Vivek Natarajan

Daniel McDuff, Mike Schaekermann, Tao Tu et al.

An accurate differential diagnosis (DDx) is a cornerstone of medical care, often reached through an iterative process of interpretation that combines clinical history, physical examination, investigations and procedures. Interactive interfaces powered by Large Language Models (LLMs) present new opportunities to both assist and automate aspects of this process. In this study, we introduce an LLM optimized for diagnostic reasoning, and evaluate its ability to generate a DDx alone or as an aid to clinicians. 20 clinicians evaluated 302 challenging, real-world medical cases sourced from the New England Journal of Medicine (NEJM) case reports. Each case report was read by two clinicians, who were randomized to one of two assistive conditions: either assistance from search engines and standard medical resources, or LLM assistance in addition to these tools. All clinicians provided a baseline, unassisted DDx prior to using the respective assistive tools. Our LLM for DDx exhibited standalone performance that exceeded that of unassisted clinicians (top-10 accuracy 59.1% vs 33.6%, [p = 0.04]). Comparing the two assisted study arms, the DDx quality score was higher for clinicians assisted by our LLM (top-10 accuracy 51.7%) compared to clinicians without its assistance (36.1%) (McNemar's Test: 45.7, p < 0.01) and clinicians with search (44.4%) (4.75, p = 0.03). Further, clinicians assisted by our LLM arrived at more comprehensive differential lists than those without its assistance. Our study suggests that our LLM for DDx has potential to improve clinicians' diagnostic reasoning and accuracy in challenging cases, meriting further real-world evaluation for its ability to empower physicians and widen patients' access to specialist-level expertise.

Yu Jiang, Vivek Natarajan, Xinlei Chen et al.

This document describes Pythia v0.1, the winning entry from Facebook AI Research (FAIR)'s A-STAR team to the VQA Challenge 2018. Our starting point is a modular re-implementation of the bottom-up top-down (up-down) model. We demonstrate that by making subtle but important changes to the model architecture and the learning rate schedule, fine-tuning image features, and adding data augmentation, we can significantly improve the performance of the up-down model on VQA v2.0 dataset -- from 65.67% to 70.22%. Furthermore, by using a diverse ensemble of models trained with different features and on different datasets, we are able to significantly improve over the 'standard' way of ensembling (i.e. same model with different random seeds) by 1.31%. Overall, we achieve 72.27% on the test-std split of the VQA v2.0 dataset. Our code in its entirety (training, evaluation, data-augmentation, ensembling) and pre-trained models are publicly available at: https://github.com/facebookresearch/pythia

Anil Palepu, Vikram Dhillon, Polly Niravath et al.

Large language models (LLMs) have shown remarkable progress in encoding clinical knowledge and responding to complex medical queries with appropriate clinical reasoning. However, their applicability in subspecialist or complex medical settings remains underexplored. In this work, we probe the performance of AMIE, a research conversational diagnostic AI system, in the subspecialist domain of breast oncology care without specific fine-tuning to this challenging domain. To perform this evaluation, we curated a set of 50 synthetic breast cancer vignettes representing a range of treatment-naive and treatment-refractory cases and mirroring the key information available to a multidisciplinary tumor board for decision-making (openly released with this work). We developed a detailed clinical rubric for evaluating management plans, including axes such as the quality of case summarization, safety of the proposed care plan, and recommendations for chemotherapy, radiotherapy, surgery and hormonal therapy. To improve performance, we enhanced AMIE with the inference-time ability to perform web search retrieval to gather relevant and up-to-date clinical knowledge and refine its responses with a multi-stage self-critique pipeline. We compare response quality of AMIE with internal medicine trainees, oncology fellows, and general oncology attendings under both automated and specialist clinician evaluations. In our evaluations, AMIE outperformed trainees and fellows demonstrating the potential of the system in this challenging and important domain. We further demonstrate through qualitative examples, how systems such as AMIE might facilitate conversational interactions to assist clinicians in their decision making. However, AMIE's performance was overall inferior to attending oncologists suggesting that further research is needed prior to consideration of prospective uses.

Alexandros Karargyris, Renato Umeton, Micah J. Sheller et al.

Medical AI has tremendous potential to advance healthcare by supporting the evidence-based practice of medicine, personalizing patient treatment, reducing costs, and improving provider and patient experience. We argue that unlocking this potential requires a systematic way to measure the performance of medical AI models on large-scale heterogeneous data. To meet this need, we are building MedPerf, an open framework for benchmarking machine learning in the medical domain. MedPerf will enable federated evaluation in which models are securely distributed to different facilities for evaluation, thereby empowering healthcare organizations to assess and verify the performance of AI models in an efficient and human-supervised process, while prioritizing privacy. We describe the current challenges healthcare and AI communities face, the need for an open platform, the design philosophy of MedPerf, its current implementation status, and our roadmap. We call for researchers and organizations to join us in creating the MedPerf open benchmarking platform.

Abhijit Guha Roy, Jie Ren, Shekoofeh Azizi et al.

We develop and rigorously evaluate a deep learning based system that can accurately classify skin conditions while detecting rare conditions for which there is not enough data available for training a confident classifier. We frame this task as an out-of-distribution (OOD) detection problem. Our novel approach, hierarchical outlier detection (HOD) assigns multiple abstention classes for each training outlier class and jointly performs a coarse classification of inliers vs. outliers, along with fine-grained classification of the individual classes. We demonstrate the effectiveness of the HOD loss in conjunction with modern representation learning approaches (BiT, SimCLR, MICLe) and explore different ensembling strategies for further improving the results. We perform an extensive subgroup analysis over conditions of varying risk levels and different skin types to investigate how the OOD detection performance changes over each subgroup and demonstrate the gains of our framework in comparison to baselines. Finally, we introduce a cost metric to approximate downstream clinical impact. We use this cost metric to compare the proposed method against a baseline system, thereby making a stronger case for the overall system effectiveness in a real-world deployment scenario.

