Evaluating the Diagnostic Robustness of Vision-Language Models Under Visual and Textual Perturbations

Standard accuracy metrics for VLMs often mask significant reliability failures in sensitive domains. In this work, we utilize a histopathology-validated brain MRI dataset to systematically assess the diagnostic robustness of four VLM families under evidence-preserving perturbations. By reordering anatomical slices and swapping target label positions, we evaluate whether models maintain consistent predictions when clinical evidence remains invariant. Our results reveal significant vulnerabilities in presentation-order stability, with models exhibiting prediction flips in up to 48.9% of cases under simple sequence reversals. We further identify a textual selection bias, where label reordering triggers inconsistent diagnoses in up to 67.8% of cases despite identical visual inputs. Negative-control tests further reveal diagnostic overcommitment: models generate categorical diagnoses in up to 76.1% of cases after expert-annotated lesion slices are removed. These results demonstrate that high accuracy can overestimate clinical reliability, masking sensitivity to sequential presentation and textual framing that is not captured by aggregate accuracy. Our findings highlight the necessity of stability-based metrics for the deployment of VLMs in safety-critical clinical applications. Our evaluation data and code will be made public upon acceptance.

Beyond Counts: A Distributional Robustness Margin For Pathology Foundation Models

Pathology foundation models are approaching clinical deployment, yet remain vulnerable to systematic non-biological variation across centres. Differences in tissue preparation, staining and scanning are strongly encoded in their representations, enabling shortcut learning and weakening generalisation across cohorts and institutions. The Robustness Index (RI) quantifies whether local representation geometry is dominated by biology or by non-biological variation, but its count-based formulation discards distance information. We show that adding distance weights changes little because the deeper limitation lies in RI's pooled, fixed-neighbourhood design, which obscures sample-level heterogeneity and effectively evaluates only a model-dependent subset of samples. We introduce the Cross-confounder Robustness Margin (CRoMa), a sample-resolved measure that directly compares distances to cross-confounder biological matches and same-confounder biological distractors. CRoMa recasts robustness as a cohort-wide margin distribution rather than a single pooled score. We evaluated frozen representations from 20 tile-level encoders across three benchmarks and 4 slide-level encoders on a fourth. Rankings by median CRoMa were broadly consistent across datasets, while the underlying distributions revealed substantial within-model heterogeneity. Every tile encoder retained a confounder-dominated lower tail, whose prevalence and severity varied markedly across models. These distinct robustness profiles frame model selection as a Pareto trade-off between typical and lower-tail robustness. Higher CRoMa was also associated with smaller shortcut-induced performance drops after supervised adaptation. By turning representation geometry into a distributional robustness readout that anticipates downstream shortcut susceptibility, CRoMa provides a principled basis for robustness assessment and model selection.