Uncertainty of Vision Medical Foundation Models

Uncertainty estimation for medical vision--language models (VLMs) using conformal prediction has gained increasing attention due to its distribution-free coverage guarantees. However, standard conformal prediction relies on exchangeability between calibration and test data and typically requires a sufficiently large calibration set to obtain reliable coverage. These assumptions are difficult to satisfy in few-shot transfer settings, where only a small labeled support set is available to adapt a pretrained VLM to a new medical task, while an unlabeled query set is used for evaluation. Supervised fine-tuning on the support set changes the model parameters and consequently shifts the nonconformity score distribution, breaking exchangeability between calibration and query samples and leading to unreliable coverage under distribution shift. Existing transductive conformal adaptation methods often preserve validity by avoiding supervised updates. While this helps maintain conformal assumptions, it underutilizes the scarce labeled support data and limits task adaptation, which is the primary objective in few-shot learning. In this setting, conformal prediction should serve as an uncertainty estimation layer that supports the adapted model, rather than preventing adaptation itself. To this end, we propose AlignCP, a framework that reconciles supervised few-shot adaptation with conformal uncertainty estimation under non-exchangeability. AlignCP learns a reweighted calibration distribution that reduces the score-level discrepancy between the labeled support set and the unlabeled query set. By aligning the one-dimensional nonconformity score distributions, AlignCP aims to close the coverage gap induced by adaptation without requiring query labels.

In critical decision support systems based on medical imaging, the reliability of AI-assisted decision-making is as relevant as predictive accuracy. Although deep learning models have demonstrated significant accuracy, they frequently suffer from miscalibration, manifested as overconfidence in erroneous predictions. To facilitate clinical acceptance, it is imperative that models quantify uncertainty in a manner that correlates with prediction correctness, allowing clinicians to identify unreliable outputs for further review. To address this necessity, this paper proposes a probabilistic optimization framework grounded in Bayesian deep learning. Specifically, the Confidence-Uncertainty Boundary Curve (CUBC) is first explored as an intermediate operational target. Grounded in this target, a novel Confidence-Uncertainty Boundary Loss (CUB-Loss) is proposed to regularize the alignment between prediction confidence and uncertainty estimates during training, imposing penalties on high-certainty errors and low-certainty correct predictions. Upon completion of training optimization, a Boundary Curve Calibration Error (BCCE) metric is further introduced to measure the degree of boundary alignment in the calibrated model. Building on this measurement, a Dual Temperature Scaling (DTS) strategy is devised to perform post-hoc refinement, further adjusting the posterior predictive distribution across different confidence-uncertainty regions. The proposed framework is validated on three distinct medical imaging tasks: automatic screening of pneumonia, diabetic retinopathy detection, and identification of skin lesions. Empirical results demonstrate that the proposed approach improves uncertainty calibration across diverse modalities, maintains robust performance in data-scarce scenarios, and remains effective on severely imbalanced datasets, underscoring its potential for real clinical deployment.

A vision-language model can answer a question about a medical image fluently and confidently while barely using the image, leaning instead on language priors. In medicine this is the failure that matters most, because the answer looks trustworthy and is not, and the only protection is a confidence score reliable enough to tell the system when to abstain. We ask a deployment question rather than an accuracy one: how much imaging work a model can safely handle alone, and which confidence signal makes that possible. We evaluate seven confidence estimators across five open-weight LVLMs and three medical visual-question-answering datasets spanning broad clinical imaging, radiology, and pathology, with every probe trained only on natural images and applied without adaptation. Recast as bounded selective prediction (automate a case only when confidence clears a threshold, defer the rest), the comparison is cautionary. The standard metrics are poor guides: discrimination barely separates the methods, and the weak calibration of a cheap self-report is cheaply removed by off-domain temperature scaling without changing deployable yield. What distinguishes a usable estimator is the high-confidence region a clinician acts on: the weakest baselines are confidently wrong on 41 to 45 percent of their errors against 1 to 4 percent for the best probe, and no estimator is reliably best across domains or models. Safe handoff is governed at two levels: base-model competence sets a ceiling, so a well-calibrated score recovers roughly a third of radiology cases at a 20 percent error tolerance but almost none of pathology; the confidence layer then decides how much of that ceiling is reachable. The usable role today is calibrated triage, not autonomy: automate the cases a calibrated score marks safe, route the rest to a clinician. We release all outputs, correctness judgments, and confidence scores, with code.