Calibrated Triage, Not Autonomy: Confidence Estimation for Medical Vision-Language Models

A vision-language model can answer a question about a chest radiograph or a pathology slide fluently and confidently while barely using the image, relying instead on language priors. In medicine this is the failure that matters most: the answer looks trustworthy and is not, and the natural safeguard is a confidence score reliable enough to say when the model should abstain. We ask a deployment question rather than an accuracy one: how much medical imaging work a vision-language model can safely defer on its own, and which confidence signal makes that possible. We evaluate nine confidence estimators, spanning training-free logit baselines, prompt-based self-reports, and trained internal probes, across five open-weight LVLMs and three medical VQA datasets covering broad clinical imaging, radiology, and pathology, every probe trained only on natural images and applied to medicine without adaptation. Recast as bounded selective prediction, the comparison is cautionary. Standard metrics mislead: discrimination barely separates the estimators, and a fixed high-confidence cutoff separates them far less than it appears, because their scores sit on incomparable scales; no estimator is reliably best across domains or models. What can be safely deferred is set at two levels: base-model competence fixes a ceiling, and the confidence layer determines how much of it is reachable. At a 20% error tolerance the strongest estimator defers about a quarter of radiology cases under a distribution-free guarantee and a third under a held-out threshold, and little to none of pathology. The usable role is calibrated triage under clinical oversight, not autonomous deferral: a good estimator makes a competent model defer safely where it is competent, but none manufactures reliability where the base model lacks it. We release all outputs, correctness judgments, and confidence scores, with code.