# HSCR: Hierarchical Self-Contrastive Rewarding for Aligning Medical Vision Language Models

arXiv: https://arxiv.org/abs/2506.00805 · HTML: https://mlsanity.com/paper/2506.00805/

## Key facts

- Cited by 1 papers in the map (data through 14 Oct 2026).
- Placed in Medical vision-language models, one of 16 directions in Multimodal LLMs / vision-language models.
- Builds on 35 of its 61 references that are in the map.
- First posted on arXiv 1 Jun 2025.

## Placed in

- Multimodal LLMs / vision-language models / [Medical vision-language models](https://mlsanity.com/mllm/medical-vision-language-models/)
- LLM alignment / RLHF / preference optimisation / [Diffusion and multimodal model alignment](https://mlsanity.com/alignment/diffusion-and-multimodal-model-alignment/)

## Builds on (most cited first, 30 of 35)

- [Attention Is All You Need](https://mlsanity.com/paper/1706.03762/) (2017)
- [Learning Transferable Visual Models From Natural Language Supervision](https://mlsanity.com/paper/2103.00020/) (2021)
- [An Image is Worth 16x16 Words: Transformers for Image Recognition at Scale](https://mlsanity.com/paper/2010.11929/) (2020)
- [LoRA: Low-Rank Adaptation of Large Language Models](https://mlsanity.com/paper/2106.09685/) (2021)
- [Direct Preference Optimization: Your Language Model is Secretly a Reward Model](https://mlsanity.com/paper/2305.18290/) (2023)
- [Improved Baselines with Visual Instruction Tuning](https://mlsanity.com/paper/2310.03744/) (2023)
- [Deep reinforcement learning from human preferences](https://mlsanity.com/paper/1706.03741/) (2017)
- [Training a Helpful and Harmless Assistant with Reinforcement Learning from Human Feedback](https://mlsanity.com/paper/2204.05862/) (2022)
- [Gaussian Error Linear Units (GELUs)](https://mlsanity.com/paper/1606.08415/) (2016)
- [LLaVA-Med: Training a Large Language-and-Vision Assistant for Biomedicine in One Day](https://mlsanity.com/paper/2306.00890/) (2023)
- [A General Theoretical Paradigm to Understand Learning from Human Preferences](https://mlsanity.com/paper/2310.12036/) (2023)
- [Aligning Large Multimodal Models with Factually Augmented RLHF](https://mlsanity.com/paper/2309.14525/) (2023)
- [Mitigating Object Hallucinations in Large Vision-Language Models through Visual Contrastive Decoding](https://mlsanity.com/paper/2311.16922/) (2023)
- [PathVQA: 30000+ Questions for Medical Visual Question Answering](https://mlsanity.com/paper/2003.10286/) (2020)
- [SLAKE: A Semantically-Labeled Knowledge-Enhanced Dataset for Medical Visual Question Answering](https://mlsanity.com/paper/2102.09542/) (2021)
- [RLHF-V: Towards Trustworthy MLLMs via Behavior Alignment from Fine-grained Correctional Human Feedback](https://mlsanity.com/paper/2312.00849/) (2023)
- [Med-Flamingo: a Multimodal Medical Few-shot Learner](https://mlsanity.com/paper/2307.15189/) (2023)
- [AMBER: An LLM-free Multi-dimensional Benchmark for MLLMs Hallucination Evaluation](https://mlsanity.com/paper/2311.07397/) (2023)
- [Preference Ranking Optimization for Human Alignment](https://mlsanity.com/paper/2306.17492/) (2023)
- [Smaug: Fixing Failure Modes of Preference Optimisation with DPO-Positive](https://mlsanity.com/paper/2402.13228/) (2024)
- [Capabilities of Gemini Models in Medicine](https://mlsanity.com/paper/2404.18416/) (2024)
- [Aligning Modalities in Vision Large Language Models via Preference Fine-tuning](https://mlsanity.com/paper/2402.11411/) (2024)
- [Beyond One-Preference-Fits-All Alignment: Multi-Objective Direct Preference Optimization](https://mlsanity.com/paper/2310.03708/) (2023)
- [LiPO: Listwise Preference Optimization through Learning-to-Rank](https://mlsanity.com/paper/2402.01878/) (2024)
- [Strengthening Multimodal Large Language Model with Bootstrapped Preference Optimization](https://mlsanity.com/paper/2403.08730/) (2024)
- [Open-Ended Medical Visual Question Answering Through Prefix Tuning of Language Models](https://mlsanity.com/paper/2303.05977/) (2023)
- [Iterative Data Smoothing: Mitigating Reward Overfitting and Overoptimization in RLHF](https://mlsanity.com/paper/2401.16335/) (2024)
- [MedCoT: Medical Chain of Thought via Hierarchical Expert](https://mlsanity.com/paper/2412.13736/) (2024)
- [Q2ATransformer: Improving Medical VQA via an Answer Querying Decoder](https://mlsanity.com/paper/2304.01611/) (2023)
- [Automated Multi-level Preference for MLLMs](https://mlsanity.com/paper/2405.11165/) (2024)

## Built on by (most cited first, 1 of 1)

- [Knowing or Guessing? Robust Medical Visual Question Answering via Joint Consistency and Contrastive Learning](https://mlsanity.com/paper/2508.18687/) (2025)

## Abstract (arXiv)

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.