Useful nonrobust features are ubiquitous in biomedical images

Deep learning (DL) has shown strong performance in medical image classification, but its trustworthy deployment remains challenging in safety-critical clinical settings, where prediction errors under perturbations may lead to severe consequences. Existing studies mainly focus on adversarial robustness (AR) from a worst-case perspective; however, such settings may be less representative of real medical applications. In this work, we investigate probabilistic robustness (PR) as a more practical measure of model trustworthiness. To this end, we construct a set of natural corruption settings for medical image classification and systematically evaluate commonly used DL models on MedMNIST v2 dataset. Our study provides a statistically grounded perspective on assessing the trustworthiness of DL models, thereby supporting their more trustworthy deployment in medical imaging applications.

Medical foundation models have achieved remarkable clinical performance, yet their robustness under real-world perturbations remains underexplored. We present a robustness benchmark comprising 40 perturbation types (12 base, 28 medical-specific) across eight imaging modalities, evaluating five VLMs (LLaVA-Med, MedGemma, MedGemma-1.5, Gemini-2.5-flash and GPT-4o-mini) on VQA, visual grounding, and captioning, alongside two segmentation models (MedSAM, SAM-Med2D) with five fine-tuning strategies. Our findings reveal: (1) Fine-tuning strategy dominates robustness, with LoRA exhibiting nearly double the degradation of full fine-tuning, while SAM-Med2D's Adapter offers favorable efficiency-robustness trade-off. (2) Medical-specific perturbations disproportionately damage segmentation, with 9 of 15 top corruptions being domain-specific. (3) LoRA-tuned visual grounding drops over 40 points, whereas zero-shot captioning remains stable (<7% drop). Zero-shot VQA shows model-dependent robustness--medical models drop under 20% while Gemini-2.5-flash drops 54%. General-purpose VLMs achieve higher VQA accuracy but fail on grounding; among medical VLMs, MedGemma demonstrates the best overall stability. These results provide deployment guidelines and underscore the necessity of domain-specific robustness evaluation for medical AI. Our code is available at: https://abnerai.github.io/MedFM-Robust.

While deep learning systems are becoming increasingly prevalent in medical image analysis, their vulnerabilities to adversarial perturbations raise serious concerns for clinical deployment. These vulnerability evaluations largely rely on Attack Success Rate (ASR), a binary metric that indicates solely whether an attack is successful. However, the ASR metric does not account for other factors, such as perturbation strength, perceptual image quality, and cross-architecture attack transferability, and therefore, the interpretation is incomplete. This gap requires consideration, as complex, large-scale deep learning systems, including Vision Transformers (ViTs), are increasingly challenging the dominance of Convolutional Neural Networks (CNNs). These architectures learn differently, and it is unclear whether a single metric, e.g., ASR, can effectively capture adversarial behavior. To address this, we perform a systematic empirical study on four medical image datasets: PathMNIST, DermaMNIST, RetinaMNIST, and CheXpert. We evaluate seven models (VGG-16, ResNet-50, DenseNet-121, Inception-v3, DeiT, Swin Transformer, and ViT-B/16) against seven attack methods at five perturbation budgets, measuring ASR, Peak Signal-to-Noise Ratio (PSNR), Structural Similarity Index Measure (SSIM), and $L_2$ perturbation magnitude. Our findings show a consistent pattern: perceptual and distortion metrics are strongly associated with one another and exhibit minimal correlation with ASR. This applies to both CNNs and ViTs. The results demonstrate that ASR alone is an inadequate indicator of adversarial robustness and transferability. Consequently, we argue that a thorough assessment of adversarial risk in medical AI necessitates multi-metric frameworks that encompass not only the attack efficacy but also its methodology and associated overheads.