, reliable, and coherent reasoning. These results suggest that incorporating counterfactual evidence verification is an important step toward building reliable AI systems for clinical decision support.

Although Multimodal Large Language Models have achieved strong performance across a wide range of vision-language tasks, they still suffer from hallucinations, where model outputs become inconsistent with the visual content, textual context, or commonsense knowledge. Existing studies primarily address this problem through coarse-grained detection. However, these approaches often provide insufficient diagnostic information for understanding hallucination types and supporting downstream hallucination mitigation. To bridge this gap, we propose fine-grained hallucination diagnosis for MLLMs, a new unified task that jointly performs hallucination detection, classification, and interpretable explanation generation. We develop an automated data generation pipeline and construct HalluScope-30K, a large-scale diagnostic dataset covering eight sources and five task categories. Based on this dataset, we design a multi-granular joint reward function and train two diagnosis models, HalluScope-4B and HalluScope-8B, which achieve state-of-the-art performance on both the MHALO benchmark and our fine-grained hallucination classification benchmark. Notably, detection and classification are mutually beneficial under joint optimization. Furthermore, diagnosis-driven feedback experiments show that the fine-grained diagnostic explanations produced by our model effectively guide target models to correct their hallucinations, with full diagnosis substantially outperforming all baselines on both Qwen3-VL-8B-Instruct and LLaVA-1.5-7B. Our code, data, and models are available at https://github.com/wkinglin/HalluScope.

Building trustworthy medical multimodal large language models (MLLMs) is critical for reliable clinical decision support. Existing medical hallucination benchmarks mainly focus on data collection, but often ignore where hallucinations originate within the reasoning process. We find that hallucination sources vary across samples: errors may arise from visual misrecognition, incorrect medical knowledge recall, or flawed reasoning integration. To enable source-level hallucination diagnosis, we introduce ClinHallu, a benchmark for stage-wise hallucination diagnosis in medical MLLM reasoning. ClinHallu contains 7,031 validated instances, where each instance is augmented with a structured reasoning trace decomposed into Visual Recognition, Knowledge Recall, and Reasoning Integration. We also use stage-replacement interventions to measure how correcting specific stages affects the final answer. Beyond evaluation, we show that trace-supervised fine-tuning reduces stage-wise hallucinations. ClinHallu provides a fine-grained hallucination testbed for diagnosing and mitigating reasoning failures in medical MLLMs. The benchmark is publicly available at https://github.com/alibaba-damo-academy/ClinHallu.