K-MaT: Knowledge-Anchored Manifold Transport for Cross-Modal Prompt Learning in Medical Imaging

Pretrained biomedical vision-language models (VLMs) such as BioMedCLIP perform well on average but often degrade on challenging modalities where inter-class margins are small and acquisition-specific variations are pronounced, especially under few-shot supervision and when modality priors differ from pretraining corpora substantially. We propose BioVLM, a prompt-learning framework that improves cross-domain generalization without extensive backbone fine-tuning. BioVLM learns a diverse prompt bank and introduces dynamic prompt selection: for each input, it selects the most discriminative prompts via a low-entropy criterion on the predictive distribution, effectively coupling sparse few-shot evidence with rich LLM semantic priors. To strengthen this coupling, we distill high-confidence LLM-derived attributes and enforce robust knowledge transfer through strong/weak augmentation consistency. At test time, BioVLM adapts by choosing modality-appropriate prompts, enabling transfer to unseen categories and domains, while keeping training lightweight and inference efficient. On 11 MedMNIST+ 2D datasets, BioVLM achieves new state of the art across three distinct generalization settings. Codes are available at https://github.com/mainaksingha01/BioVLM.

Medical vision-language models (VLMs) can appear reliable in-domain while failing when acquisition domain, paired supervision, or evaluation protocol changes. We study this failure mode as a representation-level blind spot relevant to epistemic intelligence, without claiming a formal estimator of epistemic uncertainty. Using NIH ChestXray14 and CheXpert, we first isolate source-only cross-dataset visual transfer from unsupervised domain-adaptation diagnostics. Using PadChest and OpenI, we then evaluate multimodal alignment under strict pair-index retrieval and quantify metadata-derived source-proxy information retained in frozen embeddings. Self-supervised visual initialization improves NIH-to-CheXpert transfer over supervised ImageNet initialization in matched ResNet-18 comparisons, whereas adversarial adaptation is useful only in a narrow regime and becomes unstable as adversarial pressure increases. Multimodal exact-pair retrieval remains low under external OpenI stress testing, and source-proxy information remains recoverable from learned representations. Qualitative nearest-neighbor and Grad-CAM analyses show clinically plausible cross-dataset structure and thoracic attention patterns in many cases, while device-heavy and false-positive cases remain ambiguous. Auxiliary architecture checks are task-dependent and do not support a universal backbone ranking. Overall, the study shows that apparent competence under a single protocol can conceal transfer, alignment, and shortcut-related failure modes, motivating stress-tested evaluation of medical VLMs under distribution shift.

Learning across medical imaging modalities requires making use of images without paired text and accommodating new domains while retaining existing representations. We propose a medical vision-language technique built around an expandable bank of modality experts. Its Multiway Transformer combines shared visual computation with deterministically routed feed-forward experts and a separate text pathway. A modality-aware visual tokenizer supplies targets for masked pretraining on 19.4 million unpaired image rows across seven modalities; contrastive alignment then uses 3.23 million image-text pairs. Additional fundus and optical coherence tomography experts learn from paired data while the original image and text embedding paths remain frozen. With a ViT-Large backbone, the proposed technique achieves the best or tied-best result in 24 of 25 benchmark settings across nine modalities: 10 of 11 zero-shot classification benchmarks, all 10 linear probes, and all four retrieval benchmarks. Mean balanced accuracy is 0.674 for zero-shot classification and 0.856 for linear probing, and mean bidirectional retrieval recall is 20.70%. A separate three-seed sequential experiment with matched adaptation data yields fundus and OCT retrieval gains of 14.95 and 9.31 percentage points, with no measured loss on preceding fundus or pathology tasks. The preservation argument requires unchanged existing computation paths and inference conditions, and feature-identity checks verify retention on evaluated inputs. The proposed technique provides a modular approach to learning and expanding medical vision-language representations.