# MEDVISTAGYM: A Scalable Training Environment for Thinking with Medical Images via Tool-Integrated Reinforcement Learning

arXiv: https://arxiv.org/abs/2601.07107 · HTML: https://mlsanity.com/paper/2601.07107/

## Key facts

- Cited by 4 papers in the map (data through 14 Oct 2026).
- Placed in Clinical and biomedical applications, one of 17 directions in LLM reasoning.
- Builds on 39 of its 51 references that are in the map.
- First posted on arXiv 12 Jan 2026.

## Placed in

- LLM reasoning / [Clinical and biomedical applications](https://mlsanity.com/lr/clinical-and-biomedical-applications/)
- Multimodal LLMs / vision-language models / [Medical vision-language models](https://mlsanity.com/mllm/medical-vision-language-models/)
- LLM agents and tool use / [Medical and scientific domain agents](https://mlsanity.com/agents/medical-and-scientific-domain-agents/)
- Deep reinforcement learning methods / [RL for clinical treatment and surgery](https://mlsanity.com/deeprl/rl-for-clinical-treatment-and-surgery/)

## Builds on (most cited first, 30 of 39)

- [Qwen2.5-VL Technical Report](https://mlsanity.com/paper/2502.13923/) (2025)
- [Qwen3-VL Technical Report](https://mlsanity.com/paper/2511.21631/) (2025)
- [MMMU: A Massive Multi-discipline Multimodal Understanding and Reasoning Benchmark for Expert AGI](https://mlsanity.com/paper/2311.16502/) (2023)
- [InternVL3: Exploring Advanced Training and Test-Time Recipes for Open-Source Multimodal Models](https://mlsanity.com/paper/2504.10479/) (2025)
- [LLaVA-Med: Training a Large Language-and-Vision Assistant for Biomedicine in One Day](https://mlsanity.com/paper/2306.00890/) (2023)
- [Vision-R1: Incentivizing Reasoning Capability in Multimodal Large Language Models](https://mlsanity.com/paper/2503.06749/) (2025)
- [Visual-RFT: Visual Reinforcement Fine-Tuning](https://mlsanity.com/paper/2503.01785/) (2025)
- [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)
- [DeepEyes: Incentivizing "Thinking with Images" via Reinforcement Learning](https://mlsanity.com/paper/2505.14362/) (2025)
- [RAGEN: Understanding Self-Evolution in LLM Agents via Multi-Turn Reinforcement Learning](https://mlsanity.com/paper/2504.20073/) (2025)
- [PMC-VQA: Visual Instruction Tuning for Medical Visual Question Answering](https://mlsanity.com/paper/2305.10415/) (2023)
- [Pixel Reasoner: Incentivizing Pixel-Space Reasoning with Curiosity-Driven Reinforcement Learning](https://mlsanity.com/paper/2505.15966/) (2025)
- [HuatuoGPT-o1, Towards Medical Complex Reasoning with LLMs](https://mlsanity.com/paper/2412.18925/) (2024)
- [Lingshu: A Generalist Foundation Model for Unified Multimodal Medical Understanding and Reasoning](https://mlsanity.com/paper/2506.07044/) (2025)
- [HuatuoGPT-Vision, Towards Injecting Medical Visual Knowledge into Multimodal LLMs at Scale](https://mlsanity.com/paper/2406.19280/) (2024)
- [Thinking with Images for Multimodal Reasoning: Foundations, Methods, and Future Frontiers](https://mlsanity.com/paper/2506.23918/) (2025)
- [GRIT: Teaching MLLMs to Think with Images](https://mlsanity.com/paper/2505.15879/) (2025)
- [Mini-o3: Scaling Up Reasoning Patterns and Interaction Turns for Visual Search](https://mlsanity.com/paper/2509.07969/) (2025)
- [MMedAgent: Learning to Use Medical Tools with Multi-modal Agent](https://mlsanity.com/paper/2407.02483/) (2024)
- [Adaptive Chain-of-Focus Reasoning via Dynamic Visual Search and Zooming for Efficient VLMs](https://mlsanity.com/paper/2505.15436/) (2025)
- [VerlTool: Towards Holistic Agentic Reinforcement Learning with Tool Use](https://mlsanity.com/paper/2509.01055/) (2025)
- [MMed-RAG: Versatile Multimodal RAG System for Medical Vision Language Models](https://mlsanity.com/paper/2410.13085/) (2024)
- [A Vision-Language Foundation Model to Enhance Efficiency of Chest X-ray Interpretation](https://mlsanity.com/paper/2401.12208/) (2024)
- [MedAgent-Pro: Towards Evidence-based Multi-modal Medical Diagnosis via Reasoning Agentic Workflow](https://mlsanity.com/paper/2503.18968/) (2025)
- [AgentGym-RL: Training LLM Agents for Long-Horizon Decision Making through Multi-Turn Reinforcement Learning](https://mlsanity.com/paper/2509.08755/) (2025)
- [MedRAX: Medical Reasoning Agent for Chest X-ray](https://mlsanity.com/paper/2502.02673/) (2025)
- [Collaborative Gym: A Framework for Enabling and Evaluating Human-Agent Collaboration](https://mlsanity.com/paper/2412.15701/) (2024)
- [VAGEN: Reinforcing World Model Reasoning for Multi-Turn VLM Agents](https://mlsanity.com/paper/2510.16907/) (2025)
- [VILA-M3: Enhancing Vision-Language Models with Medical Expert Knowledge](https://mlsanity.com/paper/2411.12915/) (2024)

## Built on by (most cited first, 4 of 4)

- [Meissa: Multi-modal Medical Agentic Intelligence](https://mlsanity.com/paper/2603.09018/) (2026)
- [MedLVR: Latent Visual Reasoning for Reliable Medical Visual Question Answering](https://mlsanity.com/paper/2604.09757/) (2026)
- [MIRA: Medical Image Reflection for Agentic Diagnosis](https://mlsanity.com/paper/2608.10827/) (2026)
- [Volumetric Radiology AI in the Era of Multimodal Large Language Models](https://mlsanity.com/paper/2608.20549/) (2026)

## Abstract (arXiv)

Vision language models (VLMs) achieve strong performance on general image understanding but struggle to think with medical images, especially when performing multi-step reasoning through iterative visual interaction. Medical VLMs often rely on static visual embeddings and single-pass inference, preventing models from re-examining, verifying, or refining visual evidence during reasoning. While tool-integrated reasoning offers a promising path forward, open-source VLMs lack the training infrastructure to learn effective tool selection, invocation, and coordination in multi-modal medical reasoning. We introduce MedVistaGym, a scalable and interactive training environment that incentivizes tool-integrated visual reasoning for medical image analysis. MedVistaGym equips VLMs to determine when and which tools to invoke, localize task-relevant image regions, and integrate single or multiple sub-image evidence into interleaved multimodal reasoning within a unified, executable interface for agentic training. Using MedVistaGym, we train MedVistaGym-R1 to interleave tool use with agentic reasoning through trajectory sampling and end-to-end reinforcement learning. Across six medical VQA benchmarks, MedVistaGym-R1-8B exceeds comparably sized tool-augmented baselines by 19.10% to 24.21%, demonstrating that structured agentic training--not tool access alone--unlocks effective tool-integrated reasoning for medical image analysis.