Clinically Structured Surrogate Rewards for Post-SFT Medical Image Captioning

Medical image captioning requires translating heterogeneous visual evidence into concise clinical descriptions, where errors in findings, assertion states, or anatomical relations can alter clinical meaning despite surface-level fluency. Sequence-level policy optimization can directly optimize complete captions, but common rewards rely on global text similarity, direct image-caption compatibility, or unordered concept overlap, leaving visual neighborhoods and clinical-claim structure implicit. We propose a clinically structured surrogate reward framework for post-SFT medical image captioning. The framework combines biomedical semantic and short-range lexical fidelity with two structured rewards: distributional image-neighborhood alignment, which matches the medical-image-bank distributions induced by reference and generated captions, and clinical graph consistency, which applies maximum-weight one-to-one matching to entities, assertion states, and typed relations. The four rewards are independently normalized within each rollout group, combined with fixed relative weights, and optimized with GDPO. Across organizer-evaluated hidden test sets for the Standard and Synthetical ImageCLEFmedical Caption tracks and three vision-language backbones, the method improves Overall, Relevance, and Factuality over matched SFT baselines in all six backbone-track combinations, with average relative gains of 3.4%, 2.1%, and 5.8%, respectively. Ablations and paired diagnostics indicate that the structured rewards provide complementary signals, reducing image-neighborhood divergence and improving entity-assertion-relation consistency.