# On the Out of Distribution Robustness of Foundation Models in Medical Image Segmentation

arXiv: https://arxiv.org/abs/2311.11096 · HTML: https://mlsanity.com/paper/2311.11096/

## Key facts

- Cited by 6 papers in the map (data through 14 Oct 2026).
- Builds on 39 of its 55 references that are in the map.
- First posted on arXiv 18 Nov 2023.

## Builds on (most cited first, 30 of 39)

- [Attention Is All You Need](https://mlsanity.com/paper/1706.03762/) (2017)
- [Deep Residual Learning for Image Recognition](https://mlsanity.com/paper/1512.03385/) (2015)
- [BERT: Pre-training of Deep Bidirectional Transformers for Language Understanding](https://mlsanity.com/paper/1810.04805/) (2018)
- [Learning Transferable Visual Models From Natural Language Supervision](https://mlsanity.com/paper/2103.00020/) (2021)
- [Language Models are Few-Shot Learners](https://mlsanity.com/paper/2005.14165/) (2020)
- [An Image is Worth 16x16 Words: Transformers for Image Recognition at Scale](https://mlsanity.com/paper/2010.11929/) (2020)
- [U-Net: Convolutional Networks for Biomedical Image Segmentation](https://mlsanity.com/paper/1505.04597/) (2015)
- [LLaMA: Open and Efficient Foundation Language Models](https://mlsanity.com/paper/2302.13971/) (2023)
- [Segment Anything](https://mlsanity.com/paper/2304.02643/) (2023)
- [DINOv2: Learning Robust Visual Features without Supervision](https://mlsanity.com/paper/2304.07193/) (2023)
- [Masked Autoencoders Are Scalable Vision Learners](https://mlsanity.com/paper/2111.06377/) (2021)
- [EfficientNet: Rethinking Model Scaling for Convolutional Neural Networks](https://mlsanity.com/paper/1905.11946/) (2019)
- [SGDR: Stochastic Gradient Descent with Warm Restarts](https://mlsanity.com/paper/1608.03983/) (2016)
- [Dropout as a Bayesian Approximation: Representing Model Uncertainty in Deep Learning](https://mlsanity.com/paper/1506.02142/) (2015)
- [On the Opportunities and Risks of Foundation Models](https://mlsanity.com/paper/2108.07258/) (2021)
- [V-Net: Fully Convolutional Neural Networks for Volumetric Medical Image Segmentation](https://mlsanity.com/paper/1606.04797/) (2016)
- [Fourier Features Let Networks Learn High Frequency Functions in Low Dimensional Domains](https://mlsanity.com/paper/2006.10739/) (2020)
- [TransUNet: Transformers Make Strong Encoders for Medical Image Segmentation](https://mlsanity.com/paper/2102.04306/) (2021)
- [UNet++: A Nested U-Net Architecture for Medical Image Segmentation](https://mlsanity.com/paper/1807.10165/) (2018)
- [FlowNet: Learning Optical Flow with Convolutional Networks](https://mlsanity.com/paper/1504.06852/) (2015)
- [Unsupervised Monocular Depth Estimation with Left-Right Consistency](https://mlsanity.com/paper/1609.03677/) (2016)
- [Image Segmentation Using Deep Learning: A Survey](https://mlsanity.com/paper/2001.05566/) (2020)
- [The Liver Tumor Segmentation Benchmark (LiTS)](https://mlsanity.com/paper/1901.04056/) (2019)
- [A large annotated medical image dataset for the development and evaluation of segmentation algorithms](https://mlsanity.com/paper/1902.09063/) (2019)
- [Laplace Redux -- Effortless Bayesian Deep Learning](https://mlsanity.com/paper/2106.14806/) (2021)
- [Segment Anything Model for Medical Image Analysis: an Experimental Study](https://mlsanity.com/paper/2304.10517/) (2023)
- [Aleatoric uncertainty estimation with test-time augmentation for medical image segmentation with convolutional neural networks](https://mlsanity.com/paper/1807.07356/) (2018)
- [Accuracy on the Line: On the Strong Correlation Between Out-of-Distribution and In-Distribution Generalization](https://mlsanity.com/paper/2107.04649/) (2021)
- [Bayesian SegNet: Model Uncertainty in Deep Convolutional Encoder-Decoder Architectures for Scene Understanding](https://mlsanity.com/paper/1511.02680/) (2015)
- [MS-Net: Multi-Site Network for Improving Prostate Segmentation with Heterogeneous MRI Data](https://mlsanity.com/paper/2002.03366/) (2020)

## Built on by (most cited first, 6 of 6)

- [ASPS: Augmented Segment Anything Model for Polyp Segmentation](https://mlsanity.com/paper/2407.00718/) (2024)
- [Foundation Models in Medical Imaging: A Review and Outlook](https://mlsanity.com/paper/2506.09095/) (2025)
- [Robustness Testing of Black-Box Models Against CT Degradation Through Test-Time Augmentation](https://mlsanity.com/paper/2406.19557/) (2024)
- [Deep Learning for Ophthalmology: The State-of-the-Art and Future Trends](https://mlsanity.com/paper/2501.04073/) (2025)
- [When Adaptation Hurts: Connecting Representational Drift to OOD Failures in MedSAM Fine-Tuning](https://mlsanity.com/paper/2608.21300/) (2026)
- [Beyond Calibration: Confounding Pathology Limits Foundation Model Specificity in Abdominal Trauma CT](https://mlsanity.com/paper/2602.10359/) (2026)

## Abstract (arXiv)

Constructing a robust model that can effectively generalize to test samples under distribution shifts remains a significant challenge in the field of medical imaging. The foundational models for vision and language, pre-trained on extensive sets of natural image and text data, have emerged as a promising approach. It showcases impressive learning abilities across different tasks with the need for only a limited amount of annotated samples. While numerous techniques have focused on developing better fine-tuning strategies to adapt these models for specific domains, we instead examine their robustness to domain shifts in the medical image segmentation task. To this end, we compare the generalization performance to unseen domains of various pre-trained models after being fine-tuned on the same in-distribution dataset and show that foundation-based models enjoy better robustness than other architectures. From here, we further developed a new Bayesian uncertainty estimation for frozen models and used them as an indicator to characterize the model's performance on out-of-distribution (OOD) data, proving particularly beneficial for real-world applications. Our experiments not only reveal the limitations of current indicators like accuracy on the line or agreement on the line commonly used in natural image applications but also emphasize the promise of the introduced Bayesian uncertainty. Specifically, lower uncertainty predictions usually tend to higher out-of-distribution (OOD) performance.