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This perspective reframes few-shot medical image segmentation as a sequential clinician-model decision process governed by a dual static support budget and a dynamic interaction budget. Standard static few-shot formulations break down under real-world acquisition shifts and atypical pathology, necessitating a mechanism that explicitly balances expert effort against segmentation reliability. The resulting framework unifies selective prediction, test-time adaptation, and promptable foundation models by optimizing expert queries using response-conditioned net expected value of information under strict safety and consistency gates.
Human-in-the-loop segmentation breaks down when expert attention is treated as an infinite resource鈥攁llocating clinician queries strictly by expected value of information transforms fragile few-shot models into risk-bounded decision systems.
Few-shot medical image segmentation (FSMIS) seeks to delineate unseen structures from a small support set, but its standard formulation fixes task-defining evidence before inference. This assumption is fragile when query cases exhibit acquisition shift, atypical pathology, ambiguous boundaries, or poor image quality. Prototype learning, cross-domain matching, interactive segmentation, uncertainty estimation, test-time adaptation, and promptable foundation models address parts of this problem, yet have not been jointly evaluated under a common model of expert attention and clinical risk. This Perspective reframes FSMIS as a sequential clinician-model decision problem with a static support budget $K$ and a distinct interaction budget $B$. At each step, a system accepts the current segmentation, requests feedback, or defers to full expert review. Queries vary in location and modality and are selected by response-conditioned net expected value of information; clinician-provided feedback informs bounded adaptation only after prespecified provenance, consistency, and safety gates. The framework separates distributional atypicality from predicted clinical failure and treats clinician responses as informative but fallible observations. We synthesize the transition from few-shot and cross-domain segmentation to interactive and selective adaptation, delineate the integration gap, and define four research directions with falsifiable hypotheses. Evaluation spans external-domain calibration, quality-effort trade-offs, reader studies, and prospective workflow assessment. The central claim is not that interaction alone resolves domain shift, but that scarce expert attention should be allocated only when it is expected to reduce clinically relevant risk.
