Abstract:Medical vision-language models (VLMs) enable zero-shot clinical image classification, yet reliably detecting out-of-distribution (OOD) inputs at deployment remains an open problem. No static scoring method works across all shift types: Maximum Concept Matching (MCM) on FLAIR achieves 76.4% AUROC for far-OOD but only 42.4% for covariate shifts such as ultra-wide-field fundus images, effectively random. We trace this to a structural mismatch: covariate-shifted inputs are indistinguishable from in-distribution samples in softmax space, yet occupy distinct regions in the VLM embedding space. To exploit this untapped signal, we propose PROTON (PROtotype-based Test-time ONline OOD detection), a lightweight post-hoc module that maintains an online prototype bank from high-confidence test predictions and adaptively fuses prototype distance with MCM scoring via stream-level variance statistics, requiring no model modification, training data, or prompt engineering. On the ophthalmology benchmark FLAIR + FIVES, PROTON improves MCM by +23.9 AUROC on covariate shift, +8.8 on semantic shift, and +8.1 on far-OOD, making it the only zero-shot method to improve all three without hierarchical prompts or labeled data. Code is available at this https URL, and the project page is available at this https URL.
From: Abhijit Das [view email]
[v1]
Thu, 18 Jun 2026 20:09:13 UTC (1,590 KB)
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