TCLA: Training-Free Class-wise Logit Adaptation for Medical Vision-Language Models
Authors: Tianyou Jiang, Ziyu Zhou
Organizations: University of Bern, Bern, Switzerland · Shanghai Jiao Tong University, Shanghai, China
Abstract
Medical Vision-Language Models (VLMs) exhibit strong zero-shot performance, yet their effectiveness still declines on out-of-distribution (OOD) data due to domain shifts and class bias inherited from large-scale pretraining. Existing few-shot adaptation methods typically introduce additional trainable components, which can be unstable in extremely low-data regimes (e.g., 1-shot), and lack robustness on different medical data. We present TCLA, a purely training-free few-shot adaptation method for Medical VLMs, which is fast and model-agnostic. TCLA corrects inference logits based on a small set of support samples, boosting pretrained VLMs performance by improving inter-class deconfusion and reducing domain shift. Extensive experiments on nine datasets across multiple medical imaging modalities including X-ray, Ultrasound, MRI, CT, Histopathology, demonstrate that TCLA consistently improves OOD performance of Medical VLMs and, in most of cases, outperforms existing training-based adaptation methods.
Current prompt-based and adapter-based tuning of vision-language models (VLMs) is attractive for medical imaging, where clinical data sensitivity favors frozen backbones and annotations are limited. However, these methods typically optimize only the ground-truth class, treating all other classes as equally incorrect, ignoring clinically meaningful class relations and yielding unstable decision boundaries in limited-supervision settings. We propose Omni-Geometry Knowledge Distillation (OGKD), a new framework that injects class-relation structure into the teacher to produce directional targets that preserve the ground truth while respecting inter-class geometry. Using these targets, we develop two distillation losses: Global Geometry-Aware Distillation (GAD) operates on the global image token, and Label-Guided Geometry Distillation (LGD) applies the same geometry to attentive patch tokens to improve fine-grained alignment. Across comprehensive experiments and analyses on 11 widely-used medical datasets for base-to-novel and few-shot evaluations, our OGKD achieves substantially better performance, consistently improving accuracy by an average absolute gain of 1.7%-2.8% over all prior state-of-the-art VLM adaptation counterparts. It also robustly generalizes to unseen classes and yields more reliable predictions than other approaches. Our code is available at https://github.com/tientrandinh/OGKD.
3D CT vision-language models (VLMs) classify abnormalities from text prompts in a zero-shot manner, enabling cross-institution deployment where labels are scarce and clinical tasks shift faster than supervised models can be retrained. A real CT scan, however, typically contains several co-occurring abnormalities, and the reliability of zero-shot multi-label prediction under distribution shift remains poorly understood. Test-time adaptation (TTA) updates a model on unlabeled target scans without source data or target annotations, yet existing TTA methods target multi-class softmax prediction on natural images or 2D medical segmentation, and none addresses unsupervised multi-label adaptation for zero-shot 3D CT VLMs. We study when TTA helps zero-shot 3D CT VLMs. A controlled diagnostic analysis shows that TTA is conditional: the volumetric input must preserve the encoder's depth structure, and the base representation must transfer to the target cohort, with depth reduction alone lowering internal AUROC by more than 0.12. We then focus on the regime where the base model already separates present from absent abnormalities. We introduce CARVE (Cardinality-Aware Retained-View Entropy), the first TTA method for this setting. CARVE estimates a sample-specific positive-label cardinality k^, optimizes a top-k^ objective to preserve co-occurring abnormalities, and performs memory-efficient multi-view adaptation by scoring weak 3D views without gradients before updating on a retained subset. Across contrastive CT-CLIP and anatomy-aware fVLM, CARVE provides the most consistent improvements across multi-label, three-class, and binary CT tasks when the base model is already discriminative. These results establish multi-label TTA for zero-shot 3D CT VLMs as a distinct problem and CARVE as a cardinality-aware solution.
Ailar Mahdizadeh, Puria Azadi Moghadam, Xiangteng He +1
Vision-Language Models (VLMs) such as CLIP demonstrate strong zero-shot generalization, but their performance significantly degrades in cross-domain scenarios with scarce target-domain training data (Cross-Domain Few-Shot Learning, CDFSL). In this paper, we focus on the target-domain few-shot finetuning in the CLIP-based CDFSL task. Prevailing finetuning paradigms uniformly align all image patch tokens with their corresponding textual embeddings. However, we find a counterintuitive phenomenon: actively pushing away certain low-similarity image tokens, termed "tail tokens", from their textual embeddings consistently improves target-domain performance. We delve into this phenomenon and provide a novel interpretation: under great domain shifts and scarce training data, the model can hardly extract semantic information from visual inputs; therefore, the common belief of alignment is valid only for tokens already containing sufficient semantic information; for tail tokens, forcing the alignment would lead to excessive overfitting to the scarce training, while breaking the alignment is more useful. Motivated by this, we propose Adaptive Tail-Head Alignment (ATHA), a novel fine-tuning strategy for CLIP that transforms the conventional uniform alignment paradigm to an adaptive alignment paradigm, with both alignment strengthening and weakening. Extensive experiments on four challenging CDFSL benchmarks validate our state-of-the-art performance. Our code is available at https://github.com/shuaiyi308/ATHA.