Analyzing Diagnostic Reasoning of Vision–Language Models via Zero-Shot Chain-of-Thought Prompting in Medical Visual Question Answering

Abstract

Medical Visual Question Answering (MedVQA) lies at the intersection of computer vision, natural language processing, and clinical decision-making, aiming to generate accurate responses from medical images paired with complex inquiries. Despite recent advances in vision–language models (VLMs), their use in healthcare remains limited by a lack of interpretability and a tendency to produce direct, unexplainable outputs. This opacity undermines their reliability in medical settings, where transparency and justification are critically important. To address this limitation, we propose a zero-shot chain-of-thought prompting framework that guides VLMs to perform multi-step reasoning before arriving at an answer. By encouraging the model to break down the problem, analyze both visual and contextual cues, and construct a stepwise explanation, the approach makes the reasoning process explicit and clinically meaningful. We evaluate the framework on the PMC-VQA benchmark, which includes authentic radiological images and expert-level prompts. In a comparative analysis of three leading VLMs, Gemini 2.5 Pro achieved the highest accuracy (72.48%), followed by Claude 3.5 Sonnet (69.00%) and GPT-4o Mini (67.33%). The results demonstrate that chain-of-thought prompting significantly improves both reasoning transparency and performance in MedVQA tasks.