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.
Lei Tian, Chunzheng Zhu, Kai Wu, Yifan Zhang, Haihua Yang
Native multimodal large language models (native MLLMs) jointly encode visual and linguistic sequences within a unified autoregressive Transformer, emerging as a promising paradigm for multimodal understanding. Unlike conventional ViT-based MLLMs relying on external vision encoders, ViT-free native MLLMs tokenize pixel patches directly, potentially suffering severe visual token redundancy. A pilot study confirms this: unlike ViT-based models that degrade under compression, ViT-free MLLMs tolerate aggressive compression with near-lossless or even improved performance. Yet existing compression methods target ViT-based settings, leaving native MLLMs, which stand to gain the most, unexplored. To close this gap, we introduce an analysis pipeline centered on token discriminability and cross-dimensional heterogeneous redundancy, revealing that (i) redundancy is distributed independently and heterogeneously along height and width axes, and (ii) early-layer visual tokens are indiscriminable and uniformly redundant. Guided by these findings, we propose PACE (Pareto-Adaptive Compression for Efficient Native MLLMs), the first visual token compression framework tailored for native MLLMs with Multimodal-RoPE. Leveraging dimensional decoupling of positional encoding, PACE decomposes attention into two orthogonal spatial saliency estimates along height and width, gated by a positional attention signal, yielding direction-aware importance with negligible overhead. It further casts token budget allocation as Pareto optimization over performance preservation, inference efficiency, and spatial coverage, jointly identifying optimal compression depths and retention ratios. Experiments show PACE maintains near-lossless performance at only 25%-50% visual token retention, even improving several benchmarks, while delivering over 2x FLOPs reduction.