Vision-language models for chest radiography do not always need the image
Authors: Mahshad Lotfinia, Sebastian Ziegelmayer, Lisa Adams, Daniel Truhn, Andreas Maier, Soroosh Tayebi Arasteh
Organizations: Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany · Department of Diagnostic and Interventional Radiology, TUM University Clinic, School of Medicine and Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany · Lab for AI in Medicine, RWTH Aachen University, Aachen, Germany · Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
Abstract
Medical vision-language models report strong chest radiograph accuracy, and this is increasingly read as evidence that they use the image. That inference is unsafe: a model exploiting finding-name priors scores like one that reads the scan, and no standard benchmark separates them. We introduce a causal audit that intervenes on the image, occluding the relevant region, occluding an irrelevant one, and swapping in another patient's same-label scan, and combines three behavioral metrics to test whether a correct answer depends on the image. Across nine systems, a text-only model with no image access reaches within 5.7 accuracy points of the best multimodal one, and a 119-billion-parameter multimodal model is statistically indistinguishable from a 7-billion text-only baseline. The audit splits the cohort into three models that ignore the image, one that is unstable, and five that use it selectively, for a subset of findings; the categories hold across a second dataset, resolution, and prompt phrasing. Against board-certified radiologists, a text-only model is statistically indistinguishable from a radiologist's accuracy while grounding at zero, whereas the image-using models ground at radiologist-comparable rates. Reported confidence flags ungrounded answers only when a model uses the image. Grounding audits, not accuracy, should gate clinical deployment.
Vision-language models (VLMs) are increasingly proposed for clinical decision support, yet their reliability in real-world scenarios that require integrating both visual and textual context from medical records remains poorly characterized. This paper identifies three failure modes: (1) modality over-reliance on text over images, (2) spurious reliance on irrelevant clinical history, and (3) prompt sensitivity across semantically equivalent inputs. We evaluate a diverse set of general-domain and medically-tuned open and closed VLMs on chest x-ray tasks using MIMIC-CXR. By systematically manipulating image-text alignment, clinical history, and prompt formulations, we found that VLM decisions are dominated by the text modality, even when visual evidence is available. Moreover, we observed that VLMs are heavily influenced by irrelevant reports, while minor prompt changes can reverse correct image-based predictions. Our findings underscore the need for explicit safeguards and stress-testing before considering the use of these models in clinical practice.
Vision-language models (VLMs) are increasingly used for medical image interpretation, yet they frequently hallucinate, generating clinically plausible but factually incorrect findings that pose direct patient safety risks. We introduce HalluCXR, a benchmark evaluating six architecturally diverse VLMs across 856 stratified MIMIC-CXR chest radiographs and three query types, yielding 15,408 model evaluations. An eight-category hallucination taxonomy with clinical severity ratings and a two-layer detection pipeline are validated against 250 human annotations (auto-detection F1=0.959; LLM judge F1=0.907). We find that 61.9--82.3% of outputs contain hallucinations, with clinically dangerous errors in up to 80.2%. Three key patterns emerge: normal radiographs paradoxically attract the most severe hallucinations, common findings are systematically over-fabricated while rare findings go under-detected, and response length alone predicts hallucination risk (AUC up to 0.908). A six-model ensemble reduces fabrication by up to 84.8% at the cost of increased omission; a three-model subset retains comparable performance at half the cost. These results establish that hallucination auditing, verbosity-based risk monitoring, and ensemble-based safety layers are prerequisites for clinical deployment.
Vision-language models return structured chest-radiograph findings through interfaces exposing no confidence score, so a receiving institution cannot read off how far to trust an individual judgment. Whether agreement with an institution's reference standard transfers across sites, findings, prediction directions and question formats is largely unmeasured. We evaluated three generative vision-language models on three institutional chest-radiograph corpora and six findings under two elicitation protocols, comprising more than 345,000 finding-level predictions, and estimated finding-by-direction reference agreement at a receiving institution from a small budget of local labels. Estimation strategies were then stress-tested under repeated strict institution-held-out evaluation. Under evaluation excluding the receiving institution from development entirely, adaptive selection among the seven estimators that design admits did not improve on simple fixed alternatives: it achieved a mean Brier score of 0.1083, against 0.0853 for always using a Beta-Binomial empirical-Bayes estimator and 0.0855 for a target-only logistic model. Those two differ by 0.0003, less than this family's own sensitivity to a change of solver version, and each leads in about half the settings, so no default can be recommended. Their advantage over estimators pooling across institutions was concentrated at one site and not confirmatory once clustered by institution, and a plug-in empirical-Bayes posterior-predictive count interval at a nominal 95% level covered 87.0%, less at the hardest institution. Reference agreement therefore has to be re-evaluated per site and per interface; these results concern agreement with institutional labels, not clinical correctness.