Zero-shot evaluation of open vision-language models as System 1 decision models on radiology tasks

Vision-language models that answer questions about chest radiographs are evaluated by their accuracy on labels derived from radiology reports. High benchmark accuracy is often interpreted as evidence that the model uses the image. A model that answers from the finding named in the question can score as well as a model that uses the radiograph. Keeping the question fixed, we audit eight open-weight systems by swapping in another patient's radiograph with the same or the opposite label, occluding the radiologist-marked region or an equal region elsewhere, and removing the radiograph or replacing it with noise or a photograph. On 2,548 yes-or-no questions from MIMIC-CXR, one multimodal model answers Yes regardless of the image, another multimodal model changes its answers without following the label, and four systems use the image but keep about half of their correct answers when the radiograph is swapped for an opposite-label radiograph. A medical model that receives only the question text scores 55.3% on the pooled questions, higher than two multimodal systems. It scores 91.8% where every finding is present, and answering Yes to every question scores 100% there. Where the image is necessary, the best multimodal system exceeds this model by 10.4% in balanced accuracy. The categories are unchanged on CheXpert. Confidence is not higher when a correct answer depends on the marked region. In a reader study with three radiologists, the two radiologists who read a balanced set of 200 cases score 86.0% and 82.0%, and the systems score 50.0% to 73.0%. Accuracy does not establish image use, but an intervention on the image can test it.

Many clinical decisions are a choice among a few fixed options, taken quickly and in large numbers. Such decisions also need an uncertainty estimate to know when to defer to a clinician. Generative language models answer slowly in free text and state their confidence poorly. In contrast, System 1 models answer zero-shot with a probability for each answer. However, their performance across clinical tasks is unknown. Four System 1 models, two proprietary and two with open weights, were evaluated zero-shot on 86 public tasks from 14 clinical domains in 20 languages, spanning examination questions and medical imaging. Tasks were assigned to six capability tiers before analysis. The primary outcome was the area under the receiver-operating-characteristic curve (AUROC). Secondary outcomes included calibration, language effects and comparisons with published results and generative models. Across 179,111 cases, the mean AUROC of the best model per task was 0.94 for medical knowledge, 0.93 for text understanding, 0.83 for clinical judgement from text, 0.89 for image perception, 0.84 for 2D image findings and 0.69 for volumetric findings. Imaging tasks scored 0.09 (95% CI, 0.06 to 0.11) lower than text tasks (P < 0.001). The best model matched or exceeded the best published result on 13 of 26 text tasks and on 8 of 35 imaging tasks. Triage nurses outperformed the best model (accuracy, 0.85 vs. 0.56). One decision took 0.34 to 0.44 seconds and 24 to 81 joules on open-weight models run locally. Accuracy on identical questions fell by up to 39 percentage points from English to Yoruba. Generative models of the same family were 11 to 76 times slower, with 3 to 5 percentage points higher balanced accuracy. System 1 models decide quickly, cheaply and with usable confidence when the answer is stated in a text or recalled from medical knowledge, but not when it must be judged or read from an image.

Large language models (LLMs) show promise in radiology but their deployment is limited by computational requirements that preclude use in resource-constrained clinical environments. We investigate whether small language models (SLMs) of 3-4 billion parameters can achieve strong multi-task radiology performance through LoRA fine-tuning, enabling deployment on consumer-grade CPUs. We train Qwen2.5-3B-Instruct and Qwen3-4B on 162K samples spanning 9 radiology tasks - RADS classification across 10 systems, impression generation, temporal comparison, radiology NLI, NER, abnormality detection, N/M staging, and radiology Q&A - compiled from 12 public datasets. Both models are evaluated on up to 500 held-out test samples per task with standardized metrics. Our key findings are: (1) LoRA fine-tuning dramatically improves performance over zero-shot baselines (RADS accuracy +53%, NLI +60%, N-staging +89%); (2) the two models exhibit complementary strengths - Qwen2.5 excels at structured generation tasks while Qwen3 dominates extractive tasks; (3) a task-outed oracle ensemble combining both models achieves the best performance across all tasks; (4) few-shot prompting with fine-tuned models hurts performance, demonstrating that LoRA adaptation is more effective than in-context learning for specialized domains; and (5) models can be quantized to GGUF format (~1.8-2.4GB) for CPU deployment at 4-8 tokens/second on consumer hardware. Our work demonstrates that small, efficiently fine-tuned models - which we collectively call RadLite - can serve as practical multi-task radiology AI assistants deployable entirely on consumer hardware without GPU requirements. Code and models are available at https://github.com/RadioX-Labs/RadLite