Shekoofeh Azizi, Basil Mustafa, Fiona Ryan et al.

Self-supervised pretraining followed by supervised fine-tuning has seen success in image recognition, especially when labeled examples are scarce, but has received limited attention in medical image analysis. This paper studies the effectiveness of self-supervised learning as a pretraining strategy for medical image classification. We conduct experiments on two distinct tasks: dermatology skin condition classification from digital camera images and multi-label chest X-ray classification, and demonstrate that self-supervised learning on ImageNet, followed by additional self-supervised learning on unlabeled domain-specific medical images significantly improves the accuracy of medical image classifiers. We introduce a novel Multi-Instance Contrastive Learning (MICLe) method that uses multiple images of the underlying pathology per patient case, when available, to construct more informative positive pairs for self-supervised learning. Combining our contributions, we achieve an improvement of 6.7% in top-1 accuracy and an improvement of 1.1% in mean AUC on dermatology and chest X-ray classification respectively, outperforming strong supervised baselines pretrained on ImageNet. In addition, we show that big self-supervised models are robust to distribution shift and can learn efficiently with a small number of labeled medical images.

Alexander D'Amour, Katherine Heller, Dan Moldovan et al.

ML models often exhibit unexpectedly poor behavior when they are deployed in real-world domains. We identify underspecification as a key reason for these failures. An ML pipeline is underspecified when it can return many predictors with equivalently strong held-out performance in the training domain. Underspecification is common in modern ML pipelines, such as those based on deep learning. Predictors returned by underspecified pipelines are often treated as equivalent based on their training domain performance, but we show here that such predictors can behave very differently in deployment domains. This ambiguity can lead to instability and poor model behavior in practice, and is a distinct failure mode from previously identified issues arising from structural mismatch between training and deployment domains. We show that this problem appears in a wide variety of practical ML pipelines, using examples from computer vision, medical imaging, natural language processing, clinical risk prediction based on electronic health records, and medical genomics. Our results show the need to explicitly account for underspecification in modeling pipelines that are intended for real-world deployment in any domain.

Wei-Hung Weng, Jonathan Deaton, Vivek Natarajan et al.

Class imbalance is a common problem in medical diagnosis, causing a standard classifier to be biased towards the common classes and perform poorly on the rare classes. This is especially true for dermatology, a specialty with thousands of skin conditions but many of which have low prevalence in the real world. Motivated by recent advances, we explore few-shot learning methods as well as conventional class imbalance techniques for the skin condition recognition problem and propose an evaluation setup to fairly assess the real-world utility of such approaches. We find the performance of few-show learning methods does not reach that of conventional class imbalance techniques, but combining the two approaches using a novel ensemble improves model performance, especially for rare classes. We conclude that ensembling can be useful to address the class imbalance problem, yet progress can further be accelerated by real-world evaluation setups for benchmarking new methods.

Jim Winkens, Rudy Bunel, Abhijit Guha Roy et al.

Reliable detection of out-of-distribution (OOD) inputs is increasingly understood to be a precondition for deployment of machine learning systems. This paper proposes and investigates the use of contrastive training to boost OOD detection performance. Unlike leading methods for OOD detection, our approach does not require access to examples labeled explicitly as OOD, which can be difficult to collect in practice. We show in extensive experiments that contrastive training significantly helps OOD detection performance on a number of common benchmarks. By introducing and employing the Confusion Log Probability (CLP) score, which quantifies the difficulty of the OOD detection task by capturing the similarity of inlier and outlier datasets, we show that our method especially improves performance in the `near OOD' classes -- a particularly challenging setting for previous methods.

Amirata Ghorbani, Vivek Natarajan, David Coz et al.

Despite the recent success in applying supervised deep learning to medical imaging tasks, the problem of obtaining large and diverse expert-annotated datasets required for the development of high performant models remains particularly challenging. In this work, we explore the possibility of using Generative Adverserial Networks (GAN) to synthesize clinical images with skin condition. We propose DermGAN, an adaptation of the popular Pix2Pix architecture, to create synthetic images for a pre-specified skin condition while being able to vary its size, location and the underlying skin color. We demonstrate that the generated images are of high fidelity using objective GAN evaluation metrics. In a Human Turing test, we note that the synthetic images are not only visually similar to real images, but also embody the respective skin condition in dermatologists' eyes. Finally, when using the synthetic images as a data augmentation technique for training a skin condition classifier, we observe that the model performs comparably to the baseline model overall while improving on rare but malignant conditions.

Amanpreet Singh, Vivek Natarajan, Meet Shah et al.

Studies have shown that a dominant class of questions asked by visually impaired users on images of their surroundings involves reading text in the image. But today's VQA models can not read! Our paper takes a first step towards addressing this problem. First, we introduce a new "TextVQA" dataset to facilitate progress on this important problem. Existing datasets either have a small proportion of questions about text (e.g., the VQA dataset) or are too small (e.g., the VizWiz dataset). TextVQA contains 45,336 questions on 28,408 images that require reasoning about text to answer. Second, we introduce a novel model architecture that reads text in the image, reasons about it in the context of the image and the question, and predicts an answer which might be a deduction based on the text and the image or composed of the strings found in the image. Consequently, we call our approach Look, Read, Reason & Answer (LoRRA). We show that LoRRA outperforms existing state-of-the-art VQA models on our TextVQA dataset. We find that the gap between human performance and machine performance is significantly larger on TextVQA than on VQA 2.0, suggesting that TextVQA is well-suited to benchmark progress along directions complementary to VQA 2.0.