Medical VLMs

While Multimodal Large Language Models (MLLMs) have demonstrated remarkable success in 2D medical image understanding, their extension to 3D volumetric imaging remains hindered by prohibitive annotation costs and dataset opacity. Current data formats, predominantly consisting of rigid Visual Question Answering (VQA) pairs or unstructured final clinical reports, typically fail to capture explicit clinical reasoning. To address this limitation, we introduce a large-scale structured reasoning dataset constructed via a novel slice-wise data synthesis paradigm. Inspired by the genuine diagnostic workflow of radiologists, this paradigm models visual cognition by decomposing the complex 3D reading process, translating global clinical priors into fine-grained, per-slice observations that are subsequently synthesized into an interpretable Chain-of-Thought (CoT). Crucially, this synthesized reasoning framework enforces essential clinical principles: sequential spatial tracking, multi-slice spatial awareness for artifact mitigation, and differential exclusion. To validate this approach, we instruction-tune a standard 2D-pretrained MLLM baseline using the synthesized data to enhance its volumetric comprehension. Comprehensive evaluations across multiple 3D medical benchmarks demonstrate that our method yields significant performance improvements over the 2D baseline. Furthermore, the resulting model exhibits robust spatial reasoning capabilities and rivals resource-intensive native 3D architectures, effectively bridging the performance gap. Ultimately, this data-centric strategy unlocks deep volumetric understanding and highly interpretable clinical logic without requiring computationally expensive 3D-specific pre-training. The complete repository, including datasets and training workflows, is publicly available at https://github.com/2020420145009/hounsfield.

Pathology Foundation Models (PFMs) offer powerful Whole Slide Image (WSI) representations but suffer from massive computational costs. While Knowledge Distillation (KD) can create efficient student models, existing multi-teacher methods often use suboptimal uniform weighting that ignores tissue heterogeneity. We propose LaGuadia (Language-Guided Adaptive DistillAtion), a framework that develops a compact pathology image encoder by dynamically integrating expertise from multiple PFMs under clinical linguistic guidance. Our approach utilizes a multi-stage pipeline: first, extracting visually observable clinical keywords from pathology reports; second, aligning visual features with these keywords via a Vision-Language meta-teacher (MedSigLIP) to provide dense semantic guidance; and finally, performing adaptive KD where teacher contributions are weighted based on their semantic alignment with the clinical narrative. Experiments on WSI captioning, visual question answering, and slide-level classification tasks demonstrate that an 87M parameter LaGuadia student model matches or exceeds foundation-scale models such as GigaPath and UNI, achieving strong factual consistency and robust generalization. These results highlight clinical language as an effective semantic anchor for building efficient and reliable digital pathology systems. Code is available at https://github.com/hvcl/LaGuadia.

The growing ability of large language models and vision language models to jointly interpret and reason over images and text is reshaping medical agents, moving them from task specific predictors toward autonomous systems that perceive, reason, plan, remember, and act in clinical environments. This work departs from the capability first perspective of existing literature and instead begins from clinical deployment, asking what tasks, contamination resistant benchmarks, and interactive training environments are required before medical agents can be trusted in practice. Medical agents are formalized as sequential decision making systems under partial observability, together with a three level autonomy taxonomy spanning assisted, cooperative, and fully autonomous operation. The field is organized along a unified scaling spine consisting of framework scaling, capability scaling, and environment scaling. Within this framework, clinical environment scaling, the integration of tools, data, and clinical gyms, is identified as the most actionable yet underexplored direction for agents operating in PACS, EHR, and FHIR ecosystems. Clinical self evolution, where agents improve through interaction with their environments rather than parameter scaling alone, is further positioned as a key research frontier, drawing insights from self improving agents, agent gyms, and test time compute scaling. Applications across radiology, pathology, ophthalmology, and hospital workflows are examined together with deployment challenges including hallucination, cascading failures, and fairness. By consolidating more than 300 references, with particular emphasis on advances from 2025 to 2026, this work provides a roadmap toward trustworthy, self improving medical imaging systems for real clinical practice.

