Separating Capability from Confidence: Grounded Dual-State Calibration for GRPO-Trained Medical Vision-Language Models

Medical vision-language models (VLMs) require confidence that reflects both answer correctness and patient-specific visual evidence. Recent GRPO-based methods optimize verbalized confidence together with answer generation. However, this joint optimization may interfere with answer learning and drive confidence toward near-binary values. Verbalized confidence also provides no explicit assessment of visual support. We therefore separate capability learning from confidence estimation and propose DualRead. DualRead builds on the insight that reliability can be read from the actor's internal states at critical moments in the answering process. It freezes the GRPO-trained actor and combines pre-answer solvability with a post-answer assessment of the generated answer and its visual support. To further assess whether confidence reflects visual grounding, we introduce Counterfactual Confidence Grounding AUC (CCG-AUC). It measures whether confidence decreases when real-image substitution changes the actor from correct to incorrect. Across two VLM backbones and both in- and out-of-distribution medical VQA benchmarks, DualRead improves correctness discrimination and calibration over verbalized confidence while preserving answer accuracy. CCG-AUC reveals whether confidence responds to answer-relevant visual evidence rather than primarily to non-visual cues.