# LLM-CXR: Instruction-Finetuned LLM for CXR Image Understanding and Generation

arXiv: https://arxiv.org/abs/2305.11490 · HTML: https://mlsanity.com/paper/2305.11490/

## Key facts

- Cited by 57 papers in the map (data through 14 Oct 2026).
- Placed in Clinical and biomedical applications, one of 17 directions in LLM reasoning.
- Builds on 21 of its 46 references that are in the map.
- First posted on arXiv 19 May 2023.

## Placed in

- LLM reasoning / [Clinical and biomedical applications](https://mlsanity.com/lr/clinical-and-biomedical-applications/)

## Builds on (most cited first, 21 of 21)

- [Adam: A Method for Stochastic Optimization](https://mlsanity.com/paper/1412.6980/) (2014)
- [Language Models are Few-Shot Learners](https://mlsanity.com/paper/2005.14165/) (2020)
- [The Unreasonable Effectiveness of Deep Features as a Perceptual Metric](https://mlsanity.com/paper/1801.03924/) (2018)
- [BLIP-2: Bootstrapping Language-Image Pre-training with Frozen Image Encoders and Large Language Models](https://mlsanity.com/paper/2301.12597/) (2023)
- [Neural Discrete Representation Learning](https://mlsanity.com/paper/1711.00937/) (2017)
- [Flamingo: a Visual Language Model for Few-Shot Learning](https://mlsanity.com/paper/2204.14198/) (2022)
- [Finetuned Language Models Are Zero-Shot Learners](https://mlsanity.com/paper/2109.01652/) (2021)
- [Taming Transformers for High-Resolution Image Synthesis](https://mlsanity.com/paper/2012.09841/) (2020)
- [Self-Instruct: Aligning Language Models with Self-Generated Instructions](https://mlsanity.com/paper/2212.10560/) (2022)
- [MiniGPT-4: Enhancing Vision-Language Understanding with Advanced Large Language Models](https://mlsanity.com/paper/2304.10592/) (2023)
- [CheXpert: A Large Chest Radiograph Dataset with Uncertainty Labels and Expert Comparison](https://mlsanity.com/paper/1901.07031/) (2019)
- [OFA: Unifying Architectures, Tasks, and Modalities Through a Simple Sequence-to-Sequence Learning Framework](https://mlsanity.com/paper/2202.03052/) (2022)
- [GPT-NeoX-20B: An Open-Source Autoregressive Language Model](https://mlsanity.com/paper/2204.06745/) (2022)
- [MIMIC-CXR-JPG, a large publicly available database of labeled chest radiographs](https://mlsanity.com/paper/1901.07042/) (2019)
- [Unified-IO: A Unified Model for Vision, Language, and Multi-Modal Tasks](https://mlsanity.com/paper/2206.08916/) (2022)
- [Generating Radiology Reports via Memory-driven Transformer](https://mlsanity.com/paper/2010.16056/) (2020)
- [TorchXRayVision: A library of chest X-ray datasets and models](https://mlsanity.com/paper/2111.00595/) (2021)
- [Grounding Language Models to Images for Multimodal Inputs and Outputs](https://mlsanity.com/paper/2301.13823/) (2023)
- [RoentGen: Vision-Language Foundation Model for Chest X-ray Generation](https://mlsanity.com/paper/2211.12737/) (2022)
- [Improving the Factual Correctness of Radiology Report Generation with Semantic Rewards](https://mlsanity.com/paper/2210.12186/) (2022)
- [ERNIE-ViLG: Unified Generative Pre-training for Bidirectional Vision-Language Generation](https://mlsanity.com/paper/2112.15283/) (2021)

