Uncertainty Is Not a Safety Net for Clinical VQA, but Can It Anticipate Model Failure?

Vision-language models are increasingly explored for clinical prediction from electronic health records and medical images, where identifying unreliable predictions is important for safe deployment. Uncertainty estimation (UE) enables detecting such predictions, but its evaluation depends on a correctness criterion that determines whether each model output is correct. If this criterion disagrees with human judgement or distorts downstream UE performance, conclusions about model reliability can be misleading. We introduce a two-axis framework that evaluates correctness criteria by their agreement with human judgements and fidelity to human-referenced UE performance. We assess eight criteria across three clinical prediction tasks and three models using 450 predictions annotated by two reviewers. Across the audited tasks, canonical exact matching (EM) achieved the highest observed human agreement and lowest UE distortion, while the BERT-based matching (BEM) and LLM-judge also showed strong human agreement. Across four UE methods and 23,254 clinical predictions, criterion choice changed error-detection AUROC by up to 0.146 and reversed the relative ranking of UE methods. The LLM-judge also selectively accepted invalid or uncertain outputs, accepting 16 of 30 such human-identified errors. These results demonstrate that correctness assessment is an integral component of clinical UE evaluation and should be validated before UE methods are compared.

Deploying vision-language models (VLMs) in clinical settings demands auditable behavior under realistic failure conditions, yet the failure landscape of frontier VLMs on specialized medical inputs is poorly characterized. We audit five recent frontier and grounding-aware VLMs (Gemini2.5Pro, GPT-5, o3, GLM-4.5V, Qwen2.5VL) on Medical VQA along two trust-relevant axes. Perception: all models localize anatomical and pathological targets poorly -- the best model reaches only 0.23 mean IoU and 19.1% Acc@0.5 -- and exhibit clinically dangerous laterality confusion. Pipeline integration: a self-grounding pipeline, where the same model localizes then answers, degrades VQA accuracy for every model -- driven by both inaccurate localization and format-compliance failures under the two-step prompt (parse failure rises to 70%--99% for Gemini and GPT-5 on VQA-RAD). Replacing predicted boxes with ground-truth annotations recovers and improves VQA accuracy, consistent with the failure residing in the perception module rather than in the decomposition itself. These observational findings identify grounding quality as a primary trustworthiness bottleneck in our SLAKE bounding-box setting. As a complementary fine-tuning follow-up, supervised fine-tuning of Qwen2.5VL on combined Med-VQA training data attains the highest reported SLAKE open-ended recall (85.5%) among comparable methods, suggesting that the VQA-level gap is tractable with domain adaptation; whether this also closes the perception/trustworthiness bottleneck is left to future work.

Vision-language models (VLMs) are increasingly deployed on consumer hardware where input images are degraded by compression, camera shake, and poor lighting. In such settings, a reliable uncertainty signal matters more than raw accuracy, because it determines when a system should defer rather than answer. We evaluate two small open-weight VLMs -- Qwen2-VL-2B-Instruct and SmolVLM-Instruct -- across six realistic photographic degradations at three severity levels, comparing two confidence signals: the confidence the model states in natural language, and the model's own mean token probability over its generated answer. Across 3,800 predictions, we find a large and consistent gap. Verbalized confidence in Qwen2-VL is almost constant (mean 0.87-0.90 across all conditions) and detects its own errors at chance level (AUROC 0.39-0.75, typically ~0.50), while internal token probability from the same model separates correct from incorrect answers with AUROC 0.92-0.99. In SmolVLM, verbalized confidence proved largely unobtainable: across three prompt templates, only one of five pilot attempts produced a parseable confidence value, while internal probability again yielded above-chance error detection (AUROC 0.54-0.92). Both models fail in the same place: under severe underexposure, accuracy collapses (0.99->0.22 for Qwen2-VL, 0.97->0.42 for SmolVLM) while both confidence signals barely move, and internal error-detection falls to chance. We conclude that small VLMs encode usable self-knowledge that their verbalized output does not express, that internal probability is therefore the better deferral signal in constrained deployment, and that neither signal should be trusted under severe low-light conditions.