Label-Free Foundational Model Selection for Medical Image Classification under Distribution Shift via Pseudo Label Discrepancy

Foundation models are increasingly deployed for medical image analysis. However, under the inter-institutional distribution shift typical of deployment, their performance varies widely and cannot be known without target-domain labels, which are rarely available. This leaves a practical question unresolved: given several candidate foundational models and labeled-data from a source domain, which one to deploy in an unlabeled target domain? We propose a label-free selection criterion built on SUDO, a framework for evaluating clinical AI systems without ground-truth annotations. SUDO partitions the unlabeled target data by predicted probability and, for each region, measures a pseudo-label discrepancy reflecting class contamination; aggregated across regions, this yields a score (AURCC) requiring neither target annotation nor fine-tuning. We show that AURCC can be used to rank a variety of vision-language models (BioMedCLIP, CXR-CLIP, CheXzero, MedCLIP, MedImageInsight, CLIP) on chest X-ray classification across three inter-hospital shift scenarios, under zero-shot and MLP-probe regimes. The AURCC ranking recovers the ground-truth ranking with Spearman rho up to 0.943 (p<0.05). Against the natural baseline of ranking by held-out source accuracy, AURCC is competitive when the labeled source is large and yields a more accurate ranking once it is small; the regime of interest in resource-constrained settings.