Evaluating the Diagnostic Robustness of Vision-Language Models Under Visual and Textual Perturbations

The robustness of Vision Language Models (VLMs) is commonly assessed through output-level invariance, implicitly assuming that stable predictions reflect stable multimodal processing. In this work, we argue that this assumption is insufficient. We introduce a representation-aware and frequency-aware evaluation framework that measures internal embedding drift, spectral sensitivity, and structural smoothness (spatial consistency of vision tokens), alongside standard label-based metrics. Applying this framework to modern VLMs across the SEEDBench, MMMU, and POPE datasets reveals three distinct failure modes. First, models frequently preserve predicted answers while undergoing substantial internal representation drift; for perturbations such as text overlays, this drift approaches the magnitude of inter-image variability, indicating that representations move to regions typically occupied by unrelated inputs despite unchanged outputs. Second, robustness does not improve with scale; larger models achieve higher accuracy but exhibit equal or greater sensitivity, consistent with sharper yet more fragile decision boundaries. Third, we find that perturbations affect tasks differently: they harm reasoning when they disrupt how models combine coarse and fine visual cues, but on the hallucination benchmarks, they can reduce false positives by making models generate more conservative answers.

Vision-language models (VLMs), including medical specialists, are increasingly proposed for medical imaging, yet their stated confidence is rarely evaluated separately from correctness. We use brain MRI as a controlled, high-stakes testbed for a broader failure mode in frontier multimodal systems: models can appear competent while lacking reliable self-knowledge. We present an automatically graded behavioral audit and pilot study of six instruction-tuned VLMs (five general-purpose and one medical specialist) on 4,102 images (4,032 axial/coronal/sagittal MRI slices from 250 subjects plus 70 non-brain/noise controls), with labels derived from public metadata and released expert segmentation masks rather than new human annotation. Across models, answer coverage is near-complete, but verbalized-confidence calibration is poor: ECE ranges from 0.27 to 0.40, mean confidence on incorrect answers ranges from 0.82 to 0.97, and 33-46% of answered items are high-confidence errors. The most accurate model is also the most confident on its errors, while a base/specialist family contrast suggests that medical adaptation improves tumor-presence detection without improving confidence reliability. Open-ended diagnostics further show that hallucination and abstention vary separately from multiple-choice accuracy. These findings argue that medical-image VLM evaluation should report verbalized-confidence reliability, confident error, hallucination, and abstention alongside accuracy.

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.