Thinking Like a Radiologist: A Dataset for Anatomy-Guided Interleaved Vision Language Reasoning in Chest X-ray Interpretation

Radiological diagnosis is a perceptual process in which careful visual inspection and language reasoning are repeatedly interleaved. Most medical large vision language models (LVLMs) perform visual inspection only once and then rely on text-only chain-of-thought (CoT) reasoning, which operates purely in the linguistic space and is prone to hallucination. Recent methods attempt to mitigate this issue by introducing visually related coordinates, such as bounding boxes. However, these remain a pseudo-visual solution: coordinates are still text and fail to preserve rich visual details like texture and density. Motivated by the interleaved nature of radiological diagnosis, we introduce MMRad-IVL-22K, the first large-scale dataset designed for natively interleaved visual language reasoning in chest X-ray interpretation. MMRad-IVL-22K reflects a repeated cycle of reasoning and visual inspection workflow of radiologists, in which visual rationales complement textual descriptions and ground each step of the reasoning process. MMRad-IVL-22K comprises 21,994 diagnostic traces, enabling systematic scanning across 35 anatomical regions. Experimental results on advanced closed-source LVLMs demonstrate that report generation guided by multimodal CoT significantly outperforms that guided by text-only CoT in clinical accuracy and report quality (e.g., 6\% increase in the RadGraph metric), confirming that high-fidelity interleaved vision language evidence is a non-substitutable component of reliable medical AI. Furthermore, benchmarking across seven state-of-the-art open-source LVLMs demonstrates that models fine-tuned on MMRad-IVL-22K achieve superior reasoning consistency and report quality compared with both general-purpose and medical-specific LVLMs. The project page is available at https://github.com/qiuzyc/thinking_like_a_radiologist.