Med-StepBench: A Hierarchical Reasoning Framework for Evaluating Hallucinations in Medical Vision-Language Models

Large vision-language models (VLMs) demonstrate strong performance in medical image understanding, but frequently generate clinically plausible yet incorrect statements, raising significant safety concerns. Existing medical hallucination benchmarks primarily focus on 2D imaging with one-shot diagnostic questions, offering limited insight into whether predictions are grounded in correct localization and abnormality identification, allowing critical reasoning errors to remain hidden behind seemingly correct diagnoses. We introduce Med-StepBench, the first large-scale benchmark for step-wise hallucination detection in 3D oncological PET/CT, comprising over 12,000 images and more than 1,000,000 image-statement pairs across volumetric and multi-view 2D data, which decomposes clinical reasoning into four expert-designed diagnostic stages. Using clinician-verified annotations, we perform the first step-level evaluation of general-purpose and medical VLMs, revealing systematic failure modes obscured by aggregate accuracy metrics. Furthermore, we show that current VLMs are highly susceptible to adversarial yet clinically plausible intermediate explanations, which significantly amplify hallucinations despite contradictory visual evidence. Together, our findings highlight fundamental limitations in grounding multi-step clinical reasoning and establish Med-StepBench as a rigorous benchmark for developing safer and more reliable medical VLMs.

Beyond the Global Scores: Fine-Grained Token Grounding as a Robust Detector of LVLM Hallucinations

Large vision-language models (LVLMs) achieve strong performance on visual reasoning tasks but remain highly susceptible to hallucination. Existing detection methods predominantly rely on coarse, whole-image measures of how an object token relates to the input image. This global strategy is limited: hallucinated tokens may exhibit weak but widely scattered correlations across many local regions, which aggregate into deceptively high overall relevance, thus evading the current global hallucination detectors. We begin with a simple yet critical observation: a faithful object token must be strongly grounded in a specific image region. Building on this insight, we introduce a patch-level hallucination detection framework that examines fine-grained token-level interactions across model layers. Our analysis uncovers two characteristic signatures of hallucinated tokens: (i) they yield diffuse, non-localized attention patterns, in contrast to the compact, well-focused attention seen in faithful tokens; and (ii) they fail to exhibit meaningful semantic alignment with any visual region. Guided by these findings, we develop a lightweight and interpretable detection method that leverages patch-level statistical features, combined with hidden-layer representations. Our approach achieves up to 90% accuracy in token-level hallucination detection, demonstrating the superiority of fine-grained structural analysis for detecting hallucinations.