Medical vision-language pretraining (VLP) from paired CT images and radiology reports enables scalable representation learning, but most existing methods align either whole scans with entire reports or local image regions with text fragments. These formulations underuse a key property of radiology reports: findings are organized around anatomical structures, with abnormalities described by organs, disease concepts, locations, and severity-related attributes. We propose OKA-CT, an organ-hierarchical knowledge-augmented framework for CT-report VLP. OKA-CT first converts free-text reports into organ-conditioned knowledge using radiology report parsing and LLM-assisted semantic structuring. The extracted hierarchy is used across two learning stages. Stage1 injects anatomy-grounded evidence into the CT visual representation through fine-grained organ-conditioned supervision, while Stage2 uses organ-specific report evidence to guide structured report-CT contrastive learning, where hierarchy-derived semantic soft targets treat non-paired cases with shared organ-level findings as weak semantic positives rather than uniform negatives. A lightweight query-based global branch further aggregates disease-relevant volumetric evidence for whole-scan representation. On CT-RATE and RAD-ChestCT datasets, OKA-CT achieves zero-shot abnormality diagnosis AUROCs of 84.9 and 72.2, outperforming prior CT VLP baselines. Retrieval and patch-occlusion analyses further show improved report-image alignment and stronger sensitivity to disease-associated anatomical regions.

Medical Vision-Language Models (VLMs) exhibit strong zero-shot performance, yet their effectiveness still declines on out-of-distribution (OOD) data due to domain shifts and class bias inherited from large-scale pretraining. Existing few-shot adaptation methods typically introduce additional trainable components, which can be unstable in extremely low-data regimes (e.g., 1-shot), and lack robustness on different medical data. We present TCLA, a purely training-free few-shot adaptation method for Medical VLMs, which is fast and model-agnostic. TCLA corrects inference logits based on a small set of support samples, boosting pretrained VLMs performance by improving inter-class deconfusion and reducing domain shift. Extensive experiments on nine datasets across multiple medical imaging modalities including X-ray, Ultrasound, MRI, CT, Histopathology, demonstrate that TCLA consistently improves OOD performance of Medical VLMs and, in most of cases, outperforms existing training-based adaptation methods.

Medical images require comprehensive and accurate interpretation to support the diagnosis of diverse clincial conditions. Recent vision-language generalist models offer broad task coverage and promising zero-shot capabilities, yet often lack fine-grained anatomical and lesion awareness for reliable diagnosis and spatial interpretability. In contrast, supervised specialist models achieve strong performance on specific tasks but typically lack generalization across diseases and anatomies. In this work, we present SuG, a Super-Generalist framework that unifies generalist vision-language learning with specialist objectives, enabling both broad generalization and specialist-level diagnostic capability. We perform specialist-enhanced vision-language alignment in SuG by incorporating spatial priors from multiple segmentation experts, including anatomy, class-specific lesion and class-agnostic lesion segmentors that captures lesions beyond anatomies annotated during training. To improve lesion grounding capability, we leverage lesion masks as spatial priors to calibrate text-conditioned visual attention, encouraging disease-related semantics to focus on clinically relevant regions. We evaluate SuG on extensive chest and abdominal CT benchmarks, including CT-RATE, Merlin, MedVL-CT69K, and several in-house tumor datasets. SuG achieves state-of-the-art performance across a wide range of disease diagnosis tasks and surpasses specialist models on several critical tumor diagnosis benchmarks. Furthermore, SuG demonstrates strong lesion grounding capability, including robust generalization to lesion types lacking class-specific supervision.

The rapid integration of Large Vision-Language Models (VLMs) into critical infrastructure promises to revolutionize personalized healthcare and dietary management. However, in the domain of food systems, autonomous agents face a unique and persistent challenge: the "Systemic Information Asymmetry" between visual appearance and intrinsic nutritional composition. Existing benchmarks primarily focus on coarse-grained classification tasks, such as food category recognition, which fail to evaluate the intricate reasoning chain required for real-world dietary management -- specifically, the ability to traverse from identifying hidden ingredients to estimating physical mass, and finally synthesizing safety-critical medical advice. In this paper, we introduce OmniFood-Bench, a comprehensive benchmark constructed from the MM-Food-100K dataset. Unlike previous works, OmniFood-Bench evaluates VLMs across three progressive capabilities: Basic Perception (Ingredients & Cooking Methods), Quantitative Reasoning (Portion Size & Nutritional Profiling), and Safety-Critical Advisory (Disease-Specific Recommendations). We evaluate six state-of-the-art VLMs, including gpt-5.1, gemini-3-flash, and qwen3-vl-8B. Our extensive experiments reveal a startling "Semantic-Physical Gap": while models achieve near-human accuracy in naming dishes, they exhibit catastrophic failure in mass estimation and frequently hallucinate benign advice for high-risk diabetic profiles. This work establishes a rigorous standard for trustworthiness in autonomous agents deployed for public health. The code and datasets are available in: https://anonymous.4open.science/r/OmniFood-Bench-7D0B

