Medical diagnostic reasoning requires verifiable links between visual evidence and clinical knowledge, yet current medical vision language models are aligned with objectives that reward the wrong behavior. Uniform supervised fine tuning lets easy cases dominate updates while clinically critical boundary cases saturate prematurely. Sparse rewards based only on final-answer correctness cannot assess anatomical grounding or clinical logic, inviting reward hacking through answer shortcuts. We propose MedCBR, a two-stage alignment framework coupling boundary-aware preference optimization with rubric-grounded reinforcement learning. First, we construct counterfactual boundary preferences at the model's capability frontier using empirical pass rates and preference pairs that share reasoning prefixes but diverge at decisive diagnostic branches. Difficulty Weighted Boundary Preference Optimization (DBPO) concentrates learning on this calibrated boundary region. Second, we distill reusable clinical rubrics from boundary trajectories and activate them according to prediction entropy. Entropy Gated Grounded Policy Optimization (EGPO) rewards answer correctness, anatomical grounding, and reasoning fidelity while suppressing rubric noise on reliable samples. A reference policy anchored to the boundary-aligned model couples population-level boundary priors with instance-level uncertainty, making diagnostic reasoning more accurate and clinically grounded. Experiments on six medical benchmarks show consistent improvements over strong general, specialized, and reinforcement learning baselines, reaching 61.2% average accuracy with the largest gains on challenging differential diagnosis tasks. Ablations show super-additive gains: combining the two stages exceeds the sum of their individual improvements.
As vision language models are increasingly deployed in clinical diagnosis, understanding how they internally resolve competing visual and textual signals becomes a safety imperative. Existing mechanistic analyses remain confined to unimodal text and offer no explanation for why a single misleading sentence can override a correct image based diagnosis, or why a model commits to a confident answer despite insufficient visual evidence. We find that these two safety risks, arbitration failure where textual context overrides visual grounding and brake failure where the model commits without adequate evidence, are mediated by spatially disjoint attention head populations: arbitration heads form a mid-to-deep wideband reflecting cross-layer evidence competition, while brake heads concentrate in a narrow middle-to-late layer band that regulates evidence sufficiency and abstention behavior. To ground these observations in causal circuitry, we introduce CRAFT, which localizes each failure mode to a minimal causal head set via dual criteria and verifies necessity and sufficiency through temporal probes and Tuned Lens trajectory analysis. Excising arbitration heads sharply reduces conflict following with negligible degradation on clean inputs, while excising brake heads restores appropriate abstention under degraded visual evidence. The two interventions target spatially disjoint head sets and produce distinct corrective effects, underscoring the mechanistic separability of the failure modes. Experiments across multiple medical VQA benchmarks and VLM architectures validate both the localization and interventions, demonstrating that the identified heads causally drive each failure mode and that targeted modulation generalises without retraining. The code is available at https://github.com/zhcz328/CRAFT.
Visual commissions require image agents to integrate heterogeneous source materials, preserve requirements across dependent stages, and produce coordinated deliverables. Existing evaluations examine specific capabilities and execution settings, leaving end-to-end commission completion less understood. We introduce Visual Commission Bench (VCB), comprising 600 tasks across 12 categories and three complementary tiers, from capability-focused tasks to complete commissions. VCB uses 5,039 requirement checks and separate visual quality ratings to assess content correctness, visual realization, constraint preservation, and delivery completeness without prescribing an internal workflow. We present V-Protocol, a reference agent that dynamically composes reusable task, cognitive, and expression modules at inference time. Task modules organize delivery, cognitive modules derive content, and expression modules guide visual realization. The modules exchange structured intermediate artifacts, while a shared execution harness tracks artifact revisions and dependencies, manages tool execution, and checks completion. With the same controller and image generator as the agent baselines, V-Protocol achieves 69.0\% strict task success on VCB, compared with 42.0\% for SCOPE. On Mind-Bench, strict accuracy increases from 39.2\% to 45.4\%.
Visual foundation models learn rich pathological morphology but lack explicit concept-level supervision. Vision--language pretraining can provide this supervision but requires costly image--text pairs. Here, we introduce GloSAGE, a semantic self-distillation framework that uses lesion profiles predicted by a pretrained visual teacher to construct structured pathology descriptions. Reliability-guided selection identifies image--text anchors, while Knowledge-Structured Pathology Text Synthesis and Evidence-Guided Negative-pair Construction account for partially observed lesions. Image--text alignment trains projection layers while retaining the frozen visual encoder; an intermediate Semantic Transfer Layer supplies features for downstream tasks. Developed on GloMillion and evaluated across seven glomerulus- and case-level cohorts, GloSAGE supported zero-shot lesion recognition, image--text retrieval, hard-negative discrimination and concept-intervention analyses. It outperformed its source visual model in most lesion-recognition tasks and improved lesion grading, while supporting competitive case-level disease classification, injury grading and baseline renal function estimation. Ablations supported the combined contributions of knowledge-structured text and evidence-guided negatives, and the intermediate transfer layer improved mean lesion-recognition ROC-AUC relative to the complete projection output. A frozen language model conditioned on GloSAGE features generated glomerular descriptions. These findings suggest that teacher-derived lesion profiles can provide annotation-efficient semantic supervision for extending a glomerular visual foundation model.
Wenlong Deng, Qi Zeng Facebook, Jiaming Zhang, Minghui Chen Columbia University, Zixin Ding, Christos Thrampoulidis University of British Columbia, Boying Gong Facebook, Xiaoxiao Li University of British Columbia
Data valuation is essential for enhancing the transparency and accountability of large language models (LLMs) and vision-language models (VLMs). However, existing methods typically rely on gradient computations, making them computationally prohibitive for billion-parameter models and precluding batch parallelization. In this work, we introduce For-Value, a forward-only data valuation framework that enables efficient batch-scalable value estimation while maintaining effectiveness. Leveraging the expressive power of pretrained LLMs/VLMs, we theoretically demonstrate that data valuation can be captured by the alignment between the final hidden representations and prediction errors at the last layer. In light of this insight, For-Value computes data value using a simple closed-form expression with a single forward pass, eliminating the need for costly backpropagation and enabling efficient batch calculating at scale. Extensive experiments show that For-Value matches or outperforms gradient-based baselines in detecting influential data and mislabeled data, while achieving significant efficiency improvements.
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cs.CL · cs.CV
Proceedings of the 64th Annual Meeting of the Association for Computational Linguistics (Volume 1: Long Papers) · 2026 · 正式发表