Medical Image Quality Assessment (IQA) serves as a critical safety gate for clinical AI, yet existing approaches rely on scalar metrics that fail to capture the descriptive, expert-like evaluation process central to clinical practice. We introduce MedQ-Bench, a comprehensive benchmark for language-based medical IQA evaluation with MLLMs, establishing a perception–description paradigm across 5 imaging modalities and over 40 quality attributes. The benchmark comprises two complementary tasks: MedQ-Perception probes low-level visual attribute discrimination via 2,600 expert-annotated perceptual queries; MedQ-Description covers both no-reference and comparison description sub-tasks with 708 expert-annotated samples, evaluated through a four-dimensional judging protocol. Comprehensive evaluation of 23 state-of-the-art MLLMs reveals that current models exhibit only preliminary and unstable capabilities, and highlights the urgent need for targeted optimization of MLLMs in medical IQA. Project Dataset: https://github.com/liujiyaoFDU/MedQ-Bench

Reinforcement Learning with Verifiable Rewards (RLVR) has significantly advanced reasoning capabilities in Large Language Models. However, adapting RLVR to multimodal domains suffers from a critical perception-reasoning decoupling. Existing paradigms, driven by text-centric outcome rewards, reasoning in language medium, inadvertently encourage models to bypass visual perception. We empirically validate this through blind experiments: paradoxically, state-of-the-art policies maintain or even improve performance even when visual inputs are entirely removed. This reveals that these models degenerate into blind reasoners, exploiting linguistic priors to generate plausible answers instead of attending to visual evidence. In response, we propose Thinking with Deltas, a framework driven by a Differential Visual Reasoning Policy (DVRP). DVRP introduces intrinsic supervision via visual triplets, comprising original, masked, and perturbed inputs. It optimizes the model to maximize reasoning divergence from masked inputs (enforcing visual sensitivity) while minimizing divergence from perturbed inputs (ensuring visual robustness). By aligning reasoning variations strictly with the Delta of visual information, DVRP inherently bolsters visual understanding capabilities and significantly outperforms state-of-the-art methods on both general and medical benchmarks, without requiring external annotations or auxiliary tools.