Token-Sparse Medical Multimodal Reasoning via Dual-Stream Reinforcement Learning

With the rapid advancement of large multimodal models (LMMs), inference-time overhead has become a key bottleneck for real-world deployment. Existing methods typically prune visual tokens at prefill, assuming the required visual evidence remains static during reasoning. However, we empirically show that visual evidence is strongly step-dependent: only a sparse subset of visual tokens is critical at each decoding step, and the critical set evolves across reasoning. Furthermore, we identify a coupled bottleneck where redundant visual context can steer the model toward query-irrelevant regions, lengthening the reasoning trace. Guided by these insights, we propose VisionPulse, a step-wise visual token pruning framework during reasoning. VisionPulse computes a lightweight visual attention mass to estimate the step-wise retention budget by exploiting its strong positive correlation with LMMs' effective visual token usage and retain only the most critical tokens under this budget. By enforcing visual sparsity during reasoning, VisionPulse filters redundant visual context while preserving relevant visual evidence, shortening reasoning traces naturally. Extensive experiments show that VisionPulse only retains 5% of visual tokens per step with reasoning traces shortened by 11.2%, while keeping accuracy almost unchanged.

Recent multimodal large language models have shown great promise in clinical image reasoning, but existing post-training pipelines remain predominantly outcome-centric, relying on final answer correctness or sequence-level preferences. This suffers from sparse credit assignment, making it difficult to optimize the reasoning process essential for clinical applications. Our analysis reveals that cascading errors from early-stage reasoning failures are a leading cause of incorrect predictions in medical visual question answering (VQA) benchmarks. Motivated by this, we propose Medical Reasoning-aware Policy Optimization (MRPO), an RL algorithm that incorporates step-wise process rewards. When the final answer is incorrect, MRPO assigns exponentially larger penalties to tokens in earlier invalid reasoning steps, breaking failure cascades without compromising successful paths. Across three multimodal LLM backbones, MRPO consistently outperforms standard GRPO and a recent RL baseline, and on Qwen3-VL-8B-Instruct even surpasses substantially larger medical MLLMs such as HuatuoGPT-Vision-34B by 2.79 points. Moreover, MRPO reduces early-stage reasoning failures from 64.0% to 13.0%, showing that targeted mitigation of cascading failures improves both reasoning quality and final answer accuracy. Our code is available at https://github.com/dmis-lab/MRPO

Reinforcement Learning with Verifiable Rewards (RLVR) has become an effective paradigm for improving the reasoning capability of Large Vision-Language Models (LVLMs). However, existing RLVR methods primarily rely on trajectory-level outcome rewards, which assign identical learning signals across all generated tokens. This coarse-grained credit assignment is fundamentally mismatched to multimodal reasoning, where only a sparse subset of tokens is causally grounded in visual evidence. Consequently, these pivotal perceptual tokens receive weak supervision and are often overwhelmed by language priors or reasoning-template tokens. To address this limitation, we propose Perception-Reinforced Policy Optimization (PRPO), a token-level reinforcement learning framework that explicitly identifies and reinforces pivotal perceptual tokens within long-horizon multimodal reasoning trajectories. PRPO introduces Robust Visual Dependency (RVD), a principled metric that identifies tokens whose predictions are both visually grounded and perturbation-stable, filtering out brittle or noisy visual tokens. Based on RVD, we further propose Perceptual Advantage Reshaping (PAR), a token-level credit assignment technique that amplifies perceptually informative tokens while preserving stable gradients for non-perceptual tokens. Extensive experiments on seven multimodal reasoning benchmarks demonstrate that PRPO consistently outperforms strong LVLM baselines across both 3B and 7B model scales, achieving average gains of 23.3% and 21.1%, respectively. PRPO achieves state-of-the-art performance with improved training efficiency and stronger cross-task generalization. Our findings highlight the importance of fine-grained credit assignment for scalable multimodal reinforcement learning.