KANEx: Translating Kolmogorov-Arnold Networks' Interpretability to Medical Explainability

Attention and saliency heatmaps are widely used to explain medical Vision-Language Model (VLM) outputs on chest X-rays, yet whether they truly highlight the image evidence driving predictions has not been causally tested. We audit faithfulness via overlap with radiologist bounding boxes on PadChest (n=637), attribution mass within radiologist masks on CheXlocalize (n=643), and 16x16 patch-occlusion maps that record which regions, when hidden, change the answer. We study three MedGemma-4B variants, cross-family probes on LLaVA-RAD and Qwen3-VL-8B-Instruct, and the specialist CheXagent-2-3b, with two CXR-trained classifiers (DenseNet121, ResNet50) as positive controls. A heatmap is faithful only if the model uses the image and attention concentrates on regions whose occlusion alters the prediction. No evaluated VLM meets both criteria. MedGemma and Qwen3-VL use the image, but attention anti-correlates with patch-occlusion importance (rho < 0 with 95% bootstrap CIs below zero). LLaVA-RAD's attention correlates positively, but the model is almost text-only (99.1% text-only agreement, near-zero causal mass), so correlation ties two near-zero signals. Attention also misses annotated anatomy: overlap with true regions never beats shifted or random controls, and no method places more than 22% of its mass inside radiologist masks. The two CXR classifiers pass all metrics, indicating the failure is specific to VLM heatmaps, not the evaluation. These heatmaps are visually reassuring but not faithful; clinical explanations require controlled localization metrics and causal perturbation, not visual inspection alone.

Large Vision Language Models (LVLMs) show promise in medical applications, but their inability to faithfully ground responses in visual evidence raises serious concerns about clinical trustworthiness. While visual attribution methods are widely used to explain LVLM predictions, whether these explanations actually reflect the visual evidence underlying the model's decision is largely unverified, since ground-truth annotations for internal model reasoning are typically unavailable. We address this question for chest X-ray (CXR) reasoning by developing a causal evaluation framework that retains only CXR-VQA samples for which the expert-annotated region is verified, via counterfactual editing, to be causally responsible for the model's prediction. Using this framework across 11 attribution methods, six open-source LVLMs, and two output modes (direct answer and step-by-step reasoning), we find that existing attribution methods often fail to identify the evidence used by LVLMs. To address this failure, we propose MedFocus, a concept-based attribution method that localizes clinically meaningful anatomical regions via unbalanced optimal transport and measures their causal effect on model outputs through targeted interventions. MedFocus produces spatial, concept-level, and token-level attributions and substantially outperforms prior methods, taking a step toward more trustworthy attribution for medical LVLMs. Our data and code are available at https://github.com/gzxiong/medfocus/.

Vision-Language Models (VLMs) are demonstrating significant capabilities in medical tasks like radiology analysis, yet providing faithful and interpretable explanations remains a key consideration for their responsible deployment in clinical settings. However, existing explanation methods, such as the widely used FIxLIP framework, often struggle with the fine-grained nature of modern tokenizers. The tokenization problem fragments clinical concepts---splitting terms like "saddle embolus" into scattered, meaningless subwords---which leads to noisy, semantically incoherent cross-modal attributions. Such fragmentation also results in a combinatorial explosion of interaction possibilities, obscuring the model's true reasoning. To address this, we introduce ParseFIxLIP, an extension that incorporates the Tree-Gram Parsing into the Banzhaf interaction game used by FIxLIP. This semantically informed strategy utilizes dependency parsing trees to define explanation players by grouping related text tokens into semantically coherent units. Our smart_depth grouping strategy, merging tokens according to spaCy token dependency tree, successfully mitigates concept fragmentation, yielding substantially more interpretable cross-modal interactions by unifying complex medical concepts. Quantitatively, while baselines struggled with the high dimensionality of long captions, our parsing approach maintained statistical robustness and semantic parsimony. Qualitative analysis on BiomedCLIP, validated on medical imagery (ROCOv2) and general examples, confirms that the approach accurately captures the synergistic influence of grouped words on model predictions. In conclusion, our work offers intuitive and clinically relevant insights into VLM decision-making, fulfilling the critical need for coherent explanations in the medical domain.