Amin Madani

Lena Maier-Hein, Annika Reinke, Patrick Godau et al. · utoronto

Increasing evidence shows that flaws in machine learning (ML) algorithm validation are an underestimated global problem. Particularly in automatic biomedical image analysis, chosen performance metrics often do not reflect the domain interest, thus failing to adequately measure scientific progress and hindering translation of ML techniques into practice. To overcome this, our large international expert consortium created Metrics Reloaded, a comprehensive framework guiding researchers in the problem-aware selection of metrics. Following the convergence of ML methodology across application domains, Metrics Reloaded fosters the convergence of validation methodology. The framework was developed in a multi-stage Delphi process and is based on the novel concept of a problem fingerprint - a structured representation of the given problem that captures all aspects that are relevant for metric selection, from the domain interest to the properties of the target structure(s), data set and algorithm output. Based on the problem fingerprint, users are guided through the process of choosing and applying appropriate validation metrics while being made aware of potential pitfalls. Metrics Reloaded targets image analysis problems that can be interpreted as a classification task at image, object or pixel level, namely image-level classification, object detection, semantic segmentation, and instance segmentation tasks. To improve the user experience, we implemented the framework in the Metrics Reloaded online tool, which also provides a point of access to explore weaknesses, strengths and specific recommendations for the most common validation metrics. The broad applicability of our framework across domains is demonstrated by an instantiation for various biological and medical image analysis use cases.

Annika Reinke, Minu D. Tizabi, Michael Baumgartner et al.

Validation metrics are key for the reliable tracking of scientific progress and for bridging the current chasm between artificial intelligence (AI) research and its translation into practice. However, increasing evidence shows that particularly in image analysis, metrics are often chosen inadequately in relation to the underlying research problem. This could be attributed to a lack of accessibility of metric-related knowledge: While taking into account the individual strengths, weaknesses, and limitations of validation metrics is a critical prerequisite to making educated choices, the relevant knowledge is currently scattered and poorly accessible to individual researchers. Based on a multi-stage Delphi process conducted by a multidisciplinary expert consortium as well as extensive community feedback, the present work provides the first reliable and comprehensive common point of access to information on pitfalls related to validation metrics in image analysis. Focusing on biomedical image analysis but with the potential of transfer to other fields, the addressed pitfalls generalize across application domains and are categorized according to a newly created, domain-agnostic taxonomy. To facilitate comprehension, illustrations and specific examples accompany each pitfall. As a structured body of information accessible to researchers of all levels of expertise, this work enhances global comprehension of a key topic in image analysis validation.

Weiqiu You, Cassandra Goldberg, Amin Madani et al.

Purpose: Accurate assessment of the Critical View of Safety (CVS) during laparoscopic cholecystectomy is essential to prevent bile duct injury, a complication associated with significant morbidity and mortality. While large vision-language models (LVLMs) offer flexible reasoning, their predictions remain difficult to audit and unreliable on safety-critical surgical tasks. Methods: We introduce Sum-of-Checks, a framework that decomposes each CVS criterion into expert-defined reasoning checks reflecting clinically relevant visual evidence. Given a laparoscopic frame, an LVLM evaluates each check, producing a binary judgment and justification. Criterion-level scores are computed via fixed, weighted aggregation of check outcomes. We evaluate on the Endoscapes2023 benchmark using three frontier LVLMs, comparing against direct prompting, chain-of-thought, and sub-question decomposition, each with and without few-shot examples. Results: Sum-of-Checks improves average frame-level mean average precision by 12--14% relative to the best baseline across all three models and criteria. Analysis of individual checks reveals that LVLMs are reliable on observational checks (e.g., visibility, tool obstruction) but show substantial variability on decision-critical anatomical evidence. Conclusion: Structuring surgical reasoning into expert-aligned verification checks improves both accuracy and transparency of LVLM-based CVS assessment, demonstrating that explicitly separating evidence elicitation from decision-making is critical for reliable and auditable surgical AI systems. Code is available at https://github.com/BrachioLab/SumOfChecks.

Shreya Havaldar, Helen Jin, Chaehyeon Kim et al.

As LLMs are deployed in knowledge-intensive settings (e.g., surgery, astronomy, therapy), users expect not just answers, but also meaningful explanations for those answers. In these settings, users are often domain experts (e.g., doctors, astrophysicists, psychologists) who require explanations that reflect expert-level reasoning. However, current evaluation schemes primarily emphasize plausibility or internal faithfulness of the explanation, which fail to capture whether the content of the explanation truly aligns with expert intuition. We formalize expert alignment as a criterion for evaluating explanations with T-FIX, a benchmark spanning seven knowledge-intensive domains. In collaboration with domain experts, we develop novel metrics to measure the alignment of LLM explanations with expert judgment.

Helen Jin, Shreya Havaldar, Chaehyeon Kim et al.

Feature-based methods are commonly used to explain model predictions, but these methods often implicitly assume that interpretable features are readily available. However, this is often not the case for high-dimensional data, and it can be hard even for domain experts to mathematically specify which features are important. Can we instead automatically extract collections or groups of features that are aligned with expert knowledge? To address this gap, we present FIX (Features Interpretable to eXperts), a benchmark for measuring how well a collection of features aligns with expert knowledge. In collaboration with domain experts, we propose FIXScore, a unified expert alignment measure applicable to diverse real-world settings across cosmology, psychology, and medicine domains in vision, language, and time series data modalities. With FIXScore, we find that popular feature-based explanation methods have poor alignment with expert-specified knowledge, highlighting the need for new methods that can better identify features interpretable to experts.

Guiqiu Liao, Matjaz Jogan, Marcel Hussing et al.

