Rethinking Uncertainty in Segmentation: From Estimation to Decision

Reliable uncertainty estimation is critical for medical image segmentation, where automated contours feed downstream quantification and clinical decision support. Many strong uncertainty methods require repeated inference, while efficient single-forward-pass alternatives often provide weaker failure ranking or rely on restrictive feature-space assumptions. We present $\textbf{SegWithU}$, a post-hoc framework that augments a frozen pretrained segmentation backbone with a lightweight uncertainty head. SegWithU taps intermediate backbone features and models uncertainty as perturbation energy in a compact probe space using rank-1 posterior probes. It produces two voxel-wise uncertainty maps: a calibration-oriented map for probability tempering and a ranking-oriented map for error detection and selective prediction. Across ACDC, BraTS2024, and LiTS, SegWithU is the strongest and most consistent single-forward-pass baseline, achieving AUROC/AURC of $0.9838/2.4885$, $0.9946/0.2660$, and $0.9925/0.8193$, respectively, while preserving segmentation quality. These results suggest that perturbation-based uncertainty modeling is an effective and practical route to reliability-aware medical segmentation. Source code is available at https://github.com/ProjectNeura/SegWithU.

In this study, we explore in depth a few under-studied topics at the intersection of uncertainty estimation and segmentation. Prior work has shown that the quality of uncertainty estimates can be very sensitive to a range of variables. As one of the main uses of uncertainty estimation is to help identify and deal with prediction errors in practical scenarios, any factors that affect this must be clearly identified. For example, do more challenging domains or different datasets and architectures result in worse performance when using uncertainty estimates? Can prior frames in a video sequence in fact provide useful uncertainty estimates comparable to other approaches? Is it possible to combine uncertainty estimation approaches, taking advantage of sample diversity, to get better estimates? Finally, when might it make sense to use an ensemble-based uncertainty estimate over a deterministic network? We address these questions by creating a framework for and executing a large scale study across many variables such as datasets, backbones, and downstream tasks, for both semantic and panoptic segmentation. We find that a) the more challenging task of panoptic segmentation usually results in worse performance while high performance variance between datasets and backbones indicates that generalization is not guaranteed, b) time series samples can be useful for specific configurations, but in many cases are not worth the cost, c) sample diversity shows the most promise in the downstream task of calibration, but otherwise fails to beat simpler alternatives, d) a deterministic approach is adequate for some downstream tasks, but ensembles allow for significant improvements if the right conditions can be achieved in deployment.

Uncertainty quantification complements model predictions by characterizing their reliability, which is essential for high-stakes decision making such as medical image segmentation. However, most existing methods reduce uncertainty to a scalar confidence estimate, leaving its spatial distribution semantically underconstrained. In this work, we focus on uncertainty interpretability, namely, whether estimated uncertainty behaves in a human-understandable manner with respect to sources of ambiguity. We identify three perception-aligned principles requiring the spatial distribution of uncertainty to reflect: (1) image contrast between structures, (2) severity of image corruption, and (3) geometric complexity in anatomical structures. Accordingly, we develop a principle-guided uncertainty supervision framework (PriUS) based on evidential learning, in which the corresponding supervision objectives are explicitly enforced during training. We further introduce quantitative metrics to measure the consistency between predicted uncertainty and image attributes that induce ambiguity. Experiments on ACDC, ISIC, and WHS datasets showed that, compared with state-of-the-art methods, PriUS produced more consistent uncertainty estimates while maintaining competitive segmentation performance.