Medicine is inherently multimodal, requiring clinicians to synthesize information across diverse data streams. Yet the development of multimodal foundation models is constrained by limited access to large-scale, high-quality clinical data. Although PubMed Central (PMC) offers a complementary source of expert-authored image-text data, existing PMC-derived resources remain limited in fidelity, reproducibility, and clinical validation. We introduce MedPMC, an automated, continuously updatable framework that transforms permissively licensed literature into high-fidelity infrastructure for medical multimodal models. Applied to 6.1 million PMC articles, MedPMC curated 11 million medical image-text pairs. Component evaluations showed strong performance for initial screening (F1 = 93.2), multi-panel figure detection (F1 = 96.5), figure separation (mAP = 89.8), caption separation and alignment (F1 = 81.4; ROUGE-L = 85.3), and medical figure classification (F1 = 96.5). Manual review by five annotators, three with medical training, found 95.3% of MedPMC images medically relevant, versus 19.7% in a prior PMC-derived dataset. Across 26 benchmarks spanning 11 specialties, a MedPMC-trained CLIP-style model improved average zero-shot AUC by 7.1 percentage points over the strongest architecture-matched biomedical CLIP baseline despite using fewer than half as many image-text pairs. As the vision encoder in a multimodal large language model, it improved medical visual question-answering by 1.9 and 16.9 percentage points across two benchmarks. In 10,524 Yale New Haven Health System dermatology photographs, it improved morphology-to-image retrieval Recall@5 by 11.7 percentage points. These findings show that high-fidelity literature curation strengthens medical multimodal foundation models across benchmark and clinical settings. We publicly release the framework, corpus, benchmarks, and pretrained models.

Despite rapid advances in chest X-ray (CXR) foundation models, most radiology report generation (RRG) systems still rely on heavily downsampled inputs (e.g., 256x256) due to the fixed visual token budgets of pretrained vision encoders, suppressing subtle yet clinically important cues present in native-resolution images. However, enabling high-resolution (high-res) perception remains challenging: naive tiling causes prohibitive token inflation, while global compression suppresses subtle lesions and degrades diagnostic fidelity. Inspired by radiologists' workflow, localizing suspicious regions before detailed high-res assessment. We propose Lesion-Aware High-Resolution Patch Discovery and Fusion for Chest X-ray Reporting (LePaX), the first RRG framework that enables efficient high-res CXR perception (up to 1920x1920) without increasing the vision-token count. LePaX formulates high-res perception as a constrained spatial resolution allocation problem under a fixed token budget and introduces two key components: Learnable Spatial Resolution Allocation (LSRA), which learns a spatial utility map that adaptively allocates limited high-res capacity to diagnostically relevant regions, enabling targeted extraction of high-res patches from native CXRs; and Global-Regional Fusion (GRF), which performs token-preserving region-to-global refinement by projecting high-resolution regional evidence back onto the global feature grid through spatially aligned resolution write-back, avoiding token inflation. Experiments on multiple CXR benchmarks demonstrate that LePaX consistently improves both clinical and linguistic metrics while enabling native-resolution CXR perception with over 10x fewer visual tokens than naive high-res tiling.

Wound monitoring is a critical yet underserved clinical challenge, where timely identification of severe adverse events (SAEs) such as infection, tissue deterioration, and delayed healing can significantly impact patient outcomes. While vision-language models (VLMs) show strong multimodal reasoning, they often lack domain-specific grounding to integrate wound imagery with heterogeneous clinical information, and provide limited mechanisms for detecting cases that diverge from the training distribution. We present a multimodal framework for automated wound monitoring and SAE detection. Our approach leverages paired clinical notes and wound descriptions capturing visual characteristics such as appearance, surrounding skin condition, color changes, and signs of inflammation or healing progression, encoded through a dual-stream Low-Rank Adaptation (LoRA) framework built on a frozen BiomedCLIP backbone. We introduce a cross-contextual LoRA fusion mechanism enabling information exchange between clinical semantics and visual wound descriptors, producing context-aware multimodal representations without full model fine-tuning. To identify personalized SAEs, we propose a wound-specific out-of-distribution (OOD) detection framework combining semantic matching, visual typicality, caption-text alignment, and caption-visual alignment into a unified SAE (OOD) score. To capture healing dynamics, we incorporate covariate consistency and temporal drift penalties that leverage changes in wound characteristics across visits. Experiments on a longitudinal wound dataset collected through clinical visits show promising performance on both wound healing assessment and SAE detection, highlighting the potential of semantically enriched, temporally aware vision-language systems for clinical wound monitoring and early risk identification.

