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Life sciences · Preprint
arXiv · September 22, 2026
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Medical image interpretation is high-volume and time-consuming, and while AI interpretation can reduce workload, fully autonomous deployment carries potential safety concerns and low specificity may in practice lead to increased clinician workload. Learning to Defer (L2D) addresses this by selectively routing cases between autonomous prediction and human experts by learning from input features and AI model and human performance. While theoretical guarantees have been proven for L2D, its performance has not been validated on real-world medical datasets with human reader annotations. We evaluate the predictor-rejector formulation of two-stage L2D, where the AI predictor model is fixed and separate from the trainable routing or rejector model, on Collab-CXR, a multilabel chest X-ray dataset with multiple human annotations per case. This is the first work to look at L2D in the context of real-world medical imaging data with human annotations. We further introduce a new setup, L2D with Guidance, where the decision space is extended to three choices: predict autonomously, defer to a human expert, or defer to a human expert and provide AI guidance. We compare multiple rejector architectures and loss functions, and different input feature availabilities. This is reproduced on two larger datasets, VinDr-CXR and CheXpert. Our results show that two-stage L2D with Guidance outperforms classic two-stage learning to defer, as well as human-alone, AI-alone and AI-guided human baselines. Notably, this performance is achieved with simpler loss functions compared to formally defined L2D surrogate loss functions in current literature.