Mitigating Class-Tail Undercoverage in Medical Vision-Language Models under Clinical Shift
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Computer Science > Machine Learning
arXiv:2607.28696 (cs)
[Submitted on 30 Jul 2026]
Title:Mitigating Class-Tail Undercoverage in Medical Vision-Language Models under Clinical Shift
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Abstract:Medical vision-language models (VLMs) can retain high observed marginal coverage after clinical shift while substantially under-covering an individual disease class. The affected class varies with acquisition protocol and backbone geometry, so source prevalence does not reliably reveal the failure. Existing localized and tail-aware conformal methods respectively adapt to test neighborhoods and source-frequency tails, leaving held-out class-wise coverage failure unmodeled. We introduce Class-Tail Adaptive Localized Conformal Deferral (CALCoDe), a post-hoc reliability layer for frozen medical VLMs. Cross-fitted validation predictions identify classes at risk of undercoverage, and a disjoint calibration split estimates their class-conditional tail thresholds. CALCoDe combines each protected threshold with a localized conformal threshold using a one-sided maximum. The resulting set contains every label admitted by the localized rule, with additional protection confined to validation-identified classes. An independently calibrated support audit defers cases with insufficient inlier support. Under exchangeability among accepted examples within each protected class, CALCoDe provides finite-sample coverage at the prespecified guard level and contains the corresponding localized conformal sets; coverage on shifted external cohorts is evaluated empirically. Among standard conformal baselines and recent VLM-specific conformal methods evaluated across two dermatology shifts (HAM10000 to ISIC 2019 and HAM10000 to PAD-UFES-20) and four frozen VLM backbones (BiomedCLIP, OpenAI CLIP ViT-B/32, PubMedCLIP ViT-B/32, and MedSigLIP-448), CALCoDe is the only approach whose observed marginal and worst-class accepted coverage both reach 0.95 in all eight settings. On HAM10000 to ISIC 2019, its average worst-class accepted coverage is 0.970, compared with 0.926 for sTACP and 0.864 for LCP-VLM.
| Comments: | 26 pages; supplementary material included |
| Subjects: | Machine Learning (cs.LG); Computer Vision and Pattern Recognition (cs.CV) |
| Cite as: | arXiv:2607.28696 [cs.LG] |
| (or arXiv:2607.28696v1 [cs.LG] for this version) | |
| https://doi.org/10.48550/arXiv.2607.28696
arXiv-issued DOI via DataCite (pending registration)
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View a PDF of the paper titled Mitigating Class-Tail Undercoverage in Medical Vision-Language Models under Clinical Shift, by Mushir Akhtar and 1 other authors
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