Clinically Structured Surrogate Rewards for Post-SFT Medical Image Captioning

Medical image captioning is a technique that accelerates early-stage diagnostic workflows and enhances the interpretability of medical diagnostic AI systems. However, unlike general image captioning, clinically reliable captioning remains challenging due to grayscale-based modalities, subtle anatomical cues, specialized medical phrasing, and variations in data quality. Despite recent advances in large vision-language models, fluent outputs do not necessarily guarantee sufficient alignment with clinical concept spaces or evaluation criteria. To address this issue, we propose a framework that strengthens clinical alignment by separating and enhancing training-time alignment and inference-time alignment. We build a medical image captioning pipeline that integrates single/dual vision encoders based on BioMedCLIP and SigLIP2, a Q-Former, and a LLaMA-based decoder, and examine the contribution of auxiliary learning for UMLS concept/type prediction. At inference, we apply single-embedding-based reranking to select the best caption among candidates, while at training we introduce MedPAIR-SCST, which combines clinically relevant rewards to shift the generative distribution toward improved clinical alignment. Our experiments show that complementary visual representations with a multi-encoder design and concept-level auxiliary learning help preserve clinically meaningful information. Furthermore, inference-time reranking provides a practical way to improve semantic and clinical alignment without additional training, whereas MedPAIR-SCST goes beyond selection by directly improving the model's distribution to generate more consistent and clinically grounded captions. These findings suggest that jointly leveraging selection-based alignment and reinforcement-learning-based alignment can promote more trustworthy medical image captioning even in data-constrained settings.

Image captioning remains a fundamental task for vision language understanding, yet ground-truth supervision still relies predominantly on human-annotated references. Because human annotations reflect subjective preferences and expertise, ground-truth captions are often incomplete or even incorrect, which in turn limits caption models. We argue that caption quality should be assessed by two objective aspects: completeness (does the caption cover all salient visual facts?) and correctness (are the descriptions true with respect to the image?). To this end, we introduce CCCaption: a dual-reward reinforcement learning framework with a dedicated fine-tuning corpus that explicitly optimizes these properties to generate Complete and Correct Captions. For completeness, we use diverse LVLMs to disentangle the image into a set of visual queries, and reward captions that answer more of these queries, with a dynamic query sampling strategy to improve training efficiency. For correctness, we penalize captions that contain hallucinations by validating the authenticity of sub-caption queries, which are derived from the caption decomposition. Our symmetric dual-reward optimization jointly maximizes completeness and correctness, guiding models toward captions that better satisfy these objective criteria. Extensive experiments across standard captioning benchmarks show consistent improvements, offering a principled path to training caption models beyond human-annotation imitation.

Long-form image captioning exposes a reward granularity problem in RL: captions are judged as whole sequences, while the important errors occur at the level of individual visual claims. A good dense caption should be both faithful and informative, avoiding hallucination without omitting salient details. Yet pairwise preferences, reference-based metrics, and holistic scalar rewards compress these local errors into a single sequence-level signal, obscuring the tradeoff between factuality and coverage. We introduce ClaimDiff-RL, a framework that uses reference-conditioned atomic claim differences as the reward unit for caption RL. Given an image, an actor caption, and a reference caption, a multimodal judge enumerates visually grounded differences, verifies each difference against the image, assigns open-vocabulary error types and severity levels, and produces per-difference statistics for reward composition. This makes hallucinated claims and omitted salient facts separately measurable and tunable. Experiments show that holistic scalar rewards can reduce hallucination by increasing missing facts, while ClaimDiff-RL exposes this faithfulness and coverage tradeoff and enables more balanced operating points. On a 160-image human-labeled diagnostic benchmark, public captioning benchmarks, and VQA benchmarks, ClaimDiff-RL improves the hallucination--missing-fact balance, preserves general capability, and even surpasses Gemini-3-Pro-Preview on several fine-grained Capability dimensions such as object counting, spatial relations, and scene recognition. These results suggest that typed, verifiable claim differences are an effective reward unit for fine-grained and diagnosable caption RL.