When To Adapt? Adapting the Model or Data in Federated Medical Imaging

Building foundation models for medical imaging requires pooling data across institutions, yet privacy regulations prohibit centralized aggregation. Existing Federated Foundation Models either fine-tune natural-image models with poor medical-domain transfer, or train from scratch within a single modality, lacking the flexibility to unify tasks. We identify an under-explored challenge, Imaging Modality Heterogeneity, where clients operate under two structural regimes: Overlapped (shared modalities with heterogeneous label distributions) and Non-overlapped (fully disjoint modalities per client). We propose FM$^2$, a unified framework that trains the core backbone from scratch to preserve medical domain fidelity while optionally incorporating biomedical pretrained encoders for vision-language alignment. FM$^2$ equips each client with dual Mixture-of-Experts modules (a Class-wise MoE for personalized category knowledge and a Domain-wise MoE for shared cross-modality representations), coupled with a Heterogeneous Modality Alignment (HMA) regularizer that explicitly aligns modality-specific expert parameters, admitting provable $O(1/\sqrt{T})$ convergence and generalization guarantees. FM$^2$ further incorporates Caption-Enhanced Learning (CEL), where locally retained GPT-4o-generated captions serve as a textual semantic bridge enabling representation transfer across clients with disjoint modalities, and demonstrates extensibility to Federated Medical VQA. Experiments on our MIMH benchmark (classification and CEL) and real-world medical VQA datasets confirm consistent superiority over state-of-the-art federated baselines and strong out-of-modality generalization across all three tasks.

Federated learning (FL) holds great potential for medical applications. However, statistical heterogeneity across healthcare institutions poses a major challenge for FL, as the global model struggles both to generalize across unseen patient populations and to adapt to the unique data distributions of individual hospitals. This heterogeneity also exacerbates forgetting at both the global and local level, resulting in previous learned patient patterns to be misclassified after model updates. While prior work has largely treated generalization and personalization as separate challenges, we show that a better balance between the two can be achieved through selective alignment with the global model and a modified aggregation scheme, which together mitigate the effects of statistical heterogeneity. Specifically, we introduce FedKPer, which introduces knowledge personalization into the training stage of each local device. Afterwards, generalization is considered via the global model aggregation process, where local updates that are reliable and label-diverse are emphasized. We evaluate the performance of FedKPer, devising additional metrics that relate to common consequences of forgetting. Overall, we demonstrate FedKPer improves the generalization-personalization trade-off without sacrificing retention.

Federated learning (FL) is severely hindered by statistical heterogeneity due to variations in scanners, acquisition protocols, and patient populations. Such non-IID data induces client drift during local optimization, leading to unstable convergence and suboptimal global models when parameter-based aggregation is applied. We propose a prototype-based, influence-aware federated learning framework (FedProIn) that uses multiple learnable class prototypes to capture shared semantic structures across heterogeneous clients. We introduce feature divergence loss and prototype contrastive loss to mitigate client drift by decomposing it into feature drift and prototype drift. In addition, we propose a normalized influence aggregation strategy that adaptively weights client prototypes according to their contribution to the global representation, reducing the impact of biased or low-quality updates. Experimental results on two publicly available medical datasets, HAM10000 and Matek-19, demonstrate that FedProIn achieves accuracies of (83.5% IID, 81.1% non-IID) on HAM10000 and (96.2% IID, 95.8% non-IID) on Matek-19, respectively, outperforming existing baselines in both conditions. Our code is available at https://github.com/harsh-kmr/FedProIn.