Model editing promises a fast, targeted way to correct post-deployment mistakes in medical vision-language models (VLMs) without costly retraining. However, existing multimodal model editing benchmarks focus on general-purpose tasks and do not reflect realistic clinical domain requirements and variability. To address this, we introduce M3Bench, a clinically grounded benchmark for multimodal model editing that evaluates whether an edit remains reliable, precise, and generalizable under the challenges of image and text variation, modality and protocol shifts, clinical knowledge composition, and temporal progression. M3Bench contains 16,276 questions spanning diverse anatomy, modalities, and specialties, and supports both single and sequential edits. By evaluating 4 representative editors across 6 medical and general VLMs, we find that no method excels across all criteria. Gradient-based editors achieve strong transfer but suffer from catastrophic locality violations, whereas memory-based methods preserve locality but lack compositional generality and exhibit high backbone-dependent hyperparameter sensitivity. We further attribute these failures to the latent space geometry of VLMs and how different editing methods shift its landscape. Overall, M3Bench establishes a rigorous clinical stress test for multimodal model editing and offers actionable guidance for safer post-deployment adaptation. The benchmark is publicly available at https://github.com/BioMed-AI-Lab-U-Michgan/M3Bench .

While Large Vision-Language Models (VLMs) demonstrate remarkable generic capabilities, their clinical reasoning in specialized domains like ocular surface diseases (OSDs) is severely hindered by a paucity of high-fidelity, multimodal instruction-tuning data. To dismantle this data bottleneck, we introduce IRIS, an Intelligent Recognition and Interaction System tailored for fine-grained OSD understanding via external eye photography. First, we curate IRIS-120K, the largest and most comprehensive OSD visual question-answering (VQA) dataset to date. Crucially, to overcome the semantic shallowness of conventional image-caption pairs, we propose a synergistic data generation paradigm to explicitly inject clinical priors. Our data engine operates via a dual-branch framework: 1) a Topic Finding Tree (TFT) that hierarchically anchors visual features to precise anatomical and pathological concepts, enforcing rigorous medical deduction logic; and 2) a Scene-driven strategy that synthesizes role-adaptive clinical dialogues to ensure pragmatic generalization. By explicitly aligning a compact 4B-parameter VLM on this structurally enriched corpus, IRIS achieves state-of-the-art performance, comprehensively outperforming both generalist and specialized medical VLMs with up to 34B parameters. Our findings underscore that structured knowledge injection profoundly prevails over sheer parameter scaling, unlocking the potential for resource-efficient, expert-level AI deployment on mobile edge devices for scalable OSD screening. Code, datasets, and model weights will be publicly released by this repo.

Automated radiology report generation (RRG) can ease radiologist workload, yet most existing systems produce a report in a single forward pass, with no mechanism to check a claim against the image or revisit a finding once stated. We present CogRad, a cognitively inspired multi-agent framework that structures generation around four stages of a radiologist's reading process. A Scout agent discovers anatomical regions directly from image patches via slot attention and assigns region and disease-level triage scores; an Investigator agent concentrates representational capacity on the regions Scout flags as suspicious; a Writer agent compiles these signals into a disease gated visual prefix for a large language model; and a Verifier agent supervises training with a visual entailment loss and, at inference, re-examines its own draft sentence by sentence, regenerating any report it judges insufficiently grounded. On CheXpert Plus, CogRad attains a BLEU-4 of 0.316 and a CIDEr of 0.322, the best scores among the methods we compare against. On IU X-Ray, it attains a BLEU-4 of 0.201 and a CIDEr of 0.724, leading every baseline on every standard NLG metric. We further evaluate CogRad with RadGraph F1, CheXbert F1, and a hallucination analysis to assess clinical accuracy beyond standard text-overlap metrics, complemented by ablation studies and Grad-CAM-based visualizations that characterize each agent's contribution and the model's visual grounding.

Large vision language models (VLMs) report strong accuracy on medical question-answering, yet it remains unclear whether they reason from visual evidence or exploit textual shortcuts. We introduce a counterfactual evaluation framework that decouples visual and textual contributions by substituting input images with controlled surrogates blank, pixel-shuffled, image-absent, and CLIP-retrieved hard negatives and derive a suite of grounding metrics including the Visual Reliance Score (VRS) and Visual Hallucination Rate (VHR). We further introduce CORAL (COntrastive Retrieval-Augmented Learning), a 7B-parameter LoRA fine-tune of Qwen2.5-VL-7B trained with a Contrastive Grounding Objective (CGO) that penalises answer invariance under hard-negative image swaps. On a paired controlled evaluation across four closed-form medical VQA benchmarks (PathVQA, PMC-VQA, SLAKE, VQA-RAD; n=400 total), CORAL improves macro accuracy by +6.7 pp (P(Delta>0)=0.988) and reduces VHR by 8.0 pp (P<0.001) over the matched Qwen2.5-VL-7B base; neither MedVLThinker RL variant achieves a significant gain on either metric. Cross-domain diagnostics further reveal that image substitution costs only <=6.5 pp on medical benchmarks versus 48-61 pp on general-domain tasks, situating the grounding gap that CGO targets. We discuss evaluation limitations openly including train/eval benchmark overlap and underpowered secondary metrics and release our framework, training code, and model weights to support reproducible grounding audits of medical VLMs.

