# Token-Sparse Medical Multimodal Reasoning via Dual-Stream Reinforcement Learning

arXiv: https://arxiv.org/abs/2606.31599 · HTML: https://mlsanity.com/paper/2606.31599/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in Clinical and biomedical applications, one of 17 directions in LLM reasoning.
- Builds on 43 of its 47 references that are in the map.
- First posted on arXiv 30 Jun 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/)
- Efficient LLM inference and serving / [Visual token pruning in multimodal models](https://mlsanity.com/inference/visual-token-pruning-in-multimodal-models/)

## Builds on (most cited first, 30 of 43)

- [An Image is Worth 16x16 Words: Transformers for Image Recognition at Scale](https://mlsanity.com/paper/2010.11929/) (2020)
- [Visual Instruction Tuning](https://mlsanity.com/paper/2304.08485/) (2023)
- [DeepSeek-R1: Incentivizing Reasoning Capability in LLMs via Reinforcement Learning](https://mlsanity.com/paper/2501.12948/) (2025)
- [Efficient Memory Management for Large Language Model Serving with PagedAttention](https://mlsanity.com/paper/2309.06180/) (2023)
- [Qwen2.5-VL Technical Report](https://mlsanity.com/paper/2502.13923/) (2025)
- [MMMU: A Massive Multi-discipline Multimodal Understanding and Reasoning Benchmark for Expert AGI](https://mlsanity.com/paper/2311.16502/) (2023)
- [HybridFlow: A Flexible and Efficient RLHF Framework](https://mlsanity.com/paper/2409.19256/) (2024)
- [InternVL3: Exploring Advanced Training and Test-Time Recipes for Open-Source Multimodal Models](https://mlsanity.com/paper/2504.10479/) (2025)
- [LlamaFactory: Unified Efficient Fine-Tuning of 100+ Language Models](https://mlsanity.com/paper/2403.13372/) (2024)
- [LLaVA-Med: Training a Large Language-and-Vision Assistant for Biomedicine in One Day](https://mlsanity.com/paper/2306.00890/) (2023)
- [An Image is Worth 1/2 Tokens After Layer 2: Plug-and-Play Inference Acceleration for Large Vision-Language Models](https://mlsanity.com/paper/2403.06764/) (2024)
- [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)
- [LLaVA-PruMerge: Adaptive Token Reduction for Efficient Large Multimodal Models](https://mlsanity.com/paper/2403.15388/) (2024)
- [SparseVLM: Visual Token Sparsification for Efficient Vision-Language Model Inference](https://mlsanity.com/paper/2410.04417/) (2024)
- [AdaViT: Adaptive Tokens for Efficient Vision Transformer](https://mlsanity.com/paper/2112.07658/) (2021)
- [PMC-VQA: Visual Instruction Tuning for Medical Visual Question Answering](https://mlsanity.com/paper/2305.10415/) (2023)
- [VisionZip: Longer is Better but Not Necessary in Vision Language Models](https://mlsanity.com/paper/2412.04467/) (2024)
- [PyramidDrop: Accelerating Your Large Vision-Language Models via Pyramid Visual Redundancy Reduction](https://mlsanity.com/paper/2410.17247/) (2024)
- [Pixel Reasoner: Incentivizing Pixel-Space Reasoning with Curiosity-Driven Reinforcement Learning](https://mlsanity.com/paper/2505.15966/) (2025)
- [Lingshu: A Generalist Foundation Model for Unified Multimodal Medical Understanding and Reasoning](https://mlsanity.com/paper/2506.07044/) (2025)
- [MedXpertQA: Benchmarking Expert-Level Medical Reasoning and Understanding](https://mlsanity.com/paper/2501.18362/) (2025)
- [HuatuoGPT-Vision, Towards Injecting Medical Visual Knowledge into Multimodal LLMs at Scale](https://mlsanity.com/paper/2406.19280/) (2024)
- [OmniMedVQA: A New Large-Scale Comprehensive Evaluation Benchmark for Medical LVLM](https://mlsanity.com/paper/2402.09181/) (2024)
- [MedVLM-R1: Incentivizing Medical Reasoning Capability of Vision-Language Models (VLMs) via Reinforcement Learning](https://mlsanity.com/paper/2502.19634/) (2025)
- [Med-R1: Reinforcement Learning for Generalizable Medical Reasoning in Vision-Language Models](https://mlsanity.com/paper/2503.13939/) (2025)
- [Hulu-Med: A Transparent Generalist Model towards Holistic Medical Vision-Language Understanding](https://mlsanity.com/paper/2510.08668/) (2025)
- [Self-Rewarding Vision-Language Model via Reasoning Decomposition](https://mlsanity.com/paper/2508.19652/) (2025)
- [MedTrinity-25M: A Large-scale Multimodal Dataset with Multigranular Annotations for Medicine](https://mlsanity.com/paper/2408.02900/) (2024)

## Abstract (arXiv)

Vision-language models (VLMs) combining reinforcement learning (RL) ignite remarkable progress in multimodal reasoning, yet still struggle with medical images, which typically exhibit extremely sparse visual evidence to inform clinical decision-making. We recognize that pruning visual tokens outside the grounding region greatly enhances medical reasoning. However, a united RL framework for active visual token pruning (VTP) and medical multimodal reasoning remains unestablished. Here, we propose a dual-stream RL framework, ViToS, to fulfill token pruning and question answering. ViToS trains one policy model with two task branches, where one focuses on grounding while the other conducts token-sparse reasoning after VTP. Furthermore, we solve the coupled policy learning problem by introducing the cross-feedback sequential optimization, avoiding gradient conflict and facilitating convergence of the shared policy model. Evaluated on seven medical benchmarks, our method reduces visual tokens to 77% of the original sequence length while achieving a 108.27% relative performance on Lingshu-7B and 104.16% relative performance on HuatuoGPT-Vision-7B. Overall, ViToS delivers superior performance and inference speedup, establishing an efficient paradigm for medical multimodal reasoning.