Medical Vision-Language Models (Med-VLMs) have achieved success across various tasks, yet most existing methods overlook the modality misalignment issue that can lead to untrustworthy responses in clinical settings. In this paper, we propose Hierarchical Self-Contrastive Rewarding (HSCR), a novel approach that addresses two critical challenges in Med-VLM alignment: 1) Cost-effective generation of high-quality preference data; 2) Capturing nuanced and context-aware preferences for improved alignment. HSCR first leverages the inherent capability of Med-VLMs to generate dispreferred responses with higher sampling probability. By analyzing output logit shifts after visual token dropout, we identify modality-coupled tokens that induce misalignment and derive an implicit alignment reward function. This function guides token replacement with hallucinated ones during decoding, producing high-quality dispreferred data. Furthermore, HSCR introduces a multi-level preference optimization strategy, which extends beyond traditional adjacent-level optimization by incorporating nuanced implicit preferences, leveraging relative quality in dispreferred data to capture subtle alignment cues for more precise and context-aware optimization. Extensive experiments across multiple medical tasks, including Med-VQA, medical image captioning and instruction following, demonstrate that HSCR not only enhances zero-shot performance but also significantly improves modality alignment and trustworthiness with just 2,000 training entries. Code is released on https://github.com/jiangsongtao/HSCR.

Multimodal large language models (MLLMs) still struggle with complex reasoning tasks in Visual Question Answering (VQA). While current methods have advanced by incorporating visual prompts, our study uncovers critical limitations: these approaches indiscriminately annotate all detected objects for every visual question, generating excessive visual markers that degrade task performance. This issue stems primarily from a lack of focus on key visual elements, raising two important questions: Are all objects equally important, and do all questions require visual prompts? Motivated by Dual Process Theory, which distinguishes between instinctive and deliberate cognitive modes in human reasoning, we propose FOCUS, a plug-and-play approach that dynamically adapts to the complexity of questions, combining fast intuitive judgments with deliberate analytical reasoning to enhance the vision-language reasoning capability of the MLLM. For straightforward questions, FOCUS supports efficient zero-shot reasoning. For more complex tasks, it employs the conceptualizing before observation strategy to highlight critical elements. Extensive experiments on four benchmarks—ScienceQA, TextQA, VizWiz, and MME—demonstrate that FOCUS consistently improves the performance of both open-source and black-box MLLMs, achieving significant gains across all datasets. Ablation studies further validate the importance of combining diverse cognitive strategies with refined visual information for superior performance. Code will be released.

Recent advancements in general-purpose or domain-specific multimodal large language models (LLMs) have witnessed remarkable progress for medical decision-making. However, they are designated for specific classification or generative tasks, and require model training or finetuning on large-scale datasets with sizeable parameters and tremendous computing, hindering their clinical utility across diverse resource-constrained scenarios in practice. In this paper, we propose a novel and lightweight framework Med-MoE (Mixture-of-Experts) that tackles both discriminative and generative multimodal medical tasks. The learning of Med-MoE consists of three steps: multimodal medical alignment, Instruction tuning and routing, and domain-specific MoE tuning. After aligning multimodal medical images with LLM tokens, we then enable the model for different multimodal medical tasks with instruction tuning, together with a trainable router tailored for expert selection across input modalities. Finally, the model is tuned by integrating the router with multiple domain-specific experts, which are selectively activated and further empowered by meta experts. Comprehensive experiments on both open- and close-end medical question answering (Med-VQA) and image classification tasks across datasets such as VQA-RAD, SLAKE and Path-VQA demonstrate that our model can achieve performance superior to or on par with state-of-the-art baselines, while only requiring approximately 30%-50% of activated model parameters. Extensive analysis and ablations corroborate the effectiveness and practical utility of our method.