Object-centric slot attention is a powerful framework for unsupervised learning of structured and explainable representations that can support reasoning about objects and actions, including in surgical videos. While conventional object-centric methods for videos leverage recurrent processing to achieve efficiency, they often struggle with maintaining long-range temporal coherence required for long videos in surgical applications. On the other hand, fully parallel processing of entire videos enhances temporal consistency but introduces significant computational overhead, making it impractical for implementation on hardware in medical facilities. We present Slot-BERT, a bidirectional long-range model that learns object-centric representations in a latent space while ensuring robust temporal coherence. Slot-BERT scales object discovery seamlessly to long videos of unconstrained lengths. A novel slot contrastive loss further reduces redundancy and improves the representation disentanglement by enhancing slot orthogonality. We evaluate Slot-BERT on real-world surgical video datasets from abdominal, cholecystectomy, and thoracic procedures. Our method surpasses state-of-the-art object-centric approaches under unsupervised training achieving superior performance across diverse domains. We also demonstrate efficient zero-shot domain adaptation to data from diverse surgical specialties and databases.

Zhaoxun "Lorenz" Liu, Wagner H. Souza, Jay Han et al.

Mass casualty incidents (MCIs) overwhelm healthcare systems and demand rapid, accurate patient-hospital allocation decisions under extreme pressure. Here, we developed and validated a deep reinforcement learning-based decision-support AI agent to optimize patient transfer decisions during simulated MCIs by balancing patient acuity levels, specialized care requirements, hospital capacities, and transport logistics. To integrate this AI agent, we developed MasTER, a web-accessible command dashboard for MCI management simulations. Through a controlled user study with 30 participants (6 trauma experts and 24 non-experts), we evaluated three interaction approaches with the AI agent (human-only, human-AI collaboration, and AI-only) across 20- and 60-patient MCI scenarios in the Greater Toronto Area. Results demonstrate that increasing AI involvement significantly improves decision quality and consistency. The AI agent outperforms trauma surgeons (p < 0.001) and enables non-experts to achieve expert-level performance when assisted, contrasting sharply with their significantly inferior unassisted performance (p < 0.001). These findings establish the potential for our AI-driven decision support to enhance both MCI preparedness training and real-world emergency response management.

Mustafa Khanbhai, Giulia Di Nardo, Jun Ma et al.

Effective preoperative planning requires accurate algorithms for segmenting anatomical structures across diverse datasets, but traditional models struggle with generalization. This study presents a novel machine learning methodology to improve algorithm generalization for 3D anatomical reconstruction beyond breast cancer applications. We processed 120 retrospective breast MRIs (January 2018-June 2023) through three phases: anonymization and manual segmentation of T1-weighted and dynamic contrast-enhanced sequences; co-registration and segmentation of whole breast, fibroglandular tissue, and tumors; and 3D visualization using ITK-SNAP. A human-in-the-loop approach refined segmentations using U-Mamba, designed to generalize across imaging scenarios. Dice similarity coefficient assessed overlap between automated segmentation and ground truth. Clinical relevance was evaluated through clinician and patient interviews. U-Mamba showed strong performance with DSC values of 0.97 ($\pm$0.013) for whole organs, 0.96 ($\pm$0.024) for fibroglandular tissue, and 0.82 ($\pm$0.12) for tumors on T1-weighted images. The model generated accurate 3D reconstructions enabling visualization of complex anatomical features. Clinician interviews indicated improved planning, intraoperative navigation, and decision support. Integration of 3D visualization enhanced patient education, communication, and understanding. This human-in-the-loop machine learning approach successfully generalizes algorithms for 3D reconstruction and anatomical segmentation across patient datasets, offering enhanced visualization for clinicians, improved preoperative planning, and more effective patient education, facilitating shared decision-making and empowering informed patient choices across medical applications.

Annika Reinke, Minu D. Tizabi, Carole H. Sudre et al.

While the importance of automatic image analysis is continuously increasing, recent meta-research revealed major flaws with respect to algorithm validation. Performance metrics are particularly key for meaningful, objective, and transparent performance assessment and validation of the used automatic algorithms, but relatively little attention has been given to the practical pitfalls when using specific metrics for a given image analysis task. These are typically related to (1) the disregard of inherent metric properties, such as the behaviour in the presence of class imbalance or small target structures, (2) the disregard of inherent data set properties, such as the non-independence of the test cases, and (3) the disregard of the actual biomedical domain interest that the metrics should reflect. This living dynamically document has the purpose to illustrate important limitations of performance metrics commonly applied in the field of image analysis. In this context, it focuses on biomedical image analysis problems that can be phrased as image-level classification, semantic segmentation, instance segmentation, or object detection task. The current version is based on a Delphi process on metrics conducted by an international consortium of image analysis experts from more than 60 institutions worldwide.

Lena Maier-Hein, Matthias Eisenmann, Duygu Sarikaya et al.

Recent developments in data science in general and machine learning in particular have transformed the way experts envision the future of surgery. Surgical Data Science (SDS) is a new research field that aims to improve the quality of interventional healthcare through the capture, organization, analysis and modeling of data. While an increasing number of data-driven approaches and clinical applications have been studied in the fields of radiological and clinical data science, translational success stories are still lacking in surgery. In this publication, we shed light on the underlying reasons and provide a roadmap for future advances in the field. Based on an international workshop involving leading researchers in the field of SDS, we review current practice, key achievements and initiatives as well as available standards and tools for a number of topics relevant to the field, namely (1) infrastructure for data acquisition, storage and access in the presence of regulatory constraints, (2) data annotation and sharing and (3) data analytics. We further complement this technical perspective with (4) a review of currently available SDS products and the translational progress from academia and (5) a roadmap for faster clinical translation and exploitation of the full potential of SDS, based on an international multi-round Delphi process.