See-in-Pairs: Reference Image-Guided Comparative Vision-Language Models for Medical Diagnosis

Abstract: Medical imaging diagnosis presents inherent challenges due to diseases that mimic normal anatomy and exhibit significant inter-patient variability. Clinicians routinely employ comparative reasoning-using reference images from healthy controls or previous patient examinations-to discern subtle yet diagnostically critical abnormalities. However, existing medical vision-LLMs (VLMs) focus primarily on single-image or single-series analyses and lack explicit mechanisms for comparative reasoning. Conversely, general-purpose VLMs demonstrate strong multi-image comparative reasoning capabilities but lack essential medical-domain knowledge to identify nuanced clinical differences. This work aims to bridge this gap by exploring clinically-inspired comparative analysis within VLMs, leveraging reference images to enhance diagnostic accuracy. Through extensive empirical analysis, we show that providing general-purpose VLMs with query and normative matched reference images, accompanied by clinically-informed comparative prompts, significantly improves diagnostic outcomes compared to single-image baselines, especially after supervised finetuning (SFT). Our contributions highlight the clinical relevance of comparative analysis introduce novel strategies for leveraging reference images in VLMs, empirically demonstrate enhanced performance across multiple medical visual question answering (VQA) tasks, and provide theoretical insights into the efficacy of comparative image analysis in medical diagnosis.