Ask4VG: Risk-Aware Question Selection for Reducing Prior-Driven Answers in Medical VQA

Medical visual question answering requires models to ground their responses in image evidence, because visually unsupported answers can mislead downstream interpretation. However, many medical VQA questions are generic, template-like, or highly similar in form, which can encourage models to learn question-answer shortcuts instead of image-dependent reasoning and thereby increase the risk of hallucinated responses. We propose Ask4VG, a label-free pilot framework for risk-aware question selection. Ask4VG estimates question-induced hallucination risk through counterfactual visual probing: the same question is asked under the original image, a perturbed image, a blank image, and a mismatched image, and the resulting answer relations are converted into weak supervision for a counterfactual risk estimator. The learned estimator then reranks candidate question rewrites to favor intent-preserving questions that are less invariant to missing or mismatched visual evidence before final answer generation. On VQA-RAD with Qwen2-VL-2B-Instruct, prompt-only rewriting increases counterfactual risk, whereas predicted-risk reranking reduces held-out risk from 0.658 to 0.623 and improves exact accuracy from 0.337 to 0.356. A 300-sample PMC-VQA external check shows the same direction of risk reduction with a small accuracy gain. These results suggest that question selection is a promising complement to response-level hallucination mitigation for reliable medical VQA.

Dual Causal Inference: Integrating Backdoor Adjustment and Instrumental Variable Learning for Medical VQA

Medical Visual Question Answering (MedVQA) aims to generate clinically reliable answers conditioned on complex medical images and questions. However, existing methods often overfit to superficial cross-modal correlations, neglecting the intrinsic biases embedded in multimodal medical data. Consequently, models become vulnerable to cross-modal confounding effects, severely hindering their ability to provide trustworthy diagnostic reasoning. To address this limitation, we propose a novel Dual Causal Inference (DCI) framework for MedVQA. To the best of our knowledge, DCI is the first unified architecture that integrates Backdoor Adjustment (BDA) and Instrumental Variable (IV) learning to jointly tackle both observable and unobserved confounders. Specifically, we formulate a Structural Causal Model (SCM) where observable cross-modal biases (e.g., frequent visual and textual co-occurrences) are mitigated via BDA, while unobserved confounders are compensated using an IV learned from a shared latent space. To guarantee the validity of the IV, we design mutual information constraints that maximize its dependence on the fused multimodal representations while minimizing its associations with the unobserved confounders and target answers. Through this dual mechanism, DCI extracts deconfounded representations that capture genuine causal relationships. Extensive experiments on four benchmark datasets, SLAKE, SLAKE-CP, VQA-RAD, and PathVQA, demonstrate that our method consistently outperforms existing approaches, particularly in out-of-distribution (OOD) generalization. Furthermore, qualitative analyses confirm that DCI significantly enhances the interpretability and robustness of cross-modal reasoning by explicitly disentangling true causal effects from spurious cross-modal shortcuts.

Learning to Trim: End-to-End Causal Graph Pruning with Dynamic Anatomical Feature Banks for Medical VQA

Medical Visual Question Answering (MedVQA) models often exhibit limited generalization due to reliance on dataset-specific correlations, such as recurring anatomical patterns or question-type regularities, rather than genuine diagnostic evidence. Existing causal approaches are typically implemented as static adjustments or post-hoc corrections. To address this issue, we propose a Learnable Causal Trimming (LCT) framework that integrates causal pruning into end-to-end optimization. We introduce a Dynamic Anatomical Feature Bank (DAFB), updated via a momentum mechanism, to capture global prototypes of frequent anatomical and linguistic patterns, serving as an approximation of dataset-level regularities. We further design a differentiable trimming module that estimates the dependency between instance-level representations and the global feature bank. Features highly correlated with global prototypes are softly suppressed, while instance-specific evidence is emphasized. This learnable mechanism encourages the model to prioritize causal signals over spurious correlations adaptively. Experiments on VQA-RAD, SLAKE, SLAKE-CP and PathVQA demonstrate that LCT consistently improves robustness and generalization over existing debiasing strategies.

Structure Causal Models and LLMs Integration in Medical Visual Question Answering

Medical Visual Question Answering (MedVQA) aims to answer medical questions according to medical images. However, the complexity of medical data leads to confounders that are difficult to observe, so bias between images and questions is inevitable. Such cross-modal bias makes it challenging to infer medically meaningful answers. In this work, we propose a causal inference framework for the MedVQA task, which effectively eliminates the relative confounding effect between the image and the question to ensure the precision of the question-answering (QA) session. We are the first to introduce a novel causal graph structure that represents the interaction between visual and textual elements, explicitly capturing how different questions influence visual features. During optimization, we apply the mutual information to discover spurious correlations and propose a multi-variable resampling front-door adjustment method to eliminate the relative confounding effect, which aims to align features based on their true causal relevance to the question-answering task. In addition, we also introduce a prompt strategy that combines multiple prompt forms to improve the model's ability to understand complex medical data and answer accurately. Extensive experiments on three MedVQA datasets demonstrate that 1) our method significantly improves the accuracy of MedVQA, and 2) our method achieves true causal correlations in the face of complex medical data.