Multimodal large language models (MLLMs) applied to Medical Visual Question Answering (VQA) tend to produce overconfident outputs regardless of actual correctness, and existing verbalized confidence calibration methods, developed primarily for text only LLMs, do not account for the multimodal nature of medical image understanding. This work proposes a training based framework that finetunes MLLMs to improve their calibration using a composite loss function combining a Brier style calibration term, an anchor regularizer that prevents confidence collapse toward extreme values, a contrastive image text alignment term, and a KL based model stabilization term. The alignment signal is derived from a 2×2 factorial perturbation design that crosses image presence with text integrity, probing the reliance of the model on visual modality input versus language priors. Finally, a top K KL divergence regularizer is used to protect the answering ability of the model during finetuning. Across three Medical VQA benchmarks and two architectures (MedGemma 4B IT and Qwen2 VL 7B Instruct), our method reduces calibration error by 60% or more, and improves discrimination by 26% or more, while preserving predictive accuracy. On average across benchmarks, the technique outperforms prompting based, sampling based, and training based approaches, and ablation experiments confirm that each component of the loss function is indeed necessary for improving the calibration. All code for the experiments is publicly available.
Multimodal Large Language Models (MLLMs) show great potential in medical tasks, but their elicited confidence often misaligns with actual accuracy, potentially leading to misdiagnosis or overlooking correct advice. This study presents the first comprehensive analysis of the relationship between accuracy and confidence in medical MLLMs. It proposes a novel method that combines Multi-Strategy Fusion-Based Interrogation (MS-FBI) with auxiliary expert LLM assessment, aiming to improve confidence calibration in Medical Visual Question Answering (VQA). Experiments demonstrate that our method reduces the Expected Calibration Error (ECE) by an average of 40% across three Medical VQA datasets, significantly enhancing MLLMs' reliability. The findings highlight the importance of domain-specific calibration for MLLMs in healthcare, offering a more trustworthy solution for AI-assisted diagnosis.
Reinforcement Fine-Tuning (RFT) has enabled medical Multimodal Large Language Models (MLLMs) to produce Chain-of-Thought (CoT) reasoning for visual question answering, yet these models suffer from confidence miscalibration---a systematic gap between expressed certainty and actual diagnostic accuracy that undermines clinical trust. We propose CARE, a Confidence-Aware medical REasoning framework that jointly optimizes accuracy and calibration through a dual-stage pipeline. First, a scalable Medical-CoT synthesis provides structured cold-start data for Supervised Fine-Tuning. Second, Group Relative Policy Optimization (GRPO) with a novel Confidence-Aware Reward (CAR) mechanism ties the model's confidence to diagnostic correctness within the reward signal. Across three Medical VQA benchmarks, CARE achieves the highest diagnostic accuracy while obtaining the lowest Expected Calibration Error and Hallucination Rate, establishing a foundation for trustworthy clinical decision support. Our code is available at https://github.com/anotherbricki/CARE.
Reliable evaluation of vision-language models (VLMs) and medical vision-language models (Medical-VLMs) requires calibrated confidence, particularly under realistic clinical conditions. However, existing efforts mainly focused on improving accuracy, leaving calibration in the medical domain underexplored. To this end, we propose MVC-Bench, a calibration-centric benchmark for medical image classification with VLMs and Medical-VLMs. MVC-Bench assesses the calibration across three axes: (i) robustness to modality, backbone, and domain shift (ii) effectiveness of calibration strategies and prompt-tuning methods (iii) stability under prompt-template and random-seed variations. The benchmark covers eight different backbones, three medical modalities, including fundus imaging, histopathology, and chest X-ray under in-domain and domain shift settings. It compares post-hoc calibration, train-time calibration, and zero-shot inference methods, together with six prompt-tuning methods. Across more than 1638 controlled experiments, we report accuracy and Expected Calibration Error (ECE) as primary metrics, and further report results with complementary calibration measures, including Maximum Calibration Error (MCE) and Adaptive Calibration Error (ACE). We further investigate the underlying causes of miscalibration in VLMs and Medical-VLMs and propose a simple train-time calibration method, Multi-Class Margin (MCM) regularization, which achieves lowest ECE on 10 out of 12 settings in in-domain and remains competitive under domain shifts. Collectively, MVC-Bench provides a structured evaluation framework and actionable guidance for improving calibration in safety-critical medical workflows.