A User-Centric Analysis of Explainability in AI-Based Medical Image Diagnosis

Explainability is increasingly seen as a crucial requirement in AI-based medical diagnosis, particularly in safety-critical clinical decision-making. Most existing explainability methods in healthcare operate in a post-hoc manner and are predominantly designed for unimodal data, which limits their applicability in increasingly prevalent multimodal diagnostic settings. This paper addresses the problem of self-explainable multimodal diagnosis by formulating it within the information bottleneck (IB) framework. We propose a unified learning paradigm that jointly optimizes predictive performance and modality-specific explainability by identifying the most informative elements inside each modality that contribute to diagnostic decisions. To enable tractable and stable optimization, we employ a matrix-based Renyi's $α$-order entropy functional under the assumption of sufficiently expressive encoders. Extensive experiments on representative medical datasets spanning heterogeneous modalities demonstrate that the proposed method consistently achieves strong diagnostic performance, including an absolute accuracy improvement of 9.1 percentage points on the iCTCF dataset. Moreover, the learned explanations provide transparent and modality-aware insights into feature relevance, thereby improving both the explainability and generalization.

Reliable and interpretable decision-making is essential in medical imaging, where diagnostic outcomes directly influence patient care. Despite advances in deep learning, most medical AI systems operate as opaque black boxes, providing little insight into why a particular diagnosis was reached. In this paper, we introduce Med-CAM, a framework for generating minimal and sharp maps as evidence-based explanations for Medical decision making via Classifier Activation Matching. Med-CAM trains a segmentation network from scratch to produce a mask that highlights the minimal evidence critical to model's decision for any seen or unseen image. This ensures that the explanation is both faithful to the network's behaviour and interpretable to clinicians. Experiments show, unlike prior spatial explanation methods, such as Grad-CAM and attention maps, which yield only fuzzy regions of relative importance, Med-CAM with its superior spatial awareness to shapes, textures, and boundaries, delivers conclusive, evidence-based explanations that faithfully replicate the model's prediction for any given image. By explicitly constraining explanations to be compact, consistent with model activations, and diagnostic alignment, Med-CAM advances transparent AI to foster clinician understanding and trust in high-stakes medical applications such as pathology and radiology.

Explainable Artificial Intelligence (XAI) has become essential in medical image analysis to ensure transparency of deep learning (DL)-based diagnostic systems. However, selecting appropriate XAI techniques for breast cancer recognition remains largely ad hoc, with limited systematic evaluation across different DL architectures. This study presents a systematic architecture-aware evaluation protocol to assess the effectiveness of nine widely used XAI techniques across four categories of DL models: very deep, lightweight, transformer-based and hybrid neural networks. The evaluation is conducted on a breast ultrasound dataset comprising 780 images using clinically aligned spatial metrics, including Pointing Game, Intersection over Union and Mean Coverage, to quantify agreement between generated explanations and expert-annotated lesion regions. Results indicate that explanation quality is primarily influenced by the interaction between model architecture and XAI method, rather than any single technique consistently outperforming others. Hybrid architectures produce more spatially coherent explanations, while lightweight and transformer-based models exhibit greater variability across methods. The findings show that no single technique generalises across architectures and evaluation criteria, emphasising the need for joint selection of DL models and XAI techniques. Explainability depends on both model design and explanation strategy and should not be considered independently. This work provides a structured evaluation protocol and practical guidance for selecting XAI techniques in breast cancer diagnosis, supporting more transparent clinical decision-support systems. \textcolor{blue}{Code is publicly available at https://github.com/Nishan-Charlie/Explainable-AI}