CHILD: Human-in-the-Loop OOD Detection for Safe Clinical Deployment

Deep neural networks have achieved remarkable performance across medical imaging tasks, yet their tendency to overgeneralize under distributional shifts poses a major obstacle to safe clinical deployment. Out-of-Distribution (OOD) detection methods aim to mitigate this risk, but most existing approaches rely on opaque internal signals with poorly understood semantic meaning, limiting trust in safety-critical settings. In this work, we propose an interpretable OOD detection framework that probes the stability of model predictions under class-conditioned semantic perturbations. Leveraging sparse autoencoders (SAEs), we learn class-specific concept vectors from in-distribution data that disentangle dense intermediate representations into sparse, semantically meaningful components. At inference, we perturb deeper-layer representations using the concept vectors associated with the model's predicted class and measure the class logits stability. We hypothesize that in-distribution samples exhibit low sensitivity to such perturbations, as their representations align with class-specific semantic directions, whereas OOD samples show amplified deviations due to representational misalignment. By framing OOD detection as a concept conditioned stability analysis, our approach provides both a discriminative OOD signal and an interpretable lens into the internal mechanisms driving model uncertainty, making it particularly suitable for high stakes medical applications.

Reliable out-of-distribution (OOD) detection is a critical requirement for the safe deployment of machine learning systems. Despite recent progress, state-of-the-art OOD detectors are highly susceptible to adversarial attacks, which undermines their trustworthiness in automated systems. To address this vulnerability, we apply median smoothing to baseline OOD detection scores, balancing clean and adversarial accuracies. Our key insight is that the noisy samples generated for median smoothing can be repurposed to quantify the local instability of the base score. We observe that OOD samples exhibit higher instability under perturbation. Based on this, we propose ROSS, a novel and robust post-hoc OOD detector that leverages the instability of baseline scores to further distinguish between in-distribution (ID) and OOD samples. ROSS achieves symmetric robustness, performing strongly against both score-minimising and score-maximising attacks, unlike prior work. This symmetric defence leads to state-of-the-art robustness, outperforming prior methods by up to 40 AUROC points. We demonstrate ROSS's effectiveness on extensive experiments across CIFAR-10, CIFAR-100, and ImageNet. Code is available at: https://github.com/Abdu-Hekal/ROSS.

For clinical deployment, it is essential that automated diagnostic systems remain reliable when confronted with previously unseen cases, yet deep models routinely misclassify out-of-distribution (OOD) inputs with high confidence, underscoring the need for more robust OOD detection methods. Although substantial effort has been devoted to improving model robustness, most of the existing literature assumes balanced datasets, evaluates OOD detection on coarse or non-clinical OOD sources, or lacks comprehensive assessment across diverse OOD scenarios. To address the gaps, we propose a novel methodology trained on diverse and imbalanced medical datasets and evaluated across a clinically reflective OOD spectrum. Our framework comprises three key components: (1) a Nonlinear von Mises-Fisher (NvMF) classifier capable of learning non-linear decision boundaries, with theoretical proof of its asymptotic connection to cosine classifiers; (2) a multi-expert framework in which margin-aware NvMF classifiers specialise in different regions of label distribution to better handle imbalance; and (3) an outlier expert trained explicitly to distinguish inlier from outlier data, thereby strengthening OOD detection. Evaluation on RFMiD, ISIC2019, and NCTCRC datasets demonstrates consistent improvements over state-of-the-art methods, achieving mean FPR95 reductions of 8.45%, 13.02%, and 36.90% respectively. These gains are further supported by comprehensive ablations that validated the contributions of each component. This enables reliable identification of unfamiliar cases for deferral to clinicians, supporting safer AI-assisted diagnosis in real-world workflows. Our code is available at https://github.com/redboxup/MARVEL.