Evo-PI: Aligning Medical Reasoning via Evolving Principle-Guided Supervision

Post-training via Supervised Fine-Tuning (SFT) and Reinforcement Learning (RL) is crucial for enhancing reasoning in Multimodal Large Language Models (MLLMs), yet existing paradigms often reach a performance bottleneck due to the limitations of static data. While current methods leverage self-reflection or self-evolution to push these boundaries, they still suffer from cognitive drift and hallucinated reasoning paths caused by low-quality synthetic data. To address these challenges, we propose Anchor Evolution (AnE), a new paradigm that integrates truth-anchored data curation and model evolution, achieving faithful and steady performance gains at the reasoning frontier. Specifically, we propose Truth Anchor Expansion, which pinpoints the model failing frontier via trajectory rollouts and leverages ground-truth databases to retrieve high-fidelity anchors for faithful data curation. Subsequently, we introduce the Scaffold-Stripping Mechanism to internalize reasoning capabilities. This mechanism first anchors reasoning paths via scaffold-augmented supervision to mitigate the learning complexity and distribution drift of direct SFT on raw data, then leverages RL to strip the scaffold template, thereby effectively transitioning the reasoning paths into intrinsic model capabilities. Experimental results on multimodal reasoning benchmarks show that our method substantially advances the model performance frontier, improving the base model by 10.3% across eight multimodal benchmarks and achieving state-of-the-art results. The code will be made publicly available.

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

High-stakes clinical use of large vision-language models (LVLMs) requires reasoning that is grounded in visual evidence and clinical knowledge, not just correct final answers. We introduce OpenMedReason, a large-scale, open multimodal medical reasoning corpus comprising approximately 450K image-question-answer instances whose reasoning traces are primarily derived from curated biomedical, human-authored scientific articles. OpenMedReason provides high-fidelity supervision beyond synthetic chains of thought, covering diverse medical domain vision modalities such as radiological scans, microscopic images, visible light photographs, charts, and others. We complement it with OpenMedReason-Bench, a held-out benchmark that allows fine-grained evaluation of LVLMs along three complementary axes of capability, including perception, medical knowledge, and rationale, enabling diagnostic evaluation beyond final-answer accuracy. OpenMedReason is a rich training resource that exhibits its effectiveness in both supervised fine-tuning (SFT) and reinforcement-based alignment. Training with OpenMedReason yields a 20% average improvement in VQA accuracy over the base model and achieves performance within 4.2% of the strongest comparable-scale medical LVLMs. Fine-grained performance analysis confirms that the gains are not concentrated in any single axis: OpenMedReason improves perception, medical knowledge, and rationale jointly, and its reasoning traces are preferred over those of the base model in 86.1% of pairwise comparisons. We release the code and dataset at huggingface.co/datasets/neginb/OpenMedReason.