# Text Over Image: Auditing Multimodal Robustness in Synthetic Medical Image Detection

arXiv: https://arxiv.org/abs/2606.25375 · HTML: https://mlsanity.com/paper/2606.25375/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 18 of its 34 references that are in the map.
- First posted on arXiv 24 Jun 2026.

## Builds on (most cited first, 18 of 18)

- [The Llama 3 Herd of Models](https://mlsanity.com/paper/2407.21783/) (2024)
- [Gemini 2.5: Pushing the Frontier with Advanced Reasoning, Multimodality, Long Context, and Next Generation Agentic Capabilities](https://mlsanity.com/paper/2507.06261/) (2025)
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- [InternVL3.5: Advancing Open-Source Multimodal Models in Versatility, Reasoning, and Efficiency](https://mlsanity.com/paper/2508.18265/) (2025)
- [OpenAI GPT-5 System Card](https://mlsanity.com/paper/2601.03267/) (2025)
- [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)
- [MedGemma Technical Report](https://mlsanity.com/paper/2507.05201/) (2025)
- [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)
- [Vision-Language Models for Medical Report Generation and Visual Question Answering: A Review](https://mlsanity.com/paper/2403.02469/) (2024)
- [FakeShield: Explainable Image Forgery Detection and Localization via Multi-modal Large Language Models](https://mlsanity.com/paper/2410.02761/) (2024)
- [Words or Vision: Do Vision-Language Models Have Blind Faith in Text?](https://mlsanity.com/paper/2503.02199/) (2025)
- [Anatomically-Controllable Medical Image Generation with Segmentation-Guided Diffusion Models](https://mlsanity.com/paper/2402.05210/) (2024)
- [VILA-M3: Enhancing Vision-Language Models with Medical Expert Knowledge](https://mlsanity.com/paper/2411.12915/) (2024)
- [Do Images Speak Louder than Words? Investigating the Effect of Textual Misinformation in VLMs](https://mlsanity.com/paper/2601.19202/) (2026)
- [Toward Medical Deepfake Detection: A Comprehensive Dataset and Novel Method](https://mlsanity.com/paper/2509.15711/) (2025)
- [Back-in-Time Diffusion: Unsupervised Detection of Medical Deepfakes](https://mlsanity.com/paper/2407.15169/) (2024)
- [A Hybrid Architecture for Multi-Stage Claim Document Understanding: Combining Vision-Language Models and Machine Learning for Real-Time Processing](https://mlsanity.com/paper/2601.01897/) (2026)

## Abstract (arXiv)

With the rapid adoption of generative AI, synthetic medical images pose growing risks, including diagnostic deception and insurance fraud. Although prior work has explored vision-language model (VLM)-based synthetic image detection, these evaluations typically consider images in isolation. In clinical practice, however, images are interpreted alongside structured records and metadata, and VLMs are increasingly deployed under joint image-record inputs. We uncover a previously underexamined multimodal vulnerability: when given both modalities, VLMs may overweight record context in authenticity judgments, such that the same image receives different predictions solely due to changes in its accompanying text. This raises concerns about robustness in real-world deployment. To systematically characterize this effect, we reformulate synthetic medical image detection as an audit of multimodal robustness at the image-record interface and introduce a paired benchmark that holds the image fixed while swapping controlled metadata variants. Across multiple imaging modalities, we evaluate diverse open-weight and frontier API VLMs and find that changing the metadata context alone can flip authenticity judgments, with accuracy on authentic images dropping by 61.1% on average under an explicit AI-origin tag. We further propose an inference-time mitigation pipeline that detects and neutralizes provenance shortcuts without model retraining, substantially outperforming direct prompt-based suppression on the affected subset. Our benchmark provides a standardized tool for assessing and improving multimodal robustness beyond image-only settings. Code and data will be released upon acceptance.