Learning When to Collaborate: Selective Multi-Agent Medical Reasoning via Uncertainty-Aware Routing

Jiacheng Hou, Xueliang Cui, Dan Lu, Ruxin Wang

Multi-agent systems have emerged as a promising paradigm for multimodal medical reasoning, but existing methods rely on two assumptions that hinder practical deployment: (i) always-active dense collaboration among multiple agents, and (ii) dependence on large cloud-based models that raise privacy and efficiency concerns. In this paper, we challenge both assumptions and propose SMART-Med, a fully local multi-agent method that treats collaboration as a learnable decision rather than a default behavior. Our key insight is that not every medical query requires costly multi-agent deliberation: many can be reliably solved by a single well-trained agent, while only uncertain cases benefit from expert collaboration. Based on this insight, SMART-Med introduces an uncertainty-driven routing mechanism that adaptively decides when to answer directly and when to recruit a small subset of expert agents, effectively converting dense multi-agent reasoning into selective, query-adaptive coordination. To make this routing reliable, we curate a new multimodal medical dataset MedVR-3K with high-quality reasoning traces and a difficulty hierarchy, and then fine-tune local agents using GRPO with two…