# CheXalign: Preference fine-tuning in chest X-ray interpretation models without human feedback

arXiv: https://arxiv.org/abs/2410.07025 · HTML: https://mlsanity.com/paper/2410.07025/

## Key facts

- Cited by 3 papers in the map (data through 14 Oct 2026).
- Placed in Medical LLM alignment, one of 10 directions in LLM alignment / RLHF / preference optimisation.
- Builds on 31 of its 67 references that are in the map.
- First posted on arXiv 9 Oct 2024.

## Placed in

- LLM alignment / RLHF / preference optimisation / [Medical LLM alignment](https://mlsanity.com/alignment/medical-llm-alignment/)

## Builds on (most cited first, 30 of 31)

- [Learning Transferable Visual Models From Natural Language Supervision](https://mlsanity.com/paper/2103.00020/) (2021)
- [Training language models to follow instructions with human feedback](https://mlsanity.com/paper/2203.02155/) (2022)
- [Proximal Policy Optimization Algorithms](https://mlsanity.com/paper/1707.06347/) (2017)
- [LLaMA: Open and Efficient Foundation Language Models](https://mlsanity.com/paper/2302.13971/) (2023)
- [Judging LLM-as-a-Judge with MT-Bench and Chatbot Arena](https://mlsanity.com/paper/2306.05685/) (2023)
- [Direct Preference Optimization: Your Language Model is Secretly a Reward Model](https://mlsanity.com/paper/2305.18290/) (2023)
- [BERTScore: Evaluating Text Generation with BERT](https://mlsanity.com/paper/1904.09675/) (2019)
- [Training a Helpful and Harmless Assistant with Reinforcement Learning from Human Feedback](https://mlsanity.com/paper/2204.05862/) (2022)
- [Sigmoid Loss for Language Image Pre-Training](https://mlsanity.com/paper/2303.15343/) (2023)
- [Learning to summarize from human feedback](https://mlsanity.com/paper/2009.01325/) (2020)
- [Fine-Tuning Language Models from Human Preferences](https://mlsanity.com/paper/1909.08593/) (2019)
- [Align before Fuse: Vision and Language Representation Learning with Momentum Distillation](https://mlsanity.com/paper/2107.07651/) (2021)
- [Scaling Laws for Reward Model Overoptimization](https://mlsanity.com/paper/2210.10760/) (2022)
- [A General Language Assistant as a Laboratory for Alignment](https://mlsanity.com/paper/2112.00861/) (2021)
- [A General Theoretical Paradigm to Understand Learning from Human Preferences](https://mlsanity.com/paper/2310.12036/) (2023)
- [EVA-CLIP: Improved Training Techniques for CLIP at Scale](https://mlsanity.com/paper/2303.15389/) (2023)
- [AlpacaFarm: A Simulation Framework for Methods that Learn from Human Feedback](https://mlsanity.com/paper/2305.14387/) (2023)
- [Aligning Large Multimodal Models with Factually Augmented RLHF](https://mlsanity.com/paper/2309.14525/) (2023)
- [RLAIF vs. RLHF: Scaling Reinforcement Learning from Human Feedback with AI Feedback](https://mlsanity.com/paper/2309.00267/) (2023)
- [Textbooks Are All You Need II: phi-1.5 technical report](https://mlsanity.com/paper/2309.05463/) (2023)
- [ORPO: Monolithic Preference Optimization without Reference Model](https://mlsanity.com/paper/2403.07691/) (2024)
- [SLAKE: A Semantically-Labeled Knowledge-Enhanced Dataset for Medical Visual Question Answering](https://mlsanity.com/paper/2102.09542/) (2021)
- [CheXbert: Combining Automatic Labelers and Expert Annotations for Accurate Radiology Report Labeling Using BERT](https://mlsanity.com/paper/2004.09167/) (2020)
- [Aligning Modalities in Vision Large Language Models via Preference Fine-tuning](https://mlsanity.com/paper/2402.11411/) (2024)
- [Disentangling Length from Quality in Direct Preference Optimization](https://mlsanity.com/paper/2403.19159/) (2024)
- [Preference Fine-Tuning of LLMs Should Leverage Suboptimal, On-Policy Data](https://mlsanity.com/paper/2404.14367/) (2024)
- [Scaling Laws for Reward Model Overoptimization in Direct Alignment Algorithms](https://mlsanity.com/paper/2406.02900/) (2024)
- [GREEN: Generative Radiology Report Evaluation and Error Notation](https://mlsanity.com/paper/2405.03595/) (2024)
- [PromptMRG: Diagnosis-Driven Prompts for Medical Report Generation](https://mlsanity.com/paper/2308.12604/) (2023)
- [A Vision-Language Foundation Model to Enhance Efficiency of Chest X-ray Interpretation](https://mlsanity.com/paper/2401.12208/) (2024)

## Built on by (most cited first, 3 of 3)

- [Enhancing Radiology Report Generation and Visual Grounding using Reinforcement Learning](https://mlsanity.com/paper/2512.10691/) (2025)
- [Universal Boosts, Specific Suppressors: Sparse Autoencoder Steering of Medical Vision-Language Models](https://mlsanity.com/paper/2605.24977/) (2026)
- [Analyzing and Improving Fine-grained Preference Optimization in Medical LVLMs](https://mlsanity.com/paper/2606.12590/) (2026)

## Abstract (arXiv)

Radiologists play a crucial role in translating medical images into actionable reports. However, the field faces staffing shortages and increasing workloads. While automated approaches using vision-language models (VLMs) show promise as assistants, they require exceptionally high accuracy. Most current VLMs in radiology rely solely on supervised fine-tuning. Meanwhile, additional preference fine-tuning in the post-training pipeline has become standard practice in the general domain. The challenge in radiology lies in the prohibitive cost of obtaining radiologist feedback at scale. To address this challenge, we propose an automated pipeline for preference feedback, focusing on chest X-ray radiology report generation (RRG). Specifically, our method leverages publicly available datasets containing pairs of images and radiologist-written reference reports with reference-based metrics, or Judges, eliminating the need for additional radiologist feedback. We investigate reward overoptimization via length exploitation in this setting and introduce a length-controlled version of the GREEN score. Our best-performing setup achieves state-of-the-art CheXbert scores on the MIMIC-CXR dataset for the RRG task while on average maintaining robust performance across six additional image perception and reasoning tasks.