MedStreamBench: A Time-Aware Benchmark for Streaming and Proactive Medical Video Understanding

Streaming video understanding requires models to process continuous multimodal input while maintaining temporal context. Existing evaluations are predominantly reactive: they query a model at a selected timestamp and therefore do not assess when it should respond. Proactive interaction instead requires monitoring a standing request, responding within an appropriate interval after the target event, and otherwise remaining silent. We introduce ProactiveBench, which evaluates models at one-second stream intervals without an explicit response cue. Its six subtasks vary trigger ambiguity and timing tolerance. Event Sensitivity geometrically combines response and silence rates on the same recording; four window-based subtasks distinguish early, in-window, and missed responses; and Duplicate Counting penalizes omissions and repetitions. Premature responses outnumber missed responses for four of the six evaluated systems, revealing a substantial gap in the temporal decision-making required for human-like interaction.

Streaming video models should respond the moment an event unfolds, not after the moment has passed. Yet existing online VideoQA benchmarks remain largely retrospective. They pause the video at fixed timestamps, pose questions about current or past events, and score models only at those moments. This protocol leaves streaming predictions untested. To close this gap, we introduce SPOT-Bench, featuring multi-turn proactive queries that evaluate general streaming perception and assistive capabilities required by an always-on, real-time assistant. SPOT-Bench comes with Timeliness-F1, a consolidated metric that measures streaming predictions by their temporal precision and balanced coverage across the entire video. Our benchmark reveals: (i) offline models detect events reliably but spam predictions unprompted; (ii) post-training for silence reduces spamming but induces unresponsiveness; (iii) half of the streaming video expects no response, which we term dead-time - compute spent here does not affect response latency. These findings motivate AsynKV, a training-free streaming adaptation of offline models, that retains their event perception while improving their streaming behavior. AsynKV features a long-short term memory, utilized efficiently by scaling compute during dead-time. It serves as a strong baseline on SPOT-Bench, outperforming existing streaming models, and achieves state-of-the-art on retrospective benchmarks.

Proactive streaming video understanding requires models to continuously process video streams and decide when to respond, rather than merely what to respond. This naturally introduces a decision-making problem under partial observations, where models must balance early prediction against sufficient evidence. However, existing benchmarks largely follow a "see-then-answer" paradigm, where responses are triggered only after explicit evidence appears, effectively reducing proactive reasoning to delayed perception. As a result, they fail to evaluate a model's ability to make timely and reliable decisions under incomplete observations. Moreover, training proactive models is inherently challenging due to the extreme imbalance between silence and response signals in streaming trajectories, as well as the need to jointly optimize response correctness and timing. To address these challenges, we introduce StreamPro-Bench, a new benchmark that evaluates streaming models from three complementary perspectives: Perception Understanding, Temporal Reasoning, and Proactive Agency, where the last measures a model's ability to make early yet reliable decisions under partial observations. We further propose StreamPro, a two-stage training framework for proactive learning. First, we introduce CB-Stream Loss to mitigate the severe supervision imbalance during supervised fine-tuning (SFT). Then, we apply Group Relative Policy Optimization (GRPO) with a multi-grained reward design that involves both turn-level and trajectory-level rewards. Experiments show that StreamPro significantly improves proactive performance. On StreamPro-Bench, it achieves 41.5, substantially outperforming the previous best (10.4), while also maintaining strong performance on real-time streaming benchmarks, achieving 78.9 on StreamingBench-RTVU.