# Bi-MCQ: Reformulating Vision-Language Alignment for Negation Understanding

arXiv: https://arxiv.org/abs/2601.22696 · HTML: https://mlsanity.com/paper/2601.22696/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in Medical vision-language models, one of 16 directions in Multimodal LLMs / vision-language models.
- Builds on 19 of its 25 references that are in the map.
- First posted on arXiv 30 Jan 2026.

## Placed in

- Multimodal LLMs / vision-language models / [Medical vision-language models](https://mlsanity.com/mllm/medical-vision-language-models/)

## Builds on (most cited first, 19 of 19)

- [Deep Residual Learning for Image Recognition](https://mlsanity.com/paper/1512.03385/) (2015)
- [Adam: A Method for Stochastic Optimization](https://mlsanity.com/paper/1412.6980/) (2014)
- [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)
- [Scaling Up Visual and Vision-Language Representation Learning With Noisy Text Supervision](https://mlsanity.com/paper/2102.05918/) (2021)
- [BioBERT: a pre-trained biomedical language representation model for biomedical text mining](https://mlsanity.com/paper/1901.08746/) (2019)
- [CheXpert: A Large Chest Radiograph Dataset with Uncertainty Labels and Expert Comparison](https://mlsanity.com/paper/1901.07031/) (2019)
- [Domain-Specific Language Model Pretraining for Biomedical Natural Language Processing](https://mlsanity.com/paper/2007.15779/) (2020)
- [Publicly Available Clinical BERT Embeddings](https://mlsanity.com/paper/1904.03323/) (2019)
- [ChestX-ray8: Hospital-scale Chest X-ray Database and Benchmarks on Weakly-Supervised Classification and Localization of Common Thorax Diseases](https://mlsanity.com/paper/1705.02315/) (2017)
- [When and why vision-language models behave like bags-of-words, and what to do about it?](https://mlsanity.com/paper/2210.01936/) (2022)
- [MIMIC-CXR-JPG, a large publicly available database of labeled chest radiographs](https://mlsanity.com/paper/1901.07042/) (2019)
- [MedCLIP: Contrastive Learning from Unpaired Medical Images and Text](https://mlsanity.com/paper/2210.10163/) (2022)
- [PadChest: A large chest x-ray image dataset with multi-label annotated reports](https://mlsanity.com/paper/1901.07441/) (2019)
- [CREPE: Can Vision-Language Foundation Models Reason Compositionally?](https://mlsanity.com/paper/2212.07796/) (2022)
- [MedKLIP: Medical Knowledge Enhanced Language-Image Pre-Training in Radiology](https://mlsanity.com/paper/2301.02228/) (2023)
- [Knowledge-enhanced Visual-Language Pre-training on Chest Radiology Images](https://mlsanity.com/paper/2302.14042/) (2023)
- [Vision-Language Models Do Not Understand Negation](https://mlsanity.com/paper/2501.09425/) (2025)
- [CARZero: Cross-Attention Alignment for Radiology Zero-Shot Classification](https://mlsanity.com/paper/2402.17417/) (2024)

## Abstract (arXiv)

Recent vision-language models (VLMs) achieve strong zero-shot performance via large-scale image-text pretraining and have been widely adopted in medical image analysis. However, existing VLMs remain notably weak at understanding negated clinical statements, largely due to contrastive alignment objectives that treat negation as a minor linguistic variation rather than a meaning-inverting operator. In multi-label settings, prompt-based InfoNCE fine-tuning further reinforces easy-positive image-prompt alignments, limiting effective learning of disease absence. To overcome these limitations, we reformulate vision-language alignment as a conditional semantic comparison problem, which is instantiated through a bi-directional multiple-choice learning framework(Bi-MCQ). By jointly training Image-to-Text and Text-to-Image MCQ tasks with affirmative, negative, and mixed prompts, our method implements fine-tuning as conditional semantic comparison instead of global similarity maximization. We further introduce direction-specific Cross-Attention fusion modules to address asymmetric cues required by bi-directional reasoning and reduce alignment interference. Experiments on ChestXray14, Open-I, CheXpert, and PadChest show that Bi-MCQ improves negation understanding by up to 0.47 AUC over the zero-shot performance of the state-of-the-art CARZero model, while achieving up to a 0.08 absolute gain on positive-negative combined (PNC) evaluation. Additionally, Bi-MCQ reduces the affirmative-negative AUC gap by an average of 0.12 compared to InfoNCE-based fine-tuning, demonstrating that objective reformulation can substantially enhance negation understanding in medical VLMs.