The Impact of Preprocessing Methods on Racial Encoding and Model Robustness in CXR Diagnosis

Deep learning has advanced chest X-ray (CXR) diagnosis, yet demographic biases in learned representations may contribute to performance disparities across intersectional groups. We propose a single-encoder framework combining dual-level decorrelation with prototype-guided cross-group contrastive learning to reduce demographic dependence while accounting for within-class variation. We further propose Demographic Representation Alignment Reduction (DRAR), a new metric that quantifies the reduction in demographic structure within disease representations. The framework is evaluated on four classification tasks using 34,809 CheXpert test images across eight intersectional groups, defined by age, sex and ethnicity. Compared with empirical risk minimization (ERM), our method reduces the mean equalized-odds gap from 15.41% to 10.86% and the AUC gap from 5.95% to 5.01%. Our method achieves a DRAR of 59.04% relative to ERM, with only a slight decrease in mean AUC. These results demonstrate that representation disentanglement can reduce demographic bias and improve intersectional fairness. Code is available at https://github.com/06Yujie/Fair-Medical-Imaging.

Shortcut learning denotes the widespread situation in which a classifier exploits spurious correlations rather than diagnostic features. Existing mitigation strategies mostly aim to learn shortcut-invariant representations; their empirical success is limited and they cannot be applied to classifiers using frozen foundation model encoders. We propose to reframe shortcut learning as fundamentally a calibration problem: unconstrained learning implicitly calibrates each shortcut group to its training set disease prevalence, rendering the resulting classifier necessarily over-confident in one group and under-confident in the other. Building on this insight, we prevalence-equalize calibration between shortcut groups through two encoder-agnostic methods, an in-processing regularizer and a post-hoc prevalence-equalized recalibration step. Across chest-drain-pneumothorax benchmarks on CheXpert and SIIM-ACR, spanning fine-tuned CNNs and frozen foundation-model backbones, both methods substantially outperform all baselines. Post-hoc recalibration of a standard ERM-trained DenseNet raises misaligned-group AUROC from 0.23 to 0.73, indicating that shortcut reliance degrades the classification head rather than the underlying representation. Besides two new state-of-the-art shortcut mitigation approaches, our findings more fundamentally connect shortcut learning to calibration theory and algorithmic fairness.

Vision-language models, such as contrastive language-image pre-training (CLIP)-based approaches, have reached state-of-the-art (SOTA) results in medical artificial intelligence. However, recent work reveals that CLIP-based models remain vulnerable to shortcuts. We investigate how real-world shortcuts manifest across different layers of the medical CLIP-based model, MedCLIP, and its vision encoder, a frozen ResNet-50. We attach 17 linear classification probes to the intermediate layers of the ResNet-50 and train them on three different dataset configurations and targets: NIH-CXR14 (pneumothorax) and PadChest (cardiomegaly and pneumothorax). This setup allows us to observe model behaviour during evaluation using subgroup-based calibration and layer-wise confidence curves. We find that the final linear probes achieve a high AUROC but poor calibration in the models. The layer-wise confidence analyses suggest that shortcuts emerge at different depths. Patterns consistent with localised shortcuts, such as drains, appear at later layers, while patterns consistent with diffuse shortcuts, such as scanner-specific noise patterns, emerge earlier, aligning with previous work. Finally, we conduct a manual analysis of the images, which reveals data quality issues in both NIH-CXR14 and PadChest. Our findings underscore that even SOTA models remain vulnerable to shortcuts, and the need for high-quality and well-annotated datasets to draw solid conclusions. Code can be found on our GitHub: https://github.com/nikodice4/MedCLIP_shortcuts.