# When Models Learn to Ask Why: Adaptive Causal Reasoning for Trustworthy Medical Vision-Language Models

arXiv: https://arxiv.org/abs/2603.23085 · HTML: https://mlsanity.com/paper/2603.23085/

## Key facts

- Cited by 6 papers in the map (data through 14 Oct 2026).
- Placed in Clinical and biomedical applications, one of 17 directions in LLM reasoning.
- Builds on 58 of its 109 references that are in the map.
- First posted on arXiv 24 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, 30 of 58)

- [GPT-4 Technical Report](https://mlsanity.com/paper/2303.08774/) (2023)
- [Proximal Policy Optimization Algorithms](https://mlsanity.com/paper/1707.06347/) (2017)
- [DeepSeekMath: Pushing the Limits of Mathematical Reasoning in Open Language Models](https://mlsanity.com/paper/2402.03300/) (2024)
- [DeepSeek-R1: Incentivizing Reasoning Capability in LLMs via Reinforcement Learning](https://mlsanity.com/paper/2501.12948/) (2025)
- [Self-Consistency Improves Chain of Thought Reasoning in Language Models](https://mlsanity.com/paper/2203.11171/) (2022)
- [Qwen2.5-VL Technical Report](https://mlsanity.com/paper/2502.13923/) (2025)
- [GPT-4o System Card](https://mlsanity.com/paper/2410.21276/) (2024)
- [Improved Baselines with Visual Instruction Tuning](https://mlsanity.com/paper/2310.03744/) (2023)
- [Constitutional AI: Harmlessness from AI Feedback](https://mlsanity.com/paper/2212.08073/) (2022)
- [Fine-Tuning Language Models from Human Preferences](https://mlsanity.com/paper/1909.08593/) (2019)
- [Decoupled Weight Decay Regularization](https://mlsanity.com/paper/1711.05101/) (2017)
- [Expanding Performance Boundaries of Open-Source Multimodal Models with Model, Data, and Test-Time Scaling](https://mlsanity.com/paper/2412.05271/) (2024)
- [Training Language Models to Self-Correct via Reinforcement Learning](https://mlsanity.com/paper/2409.12917/) (2024)
- [PMC-VQA: Visual Instruction Tuning for Medical Visual Question Answering](https://mlsanity.com/paper/2305.10415/) (2023)
- [Chain-of-Thought Reasoning Without Prompting](https://mlsanity.com/paper/2402.10200/) (2024)
- [HuatuoGPT-Vision, Towards Injecting Medical Visual Knowledge into Multimodal LLMs at Scale](https://mlsanity.com/paper/2406.19280/) (2024)
- [Towards Generalist Foundation Model for Radiology by Leveraging Web-scale 2D&3D Medical Data](https://mlsanity.com/paper/2308.02463/) (2023)
- [FutureSightDrive: Thinking Visually with Spatio-Temporal CoT for Autonomous Driving](https://mlsanity.com/paper/2505.17685/) (2025)
- [Improve Vision Language Model Chain-of-thought Reasoning](https://mlsanity.com/paper/2410.16198/) (2024)
- [Hulu-Med: A Transparent Generalist Model towards Holistic Medical Vision-Language Understanding](https://mlsanity.com/paper/2510.08668/) (2025)
- [JanusVLN: Decoupling Semantics and Spatiality with Dual Implicit Memory for Vision-Language Navigation](https://mlsanity.com/paper/2509.22548/) (2025)
- [Hume: Introducing System-2 Thinking in Visual-Language-Action Model](https://mlsanity.com/paper/2505.21432/) (2025)
- [SA-Med2D-20M Dataset: Segment Anything in 2D Medical Imaging with 20 Million masks](https://mlsanity.com/paper/2311.11969/) (2023)
- [Toward Understanding Why Adam Converges Faster Than SGD for Transformers](https://mlsanity.com/paper/2306.00204/) (2023)
- [The Choice of Divergence: A Neglected Key to Mitigating Diversity Collapse in Reinforcement Learning with Verifiable Reward](https://mlsanity.com/paper/2509.07430/) (2025)
- [GSCo: Towards Generalizable AI in Medicine via Generalist-Specialist Collaboration](https://mlsanity.com/paper/2404.15127/) (2024)
- [Your Group-Relative Advantage Is Biased](https://mlsanity.com/paper/2601.08521/) (2026)
- [Exploring Efficient Open-Vocabulary Segmentation in the Remote Sensing](https://mlsanity.com/paper/2509.12040/) (2025)
- [What Is The Best 3D Scene Representation for Robotics? From Geometric to Foundation Models](https://mlsanity.com/paper/2512.03422/) (2025)
- [Advancing Medical Imaging with Language Models: A Journey from N-grams to ChatGPT](https://mlsanity.com/paper/2304.04920/) (2023)

## Built on by (most cited first, 6 of 6)

- [Beyond Accuracy: Measuring Bias Acknowledgment in Chain-of-Thought Reasoning for Responsible AI Evaluation](https://mlsanity.com/paper/2606.15127/) (2026)
- [Driver-WM: A Driver-Centric Traffic-Conditioned Latent World Model for In-Cabin Dynamics Rollout](https://mlsanity.com/paper/2605.05092/) (2026)
- [What's Missing in Screen-to-Action? Towards a UI-in-the-Loop Paradigm for Multimodal GUI Reasoning](https://mlsanity.com/paper/2604.06995/) (2026)
- [Dynamic Model Merging Made Slim](https://mlsanity.com/paper/2605.18904/) (2026)
- [TopoAgent: An Agentic Framework for Automated Topology Learning in Medical Imaging](https://mlsanity.com/paper/2606.29763/) (2026)
- [SquidAgent: Parallelize Wisely, Coordinate Efficiently](https://mlsanity.com/paper/2610.08647/) (2026)

## Abstract (arXiv)

Vision-Language Models (VLMs) have enabled interpretable medical diagnosis by integrating visual perception with linguistic reasoning. Yet, existing medical chain-of-thought (CoT) models lack explicit mechanisms to represent and enforce causal reasoning, leaving them vulnerable to spurious correlations and limiting their clinical reliability. We pinpoint three core challenges in medical CoT reasoning: how to adaptively trigger causal correction, construct high-quality causal-spurious contrastive samples, and maintain causal consistency across reasoning trajectories. To address these challenges, we propose MedCausalX, an end-to-end framework explicitly models causal reasoning chains in medical VLMs. We first introduce the CRMed dataset providing fine-grained anatomical annotations, structured causal reasoning chains, and counterfactual variants that guide the learning of causal relationships beyond superficial correlations. Building upon CRMed, MedCausalX employs a two-stage adaptive reflection architecture equipped with langlecausalrangle and langleverifyrangle tokens, enabling the model to autonomously determine when and how to perform causal analysis and verification. Finally, a trajectory-level causal correction objective optimized through error-attributed reinforcement learning refines the reasoning chain, allowing the model to distinguish genuine causal dependencies from shortcut associations. Extensive experiments on multiple benchmarks show that MedCausalX consistently outperforms state-of-the-art methods, improving diagnostic consistency by +5.4 points, reducing hallucination by over 10 points, and attaining top spatial grounding IoU, thereby setting a new standard for causally grounded medical reasoning. The code and dataset are available at https://github.com/zhcz328/MedCausalX.