Large vision-language models (LVLMs) have achieved strong performance across many medical imaging tasks, yet their application to ultrasound remains limited due to its inherent complexity and variability. In this work, we revisit what is truly needed to enable real-world ultrasound understanding. Instead of introducing complex architectures or elaborate training strategies, we show that data scale and clinically faithful data alignment are the key factors. We construct a large-scale dataset of 1.5M real-world ultrasound examinations, containing 17.7M images, multi-organ coverage, and paired uncurated clinical reports. Crucially, we organize the data at the examination level, aligning multiple images with their corresponding reports to reflect real clinical workflows. We then fine-tune a standard LVLM using low-rank adaptation (LoRA) on this dataset without task-specific modifications. Surprisingly, this simple recipe already leads to strong performance across diverse ultrasound understanding tasks, outperforming prior methods designed with more complex pipelines. Beyond these results, we present model and data scaling analyses that provide insights into the role of scale in ultrasound LVLMs.

Traditional Chinese Medicine (TCM) diagnosis, particularly through tongue inspection, faces persistent challenges in subjectivity and reproducibility. The application of multimodal artificial intelligence to TCM clinical tasks, such as syndrome differentiation and prescription generation, is significantly hampered by the semantic gap between visual tongue features and textual reasoning, as well as the lack of large-scale, standardized datasets. To address these challenges, we introduce MMIR-TCM, a novel framework that emulates the diagnostic process of TCM experts by integrating multimodal large language model(MLLM) with memory-augmented segmentation and retrieval-augmented generation (RAG). Employing a three-stage architecture, MMIR-TCM integrates a training-free Memory-SAM module for robust tongue extraction, a fine-tuned Qwen3-VL model for structured tongue diagnosis generation, and a Qwen3-based RAG component for evidence-grounded clinical decision support generation. The framework was developed and validated using MedTCM, a new large-scale multimodal dataset that we introduce specifically for advanced TCM research. To properly evaluate our framework's clinical accuracy, which existing metrics fail to capture, we also developed TDEU, a domain-specific evaluation metric incorporating semantic understanding and diagnostic importance. Our comprehensive experiments demonstrate that MMIR-TCM significantly outperforms leading models, including GPT-4o and Gemini 2.5 Flash.

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 four multimodal LLM backbones, MRPO consistently outperforms standard GRPO and a recent RL baseline, and on Qwen3-VL-8B-Thinking even surpasses substantially larger medical MLLMs such as HuatuoGPT-Vision-34B by 4.59 points. Moreover, MRPO reduces early-stage reasoning failures from 58.6% to 13.4%, 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

Despite recent progress, the reasoning capabilities of large multimodal language models (MLLMs) remain fundamentally constrained by static supervision, where fixed prompts, rules, or reward models provide non-adaptive guidance throughout training. Such static signals are often sufficient to enforce output formats, but fail to shape the underlying reasoning process, leading to brittle generalization and performance saturation in complex decision-making tasks. We propose Evo-PI, a principle-centric learning framework that treats reasoning principles as explicit, language-based supervision signals that can be generated, evaluated, and iteratively evolved. Instead of relying on fixed rewards, Evo-PI enables a co-evolutionary loop in which principles guide model reasoning, while model behaviors in turn refine the principles that supervise them. This dynamic alignment mechanism allows supervision to progressively adapt to the model's reasoning deficiencies. We instantiate Evo-PI in medical visual question answering as a high-stakes testbed requiring structured visual-textual reasoning. Across eight benchmarks and multiple model backbones, Evo-PI consistently improves reasoning accuracy, achieving gains of up to 24.6%. Our results suggest that evolving principle-guided supervision offers a scalable and general paradigm for training expert-aligned reasoning in MLLMs. Code is available at https://github.com/zhengxianda/Evo_PI.