## Built on by (most cited first, 30 of 57)

- [A Survey of Large Language Models for Healthcare: from Data, Technology, and Applications to Accountability and Ethics](https://mlsanity.com/paper/2310.05694/) (2023)
- [Enhanced Contrastive Learning with Multi-view Longitudinal Data for Chest X-ray Report Generation](https://mlsanity.com/paper/2502.20056/) (2025)
- [GEMeX: A Large-Scale, Groundable, and Explainable Medical VQA Benchmark for Chest X-ray Diagnosis](https://mlsanity.com/paper/2411.16778/) (2024)
- [ReXrank: A Public Leaderboard for AI-Powered Radiology Report Generation](https://mlsanity.com/paper/2411.15122/) (2024)
- [Longitudinal Data and a Semantic Similarity Reward for Chest X-Ray Report Generation](https://mlsanity.com/paper/2307.09758/) (2023)
- [PeFoMed: Parameter Efficient Fine-tuning of Multimodal Large Language Models for Medical Imaging](https://mlsanity.com/paper/2401.02797/) (2024)
- [LLM-driven Multimodal Target Volume Contouring in Radiation Oncology](https://mlsanity.com/paper/2311.01908/) (2023)
- [MedVH: Towards Systematic Evaluation of Hallucination for Large Vision Language Models in the Medical Context](https://mlsanity.com/paper/2407.02730/) (2024)
- [Has Multimodal Learning Delivered Universal Intelligence in Healthcare? A Comprehensive Survey](https://mlsanity.com/paper/2408.12880/) (2024)
- [Transforming Wearable Data into Personal Health Insights using Large Language Model Agents](https://mlsanity.com/paper/2406.06464/) (2024)
- [A Survey on Trustworthiness in Foundation Models for Medical Image Analysis](https://mlsanity.com/paper/2407.15851/) (2024)
- [M4CXR: Exploring Multi-task Potentials of Multi-modal Large Language Models for Chest X-ray Interpretation](https://mlsanity.com/paper/2408.16213/) (2024)
- [Chest-Diffusion: A Light-Weight Text-to-Image Model for Report-to-CXR Generation](https://mlsanity.com/paper/2407.00752/) (2024)
- [FactCheXcker: Mitigating Measurement Hallucinations in Chest X-ray Report Generation Models](https://mlsanity.com/paper/2411.18672/) (2024)
- [MedUnifier: Unifying Vision-and-Language Pre-training on Medical Data with Vision Generation Task using Discrete Visual Representations](https://mlsanity.com/paper/2503.01019/) (2025)
- [Advancing Text-Driven Chest X-Ray Generation with Policy-Based Reinforcement Learning](https://mlsanity.com/paper/2403.06516/) (2024)
- [MedOrch: Medical Diagnosis with Tool-Augmented Reasoning Agents for Flexible Extensibility](https://mlsanity.com/paper/2506.00235/) (2025)
- [MedFILIP: Medical Fine-grained Language-Image Pre-training](https://mlsanity.com/paper/2501.10775/) (2025)
- [DDaTR: Dynamic Difference-aware Temporal Residual Network for Longitudinal Radiology Report Generation](https://mlsanity.com/paper/2505.03401/) (2025)
- [Can Medical Vision-Language Pre-training Succeed with Purely Synthetic Data?](https://mlsanity.com/paper/2410.13523/) (2024)
- [OmniGeo: Towards a Multimodal Large Language Models for Geospatial Artificial Intelligence](https://mlsanity.com/paper/2503.16326/) (2025)
- [MedTVT-R1: A Multimodal LLM Empowering Medical Reasoning and Diagnosis](https://mlsanity.com/paper/2506.18512/) (2025)
- [Trustworthy Medical Imaging with Large Language Models: A Study of Hallucinations Across Modalities](https://mlsanity.com/paper/2508.07031/) (2025)
- [A Survey of Deep Learning-based Radiology Report Generation Using Multimodal Data](https://mlsanity.com/paper/2405.12833/) (2024)
- [MedXChat: A Unified Multimodal Large Language Model Framework towards CXRs Understanding and Generation](https://mlsanity.com/paper/2312.02233/) (2023)
- [Enhancing Collaborative Semantics of Language Model-Driven Recommendations via Graph-Aware Learning](https://mlsanity.com/paper/2406.13235/) (2024)
- [XGeM: A Multi-Prompt Foundation Model for Multimodal Medical Data Generation](https://mlsanity.com/paper/2501.04614/) (2025)
- [Unleashing the Potential of Large Language Models for Text-to-Image Generation through Autoregressive Representation Alignment](https://mlsanity.com/paper/2503.07334/) (2025)
- [CheXGenBench: A Unified Benchmark For Fidelity, Privacy and Utility of Synthetic Chest Radiographs](https://mlsanity.com/paper/2505.10496/) (2025)
- [Leveraging Task-Specific Knowledge from LLM for Semi-Supervised 3D Medical Image Segmentation](https://mlsanity.com/paper/2407.05088/) (2024)

## Abstract (arXiv)

Following the impressive development of LLMs, vision-language alignment in LLMs is actively being researched to enable multimodal reasoning and visual IO. This direction of research is particularly relevant to medical imaging because medical image analysis and generation consist of reasoning based on a combination of visual features and prior knowledge. Many recent works have focused on training adapter networks that serve as an information bridge between image processing networks and LLMs; but presumably, in order to achieve maximum reasoning potential of LLMs on visual information as well, visual and language features should be allowed to interact more freely. This is especially important in the medical domain because understanding and generating medical images such as chest X-rays (CXR) require not only accurate visual and language-based reasoning but also a more intimate mapping between the two modalities. Thus, taking inspiration from previous work on the transformer and VQ-GAN combination for bidirectional image and text generation, we build upon this approach and develop a method for instruction-tuning an LLM pre-trained only on text to gain vision-language capabilities for medical images. Specifically, we leverage a pretrained LLM's existing question-answering and instruction-following abilities to teach it to understand visual inputs by instructing it to answer questions about image inputs and, symmetrically, output both text and image responses appropriate to a given query by tuning the LLM with diverse tasks that encompass image-based text-generation and text-based image-generation. We show that our model, LLM-CXR, trained in this approach shows better image-text alignment in both CXR understanding and generation tasks while being smaller in size compared to previously developed models that perform a narrower range of tasks. The code is at https://github.com/hyn2028/llm-cxr.