Vision Language Models (VLMs) have shown promise in automating image diagnosis and interpretation in clinical settings. However, developing specialist medical VLMs requires substantial computational resources and carefully curated datasets, and it remains unclear under which conditions generalist and specialist medical VLMs each perform best. This study highlights the complementary strengths of specialist medical and generalist VLMs. Specialists remain valuable in modality-aligned use cases, but we find that efficiently fine-tuned generalist VLMs can achieve comparable or even superior performance in most tasks, particularly when transferring to unseen or rare OOD medical modalities. These results suggest that generalist VLMs, rather than being constrained by their lack of specialist medical pretraining, may offer a scalable and cost-effective pathway for advancing clinical AI development.