Vision-language models (VLMs) combining reinforcement learning (RL) ignite remarkable progress in multimodal reasoning, yet still struggle with medical images, which typically exhibit extremely sparse visual evidence to inform clinical decision-making. We recognize that pruning visual tokens outside the grounding region greatly enhances medical reasoning. However, a united RL framework for active visual token pruning (VTP) and medical multimodal reasoning remains unestablished. Here, we propose a dual-stream RL framework, ViToS, to fulfill token pruning and question answering. ViToS trains one policy model with two task branches, where one focuses on grounding while the other conducts token-sparse reasoning after VTP. Furthermore, we solve the coupled policy learning problem by introducing the cross-feedback sequential optimization, avoiding gradient conflict and facilitating convergence of the shared policy model. Evaluated on seven medical benchmarks, our method reduces visual tokens to 77% of the original sequence length while achieving a 108.27% relative performance on Lingshu-7B and 104.16% relative performance on HuatuoGPT-Vision-7B. Overall, ViToS delivers superior performance and inference speedup, establishing an efficient paradigm for medical multimodal reasoning.

Multimodal large language models (MLLMs) show strong promise for clinical VQA and radiology report generation, yet inference-time hallucinations still undermine trustworthy use: models can produce fluent conclusions that conflict with imaging evidence. Existing mitigation strategies typically rely on additional training, external retrieval/knowledge bases, or multi-stage post-hoc verification, which increases cost and pipeline complexity and often generalizes poorly across models and tasks.To address this, we propose a holistic, training-free evidence-injection framework that systematically mitigates hallucinations through dual-side evidence injection. By leveraging ROI priors acquired using MedSAM in our implementation, we recalibrate the visual perception trajectory via ROI-guided activation modulation while anchoring the textual reasoning trajectory by mapping anatomical coordinates into discrete semantic tokens as verifiable external memory. Then we introduce a task-aware dynamic router to select modality-specific interventions based on task semantics, balancing perceptual grounding and linguistic fluency. We conduct systematic evaluations on 2 tasks and 5 datasets using \texttt{LLaVA-1.5-7B}, \texttt{LLaVA-Med-1.5-7B}, \texttt{Qwen3-VL-8B/32B}, and \texttt{InternVL-3.5-8B/38B}. Controlled ablations and visualizations further validate the framework, which consistently outperforms baselines across medical benchmarks, improving close-ended accuracy by up to $\sim\mathbf{6}\%\uparrow$ and reducing open-ended hallucinations by $\sim\mathbf{35}\%\downarrow$. The code has been made available on GitHub: \href{https://github.com/Henry991115/SPRG}{\textcolor{blue}{https://github.com/Henry991115/SPRG}}.

Surgical vision-language foundation models typically adopt educational materials, such as surgical lecture videos, to transfer surgical knowledge encoded in language into visual representations. These knowledge are multi-dimensional and hierarchical: fine-grained action cues appear in narration, mid-level key steps are summarized in subsection headings, and global procedural context, such as patient history and surgical strategy, is described in abstract texts. Prior work largely collapses these heterogeneous signals into a single flat embedding space, implicitly assuming independence across hierarchy levels. However, this is suboptimal because it ignores cross-level semantic containment, e.g., actions belong to steps, steps compose phases, weakens long-range dependency modeling. To this end, we propose a hyperbolic surgical video-language pre-training framework that explicitly preserves the hierarchical structure by mitigating structural false negatives induced by procedural context and enforcing semantic consistency between parent phases and their constituent child steps. Extensive experiments on multiple surgical benchmarks show consistent gains in zero- and few-shot phase recognition across procedures and institutions.

Multimodal Large Models have significantly advanced automated breast ultrasound diagnosis. However, most existing frameworks utilize opaque, end-to-end paradigms prioritizing global statistical correlations over structured clinical reasoning. Consequently, these models remain susceptible to shortcut learning amid extreme real-world epidemiological imbalances, often bypassing rare but decisive malignant indicators for dominant benign patterns. To address this disconnect, we propose Latent-CURE, a novel diagnostic framework driven by asymmetric weighted chain-of-thought methodology grounded in latent space reasoning. Unlike traditional approaches, our framework constructs an implicit reasoning trajectory forcing the model to sequentially infer standardized BI-RADS morphological descriptors before converging on a final diagnosis. Furthermore, to combat the extreme scarcity of critical malignant features, we couple this architecture with a dual-asymmetric optimization strategy. By dynamically adjusting margins and weights, this strategy safeguards high-specificity malignant descriptors from being overshadowed by common benign priors. Comprehensive evaluations demonstrate that our knowledge-injected approach provides transparent clinical evidence while achieving robust, accurate diagnostic performance in imbalanced medical cohorts.

