When Evidence Vanishes: Distilling Visual-Evidence Dependency in Medical Vision-Language Models

Medical vision--language models (VLMs) have shown strong potential for medical visual question answering (VQA), yet their reasoning remains largely text-centric: images are encoded once as static context, and subsequent inference is dominated by language. This paradigm is fundamentally limited in clinical scenarios, where accurate answers often depend on subtle, localized visual evidence that cannot be reliably preserved in static embeddings. We propose MedLVR, a latent visual reasoning framework that introduces an explicit visual evidence state into autoregressive decoding. Instead of relying solely on text-based intermediate reasoning, MedLVR interleaves a short latent reasoning segment within the decoder by reusing hidden states as continuous latent steps, enabling iterative preservation and refinement of query-relevant visual evidence before answer generation. To support effective visual supervision, we adopt a two-stage training strategy: region of interest (ROI)-supervised fine-tuning aligns latent states with clinically relevant image evidence, and Visual-Latent Policy Optimization (VLPO) further optimizes latent reasoning and answer generation under outcome-level rewards. Experiments on OmniMedVQA and five external medical VQA benchmarks show that MedLVR consistently outperforms recent reasoning baselines and improves the average score over the Qwen2.5-VL-7B backbone from 48.3% to 53.4%. These results show that latent visual reasoning provides an effective mechanism for preserving diagnostically relevant visual evidence and improving the reliability of medical VQA.

A central goal of vision-language model (VLM) distillation is to transfer both the teacher's language capabilities and its visual understanding. However, existing methods primarily supervise the student's output, leaving visual understanding implicit. Our analysis reveals that a student can match the teacher's answer without relying on the same visual evidence, raising the question: how can we ensure the student responds to the visual information that actually determines the answer? To this end, we propose Cross-World On-Policy Distillation (CW-OPD), which explicitly supervises the student's response to changes in visual evidence. For each example, CW-OPD constructs two visual worlds that share the question and scene context but differ in answer-critical evidence, yielding different answers. We perform on-policy distillation in both worlds and distill the teacher's cross-world belief transition, encouraging the student to match not only what the teacher predicts but also why its prediction changes with the evidence. A gradient analysis shows that this term is invariant to errors shared by both worlds and supplies a corrective signal invisible to endpoint matching alone. In this way, CW-OPD makes reliance on the relevant visual evidence an explicit distillation target rather than an implicit consequence of output matching. To diagnose whether a model truly grounds its answers in visual evidence, we introduce CWBench, which measures cross-world consistency via Cross-World Pair Accuracy (CWPA). Experiments on Qwen3.5-4B show that CW-OPD outperforms the strongest baseline by 1.2 points on average, and the 4B student exceeds DeepSeek-V4.1 (552B) by 22.4 CWPA points on CWBench. Code is released in https://github.com/baokou-fw2/CWAD.

The reasoning gap between large and compact vision-language models (VLMs) limits the deployment of medical AI on portable clinical devices. Compact VLMs of 2--4B parameters can run on resource-constrained hardware but lack the multi-step reasoning capacity needed for interpretable clinical decision support. Existing knowledge distillation methods transfer answers without the reasoning process behind them. Medical visual question answering (VQA) serves as a testbed for this problem, as it requires models to integrate visual evidence with clinical knowledge through structured reasoning chains. We introduce LiteMedCoT-VL, a pipeline that transfers chain-of-thought reasoning from a 235B teacher model to 2B student models through LoRA-based fine-tuning on explanation-enriched training data. All inference is conducted without image captions by default, simulating the clinical scenario in which a physician interprets a medical image directly without an accompanying radiology report. On the PMC-VQA benchmark, LiteMedCoT-VL achieves 64.9% accuracy, exceeding the zero-shot Qwen3-VL-4B baseline of 53.9% by 11.0 percentage points and outperforming all published baselines. This result indicates that a 2B model with reasoning distillation can match or exceed models with twice the parameters. Visual grounding analysis shows that the model relies on image content rather than exploiting textual priors. Our code is publicly available at https://anonymous.4open.science/r/LiteMedCoT-VL.