# Inference-Time Agentic Decision Rules Beat Longer Evolving Search for Multi-Image Medical Reasoning

arXiv: https://arxiv.org/abs/2607.27564 · HTML: https://mlsanity.com/paper/2607.27564/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in Medical and scientific domain agents, one of 16 directions in LLM agents and tool use.
- Builds on 19 of its 33 references that are in the map.
- First posted on arXiv 30 Jul 2026.

## Placed in

- LLM agents and tool use / [Medical and scientific domain agents](https://mlsanity.com/agents/medical-and-scientific-domain-agents/)

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

- [InstructBLIP: Towards General-purpose Vision-Language Models with Instruction Tuning](https://mlsanity.com/paper/2305.06500/) (2023)
- [Qwen-VL: A Versatile Vision-Language Model for Understanding, Localization, Text Reading, and Beyond](https://mlsanity.com/paper/2308.12966/) (2023)
- [LLaVA-Med: Training a Large Language-and-Vision Assistant for Biomedicine in One Day](https://mlsanity.com/paper/2306.00890/) (2023)
- [Large Language Models Are Human-Level Prompt Engineers](https://mlsanity.com/paper/2211.01910/) (2022)
- [SEED-Bench: Benchmarking Multimodal LLMs with Generative Comprehension](https://mlsanity.com/paper/2307.16125/) (2023)
- [Automatic Prompt Optimization with "Gradient Descent" and Beam Search](https://mlsanity.com/paper/2305.03495/) (2023)
- [Promptbreeder: Self-Referential Self-Improvement Via Prompt Evolution](https://mlsanity.com/paper/2309.16797/) (2023)
- [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)
- [Med-Flamingo: a Multimodal Medical Few-shot Learner](https://mlsanity.com/paper/2307.15189/) (2023)
- [RLPrompt: Optimizing Discrete Text Prompts with Reinforcement Learning](https://mlsanity.com/paper/2205.12548/) (2022)
- [BiomedGPT: A Generalist Vision-Language Foundation Model for Diverse Biomedical Tasks](https://mlsanity.com/paper/2305.17100/) (2023)
- [OmniMedVQA: A New Large-Scale Comprehensive Evaluation Benchmark for Medical LVLM](https://mlsanity.com/paper/2402.09181/) (2024)
- [ShinkaEvolve: Towards Open-Ended And Sample-Efficient Program Evolution](https://mlsanity.com/paper/2509.19349/) (2025)
- [HealthGPT: A Medical Large Vision-Language Model for Unifying Comprehension and Generation via Heterogeneous Knowledge Adaptation](https://mlsanity.com/paper/2502.09838/) (2025)
- [A Vision-Language Foundation Model to Enhance Efficiency of Chest X-ray Interpretation](https://mlsanity.com/paper/2401.12208/) (2024)
- [Many-Shot In-Context Learning in Multimodal Foundation Models](https://mlsanity.com/paper/2405.09798/) (2024)
- [MedFrameQA: A Multi-Image Medical VQA Benchmark for Clinical Reasoning](https://mlsanity.com/paper/2505.16964/) (2025)
- [Medical Adaptation of Large Language and Vision-Language Models: Are We Making Progress?](https://mlsanity.com/paper/2411.04118/) (2024)

## Abstract (arXiv)

Multi-image medical VQA is not merely a prompt-length problem; it is a fundamental challenge of agentic decision-making. Medical vision-language agents must aggregate evidence across ordered images, remain robust to answer-order perturbations, and avoid overfitting to noisy search-time feedback. We study MedFrameQA through a controlled comparison of five inference-time agentic strategies, optimized using the same high-budget ShinkaEvolve configuration and evaluated on a reproducible internal frozen split (1,331 evolution, 665 holdout, 855 final test). Across five independent repeated runs, the strongest method emerges as the simplest robust aggregator: the order-vote policy achieves 57.89 ± 0.65% final-test accuracy, significantly outperforming the fixed baseline (52.73 ± 0.42%) and the more complex, albeit brittle, order-rerank variant (55.79 ± 0.43%). Paired bootstrap analysis confirms these significant gains. Extending the evolutionary search budget from 50 to 100 generations yields no generalization benefit: while holdout performance marginally increases, final-test accuracy drops from 57.89% to 56.02%. Our findings suggest that for multi-image medical reasoning, defining the correct agentic decision rule is substantially more impactful than expanding the optimization search budget.