Vision-language foundation models have shown strong potential in medical image analysis. Although foundation models for ultrasound imaging have recently emerged, the domain remains particularly challenging due to severe speckle noise, acquisition variability, and subtle anatomical boundaries, leading to high inter-observer variability. Existing CLIP-based models rely primarily on global image-text alignment, limiting their sensitivity to clinically decisive local structures. We propose SonoCLIP, the first million-scale region-controllable fetal ultrasound vision-language foundation model that integrates segmentation masks as mask-channel visual prompts within the vision encoder, enabling joint global-local contrastive representation learning. To support scalable region-text alignment, we introduce a sigmoid-based pairwise contrastive loss that improves stability under large-scale supervision. We further curate a 1.44M-image multimodal fetal ultrasound dataset spanning 24 standard planes for large-scale pretraining. Extensive cross-center evaluations demonstrate that SonoCLIP achieves superior zero-shot transfer performance under both global and mask-guided inference, establishing a controllable and clinically oriented foundation model for fetal ultrasound analysis. Our code and data are available at https://github.com/Harrison-one/SonoCLIP.

A synthetic measurement of model competence is useful only if it survives the move to real data, yet the real labels that would verify it are exactly what medical imaging lacks. We ask whether transfer can be predicted in advance, label-free, and answer with a mechanism: on synthetic digital twins, competence that is donor-driven (a property of the transplanted nodule) survives the synthetic to real change of host, while host-driven competence (a property of the surrounding anatomy) need not. We test this on three lung CT vision-language tasks chosen to span that axis, across five public VLMs, four guidance conditions, and seven real datasets. The prediction holds in every case: presence and size orderings transfer (R2 >= 0.96), lobe does not; the split survives leave-source-out calibration, and the diagnostic names that boundary before any real label. TrialCouncil, a training-free council calibrated only on synthetic CT, confirms it by matching the best fixed model exactly where transfer is predicted. The contribution is not the router but the finding that transfer itself is predictable, label-free, from synthetic data alone.

Large vision-language models (LVLMs) are increasingly used for clinical image understanding, yet they remain vulnerable to \emph{hallucinations}--producing textual findings or attributes not supported by the image. We present a vision-traceable hallucination detection framework that audits arbitrary LVLM responses via visual evidence grounding, requiring neither modification nor internal access to the hidden states of LVLMs. Given an LVLM response, we extract visually verifiable entities and use a medical-domain-adapted Qwen-VL grounding verifier to localize each entity on the input image. To enhance the robustness of our detection method, we introduce a counterfactual entity perturbation method and estimate visual evidence uncertainty by contrasting factual and counterfactual grounding results. Specifically, we compute an entity-level uncertainty score from the positive confidence, counterfactual confidence, and their grounding overlap for binary hallucination decision-making. Experiments on multiple medical imaging modalities and LVLM backbones demonstrate that our method consistently improves hallucination detection performance over recent baselines, while providing interpretable localization evidence and strong cross-model transferability. Code and dataset are available at https://github.com/Agentic-CliniAI/CounterVHD.

Echocardiography is the most widely used non-invasive cardiac imaging modality, providing essential information for cardiovascular diagnosis. Interpreting an echocardiogram requires synthesizing complementary evidence across multiple heart views to identify abnormalities and produce structured clinical reports. While recent efforts focus on improving classification performance, most models lack explicit diagnostic reasoning and spatially grounded anatomical evidence, limiting clinician trust. We present EchoSonar-R, a multi-view reasoning-enabled vision-language model that jointly performs multi-label disease classification and report generation from echocardiography studies. EchoSonar-R combines a spatiotemporal video encoder with a structure-aware cardiac detector that provides spatially grounded anatomical cues to improve interpretability and clinician trust during cross-view reasoning. EchoSonar-R is trained in two stages: supervised fine-tuning (SFT) on reasoning-annotated targets, followed by Group Relative Policy Optimization (GRPO) with task-specific rewards that jointly align classification and report generation within a unified reinforcement-learning framework. Across a private multi-view dataset and two public benchmarks, EchoSonar-R improves macro balanced accuracy by 17.1% on the private set and 6.1% on MIMICEchoQA over the strongest baseline, achieves a GREEN clinical faithfulness score of 0.800, and produces interpretable reasoning traces grounded in multi-view visual evidence.

