Multimodal large language models (MLLMs) have shown great potential in medical applications, yet existing benchmarks inadequately capture real-world clinical complexity. We introduce MEDSYN, a multilingual, multimodal benchmark of highly complex clinical cases with up to 7 distinct visual clinical evidence (CE) types per case. Mirroring clinical workflow, we evaluate 18 MLLMs on differential diagnosis (DDx) generation and final diagnosis (FDx) selection. While frontier models often match or even outperform human experts on DDx generation, all MLLMs exhibit a much larger DDx–FDx performance gap compared to expert clinicians, indicating a failure mode in synthesis of heterogeneous CE types. Ablations attribute this failure to (i) overreliance on less discriminative textual CE (e.g., medical history) and (ii) a cross-modal CE utilization gap. We introduce Evidence Sensitivity to quantify the latter and show that a smaller gap correlates with higher diagnostic accuracy. Finally, we demonstrate how it can be used to guide interventions to improve model performance. https://github.com/jianing-lab/MEDSYN.

Stochastic sampling strategies are widely adopted in large language models (LLMs) to balance output coherence and diversity. These heuristics are often inherited in Multimodal LLMs (MLLMs) without task-specific justification. However, we contend that stochastic decoding can be suboptimal for Visual Question Answering (VQA). VQA is a closed-ended task with head-heavy answer distributions where uncertainty is usually epistemic, arising from missing or ambiguous visual evidence rather than plausible continuations. In this work, we provide a theoretical formalization of the relationship between model calibration and predictive accuracy, and derive the sufficient conditions for greedy decoding optimality. Extensive experiments provide empirical evidence for the superiority of greedy decoding over stochastic sampling across multiple benchmarks. Furthermore, we propose Greedy Decoding for Reasoning Models, which outperforms both stochastic sampling and standard greedy decoding in multimodal reasoning scenarios. Overall, our results caution against naively inheriting LLMs decoding heuristics in MLLMs and demonstrate that greedy decoding can be an efficient yet strong default for VQA.

Large Language Models (LLMs) show great potential as clinical agents, yet existing benchmarks reduce clinical workflows to static predictions or unconstrained Markov Decision Processes (MDPs) with coarse action sets. To address this, we introduce GPAgentBench-2K, the first Constrained MDP (CMDP) LLM-agent benchmark for primary-care clinical decision-making, constructed from expert-validated records of real-world GP encounters. Our environment models a full spectrum of six foundational clinical actions, imposes a topological workflow prior over the action space, and operationalizes safety-informed abstention as a first-class outcome. Evaluating 16 state-of-the-art LLMs reveals a significant performance degradation as the action space scales. Crucially, we uncover a clinical quality-safety gap: even frontier models with the highest diagnosis accuracy violate safety constraints in over half of high-risk cases. Finally, we establish a reference point using Constrained Group Relative Policy Optimization (C-GRPO), and show that while explicitly modeling constraints improves performance over unconstrained RL methods, it remains far from clinically acceptable safety.

We study object hallucination in Multimodal Large Language Models (MLLMs) and improve visual contrastive decoding (VCD) by constructing an object-aligned auxiliary view. We leverage object-centric attention in self-supervised Vision Transformers. In particular, we remove the most salient visual evidence to construct an auxiliary view that disrupts unsupported tokens and produces a stronger contrast signal. Our method is prompt-agnostic, model-agnostic, and can be seamlessly plugged into the existing VCD pipeline with little computation overhead, i.e., a single cacheable forward pass. Empirically, our method demonstrates consistent gains on two popular object hallucination benchmarks across two MLLMs.