Bias-constrained multimodal intelligence for equitable and reliable clinical AI

Large Vision-Language Models (LVLMs) specialized in healthcare are emerging as a promising research direction due to their potential impact in clinical and biomedical applications. However, progress is constrained by the scarcity of high-quality medical multimodal data, concerns about robustness in safety-critical settings, and the narrow and potentially contaminated evaluation benchmarks that limit reliable assessment. To address these issues, the field requires state-of-the-art solutions to be fully open and reproducible systems in which all components can be inspected, evaluated, and improved. This work introduces Aloe-Vision-Data, a large-scale, quality-filtered mixture which integrates both medical and general domains across multimodal and text-only sources, designed for direct use in model fine-tuning. Building on this dataset, we train the Aloe-Vision family of medical LVLMs, openly released with full weights, training recipes and data, in two scales (7B and 72B). Through comprehensive benchmarking, we demonstrate that high quality training mixtures produce balanced LVLMs which yield significant gains over the baseline models without compromising general capabilities, achieving competitive performance with respect to state-of-the-art alternatives. To support reliable evaluation, we introduce CareQA-Vision, a carefully curated vision benchmark derived from MIR and EIR exams, the residency entrance exams for medical and nursing specialists in Spain, offering novel vision questions with low likelihood of contamination. Finally, we show that current LVLMs remain vulnerable to adversarial and misleading inputs, underscoring reliability challenges in clinical contexts.

Vision-language models (VLMs) are increasingly proposed for clinical decision support, yet their reliability in real-world scenarios that require integrating both visual and textual context from medical records remains poorly characterized. This paper identifies three failure modes: (1) modality over-reliance on text over images, (2) spurious reliance on irrelevant clinical history, and (3) prompt sensitivity across semantically equivalent inputs. We evaluate a diverse set of general-domain and medically-tuned open and closed VLMs on chest x-ray tasks using MIMIC-CXR. By systematically manipulating image-text alignment, clinical history, and prompt formulations, we found that VLM decisions are dominated by the text modality, even when visual evidence is available. Moreover, we observed that VLMs are heavily influenced by irrelevant reports, while minor prompt changes can reverse correct image-based predictions. Our findings underscore the need for explicit safeguards and stress-testing before considering the use of these models in clinical practice.

Automated glaucoma detection is critical for preventing irreversible vision loss and reducing the burden on healthcare systems. However, ensuring fairness across diverse patient populations remains a significant challenge. In this paper, we propose FairEnc, a fair pretraining method for vision-language models (VLMs) that enables simultaneous debiasing across multiple sensitive attributes. FairEnc jointly mitigates biases in both textual and visual modalities with respect to multiple sensitive attributes, including race, gender, ethnicity, and language. Specifically, for the textual encoder, we leverage a large language model to generate synthetic clinical descriptions with varied sensitive attributes while preserving disease semantics, and employ a contrastive alignment objective to encourage demographic-invariant representations. For the visual encoder, we propose a dual-level fairness strategy that combines mutual information regularization to reduce statistical dependence between learned features and demographic groups, with multi-discriminator adversarial debiasing. Comprehensive experiments on the publicly available Harvard-FairVLMed dataset demonstrate that FairEnc effectively reduces demographic disparity as measured by DPD and DEOdds while achieving strong diagnostic performance under both zero-shot and linear probing evaluations. Additional experiments on the private FairFundus dataset show that FairEnc consistently preserves fairness advantages under cross-domain and cross-modality settings and maintains diagnostic performance within a competitive range. These results highlight FairEnc's ability to generalize fairness under distribution shifts, supporting its potential for more equitable deployment in real-world clinical settings. Our codebase and synthetic clinical notes are available at https://github.com/Mohamed-Elhabebe/FairEnc