# ClinCoT: Clinical-Aware Visual Chain-of-Thought for Medical Vision Language Models

arXiv: https://arxiv.org/abs/2603.01124 · HTML: https://mlsanity.com/paper/2603.01124/

## Key facts

- Cited by 1 papers in the map (data through 14 Oct 2026).
- Placed in Clinical and biomedical applications, one of 17 directions in LLM reasoning.
- Builds on 16 of its 36 references that are in the map.
- First posted on arXiv 1 Mar 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/)

## Builds on (most cited first, 16 of 16)

- [Proximal Policy Optimization Algorithms](https://mlsanity.com/paper/1707.06347/) (2017)
- [LoRA: Low-Rank Adaptation of Large Language Models](https://mlsanity.com/paper/2106.09685/) (2021)
- [BioMistral: A Collection of Open-Source Pretrained Large Language Models for Medical Domains](https://mlsanity.com/paper/2402.10373/) (2024)
- [Lingshu: A Generalist Foundation Model for Unified Multimodal Medical Understanding and Reasoning](https://mlsanity.com/paper/2506.07044/) (2025)
- [Aligning Modalities in Vision Large Language Models via Preference Fine-tuning](https://mlsanity.com/paper/2402.11411/) (2024)
- [RLAIF-V: Open-Source AI Feedback Leads to Super GPT-4V Trustworthiness](https://mlsanity.com/paper/2405.17220/) (2024)
- [Direct Preference Optimization with an Offset](https://mlsanity.com/paper/2402.10571/) (2024)
- [Med42-v2: A Suite of Clinical LLMs](https://mlsanity.com/paper/2408.06142/) (2024)
- [Enhancing Visual-Language Modality Alignment in Large Vision Language Models via Self-Improvement](https://mlsanity.com/paper/2405.15973/) (2024)
- [Zero-Shot ECG Classification with Multimodal Learning and Test-time Clinical Knowledge Enhancement](https://mlsanity.com/paper/2403.06659/) (2024)
- [Detecting and Evaluating Medical Hallucinations in Large Vision Language Models](https://mlsanity.com/paper/2406.10185/) (2024)
- [CoMT: Chain-of-Medical-Thought Reduces Hallucination in Medical Report Generation](https://mlsanity.com/paper/2406.11451/) (2024)
- [STLLaVA-Med: Self-Training Large Language and Vision Assistant for Medical Question-Answering](https://mlsanity.com/paper/2406.19973/) (2024)
- [MMedPO: Aligning Medical Vision-Language Models with Clinical-Aware Multimodal Preference Optimization](https://mlsanity.com/paper/2412.06141/) (2024)
- [Fine-Grained Verifiers: Preference Modeling as Next-token Prediction in Vision-Language Alignment](https://mlsanity.com/paper/2410.14148/) (2024)
- [SSS: Semi-Supervised SAM-2 with Efficient Prompting for Medical Imaging Segmentation](https://mlsanity.com/paper/2506.08949/) (2025)

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

- [Towards Enhancing 3D Spatial Reasoning in Medical Multimodal Large Language Models](https://mlsanity.com/paper/2607.13860/) (2026)

## Abstract (arXiv)

Medical Vision-Language Models have shown promising potential in clinical decision support, yet they remain prone to factual hallucinations due to insufficient grounding in localized pathological evidence. Existing medical alignment methods primarily operate at the response level through preference optimization, improving output correctness but leaving intermediate reasoning weakly connected to visual regions. Although chain-of-thought (CoT) enhances multimodal reasoning, it remains largely text-centric, limiting effective integration of clinical visual cues. To address this gap, we propose ClinCoT, a clinical-aware visual chain-of-thought framework that transforms preference optimization from response-level correction to visual-driven reasoning. We introduce an automatic data generation pipeline that constructs clinically grounded preference pairs through reasoning with hypotheses-driven region proposals. Multiple Med-LLMs evaluators rank and assign scores to each response, and these rankings serve as supervision to train the target model. We further introduce a scoring-based margin-aware optimization strategy that incorporates both preference ranking and score difference to refine region-level reasoning trajectories. To maintain alignment as the model's policy evolves during training, we adopt an iterative learning scheme that dynamically regenerates preference data. Extensive experiments on three medical VQA and report generation benchmarks demonstrate that ClinCoT consistently improves factual grounding and achieves superior performance compared with existing preference-based alignment methods.