Large Vision-Language Models (LVLMs) specialized in healthcare are emerging as a promising research direction due to their potential impact in clinical and biomedical applications. However, progress is constrained by the scarcity of high-quality medical multimodal data, concerns about robustness in safety-critical settings, and the narrow and potentially contaminated evaluation benchmarks that limit reliable assessment. To address these issues, the field requires state-of-the-art solutions to be fully open and reproducible systems in which all components can be inspected, evaluated, and improved. This work introduces Aloe-Vision-Data, a large-scale, quality-filtered mixture which integrates both medical and general domains across multimodal and text-only sources, designed for direct use in model fine-tuning. Building on this dataset, we train the Aloe-Vision family of medical LVLMs, openly released with full weights, training recipes and data, in two scales (7B and 72B). Through comprehensive benchmarking, we demonstrate that high quality training mixtures produce balanced LVLMs which yield significant gains over the baseline models without compromising general capabilities, achieving competitive performance with respect to state-of-the-art alternatives. To support reliable evaluation, we introduce CareQA-Vision, a carefully curated vision benchmark derived from MIR and EIR exams, the residency entrance exams for medical and nursing specialists in Spain, offering novel vision questions with low likelihood of contamination. Finally, we show that current LVLMs remain vulnerable to adversarial and misleading inputs, underscoring reliability challenges in clinical contexts.

Reasoning in multimodal large language models (MLLMs) has shown strong promise in medical imaging. However, this reasoning is usually free-form text judged only by its final answer, making it hard to interpret and verify, especially in 3D radiology, where a diagnosis should be traceable to evidence in the scan. Existing chest CT question-answering datasets compound this by reducing expert radiology reports to answer-only pairs, dropping the reasoning that links findings to conclusions and omitting the patient history clinicians rely on. As a result, reasoning-capable 3D chest CT MLLMs remain out of reach, as neither the structured supervision needed to train them nor the protocol needed to verify their reasoning yet exists. We introduce CORTEX (Clinically Organized Reasoning and sTructured EXplanation), a structured reasoning benchmark for 3D chest CT. For each question, CORTEX restores the missing reasoning as a four-stage diagnostic trace mirroring a radiologist's workflow: task understanding, visual observation, diagnostic reasoning, and answer synthesis. We generate these traces using frontier large language models with broad medical and general-domain knowledge, then filter and verify them with a stage-level evaluation protocol combining automated rubric scoring with expert radiologist review. Crucially, both the reasoning structure and evaluation rubrics are designed in close collaboration with clinicians. Built on CT-RATE, a large, publicly available chest CT dataset without reasoning annotations, CORTEX comprises 76,177 validated reasoning traces across open-ended VQA, closed-ended VQA, and report generation, providing both the structured supervision and the stage-level evaluation protocol needed to build and evaluate trustworthy reasoning models for 3D chest CT. Our dataset and evaluation code is available at https://huggingface.co/datasets/aneesurhashmi/cortex

Multimodal large language models (MLLMs) applied to Medical Visual Question Answering (VQA) tend to produce overconfident outputs regardless of actual correctness, and existing verbalized confidence calibration methods, developed primarily for text only LLMs, do not account for the multimodal nature of medical image understanding. This work proposes a training based framework that finetunes MLLMs to improve their calibration using a composite loss function combining a Brier style calibration term, an anchor regularizer that prevents confidence collapse toward extreme values, a contrastive image text alignment term, and a KL based model stabilization term. The alignment signal is derived from a $2 \times 2$ factorial perturbation design that crosses image presence with text integrity, probing the reliance of the model on visual modality input versus language priors. Finally, a top K KL divergence regularizer is used to protect the answering ability of the model during finetuning. Across three Medical VQA benchmarks and two architectures (MedGemma 4B IT and Qwen2 VL 7B Instruct), our method reduces calibration error by 60% or more, and improves discrimination by 26% or more, while preserving predictive accuracy. On average across benchmarks, the technique outperforms prompting based, sampling based, and training based approaches, and ablation experiments confirm that each component of the loss function is indeed necessary for improving the calibration. All code for the experiments is publicly available.

Transcatheter Aortic Valve Replacement (TAVR) planning requires meticulous multimodal reasoning. However, adapting Multimodal Large Language Models (MLLMs) to this high-stakes domain is severely impeded by diagnostic hallucinations, where generated text lacks anatomical grounding. To address this, TAVR-VLM is introduced: a novel framework featuring Risk-Conditioned Causal Grounding Attention (R-CGA) that instantiates a model-internal ``Risk $\rightarrow$ Region $\rightarrow$ Word'' structural grounding pathway. R-CGA compresses multimodal inputs into a causal risk bottleneck, purifying dense visual features into a global risk mask. During autoregressive generation, a support-projected causal consistency objective constrains token-level grounding within the risk-defined support mask. Evaluated on $\text{M}^3\text{TAVR}$, a comprehensive 1,482-patient cohort, TAVR-VLM establishes a new state-of-the-art. It achieves an AUROC of 0.896, boosts CIDEr to 0.936, and drastically reduces the hallucination rate to 8.1%, thereby improving interpretability for evidence-based surgical AI.