Clinical Imaging 65 (2020) 96–99

Contents lists available at ScienceDirect

Clinical Imaging
journal homepage: www.elsevier.com/locate/clinimag

Understanding artificial intelligence based radiology studies: What is T

overfitting?
⁎
Simukayi Mutasa, Shawn Sun, Richard Ha
Columbia University Medical Center, New York Presbyterian Hospital, 622 West 168th Street, PB-1-301, New York, NY 10032, United States of America

A R T I C LE I N FO A B S T R A C T

Keywords: Artificial intelligence (AI) is a broad umbrella term used to encompass a wide variety of subfields dedicated to
Overfitting creating algorithms to perform tasks that mimic human intelligence. As AI development grows closer to clinical
Artificial intelligence integration, radiologists will need to become familiar with the principles of artificial intelligence to properly
Machine learning evaluate and use this powerful tool. This series aims to explain certain basic concepts of artificial intelligence,
and their applications in medical imaging starting with a concept of overfitting.

“Radiologists will not be replaced by AI. Radiologists who use and

1. Introduction
Artificial intelligence (AI) is a broad umbrella term used to en-
compass a wide variety of subfields dedicated to, simply put, creating
algorithms to perform tasks that mimic human intelligence. Machine
learning is a subfield of artificial intelligence which involves the crea-
tion of algorithms that can parse data and modify themselves to pro-
duce a desired output. This was applied heavily to the field of computer
vision; it frequently used hand-crafted features such as edge detection
algorithms or shape detectors. Deep learning is a type of machine
learning that uses multiple layers to extract progressively higher level
features as the algorithm is trained on structured data and creates its
own composition of features which it determines to be important. There
is much excitement around deep learning's ability to discover pre-
viously unknown relationships in data and perform almost any complex
mapping with correct training.
Since the success of AlexNet on the Image Net challenge in 2012,
deep learning algorithms have seen remarkable advancements in the
field of medical imaging [1–3]. This technology has been applied to
oncological detection, characterization, and monitoring in recent stu-
dies and has achieved impressive results [4–15]. Recently, we are be-
ginning to see research results which suggest performance similar to, or
better than, radiologists for various tasks [16]. As development grows
closer to clinical integration, radiologists will need to become familiar
with the principles of artificial intelligence to properly evaluate and use
this powerful tool. This series aims to explain certain basic concepts of
artificial intelligence, and their applications in medical imaging starting
with a concept of overfitting.
understand AI will replace radiologists who don't.”
Curt Langlotz [17]
2. Overfitting
Overfitting is a major obstacle for AI technology, but what exactly,
is overfitting? Burnham describes “the essence of overfitting is to have
unknowingly extracted some of the residual variation as if that varia-
tion represented underlying model structure” [18]. In layman's terms,
overfitting means that an AI model has learned in a manner that is only
applicable to the training sample and is no longer generalizable to the
overall population (Fig. 1).
For example, if an algorithm designed to distinguish between dogs
and cats is trained only with the German shepherd dogs and Siamese
cats in (Fig. 2), it will perform well if subsequently tested only on
German shepherd dogs and Siamese cats. However, if the algorithm is
then asked to distinguish other types of dogs and cats (Fig. 3), which it
has not seen before, its performance will decrease substantially.
We can recognize that certain characteristics, such as the white fur
pattern and blue eye color of Siamese cats, pertain to that individual
species, but are not representative of all cats. However, if the model
only has access to the pictures in Fig. 2, it will have no way of learning
this piece of knowledge. Medical studies will similarly require diverse
training samples in order to draw generalizable conclusions that will
apply to the population at large.

⁎
Corresponding author at: Columbia University Medical Center, New York Presbyterian Hospital, 622 West 168th Street, PB-1-301, New York, NY 10032, United
States of America.
E-mail addresses: stm9116@nyp.org (S. Mutasa), shs2179@cumc.columbia.edu (S. Sun), rh2616@columbia.edu (R. Ha).

https://doi.org/10.1016/j.clinimag.2020.04.025
Received 9 March 2020; Received in revised form 10 April 2020; Accepted 17 April 2020
0899-7071/ © 2020 Elsevier Inc. All rights reserved.
S. Mutasa, et al. Clinical Imaging 65 (2020) 96–99

Fig. 1. A graphical representation of overfitting. (Left) The trend line hasn't learned enough patterns from the data and has failed to capture the dominant trend.
(Middle) The trend line is a good fit for this set of data. (Right) The trend line has learned too many patterns and has lost the dominant trend. This algorithm would
not be generalizable to new data.

Fig. 2. Example of German shepherd dogs and Siamese cats.

Fig. 3. Example of different types of dogs and cats.

2.1. Digging deeper
A typical deep learning algorithm consists of a neural network ar-
chitecture that begins with an input, connects to layers of nodes, and
ultimately ends in an output. During the learning process, the para-
meters or “weights” within the nodes are continuously adjusted to
minimize the difference between the output and the correct answer
(ground truth). This extracts the features in the input that were most
important to solving the question. However, if a model is run through
the same training data too many times without enough regularization,
the model will inevitably capture residual variation, or noise, as fea-
tures and interpret these as parameters useful for prediction, thus de-
creasing the overall generalizability [18,19].
3. Overcoming overfitting
The most effective way to mitigate overfitting is to collect more
training data. Ideally your training data would be truly representative
of the overall population. In the case of distinguishing cats and dogs,
examples of many species of dogs and cats would be necessary in the
training set (Fig. 3). In the original ImageNet competition, where deep
learning neural networks first publicly demonstrated their power, re-
searchers had the luxury of having 1.4 million images to work with
[21]. These datasets are orders of magnitude larger than the medical
image datasets most AI radiology studies are using, and represent one
major reason why current medical studies may be prone to overfitting
[22,23]. Though there is no set number of “sufficient” training data, as
this number will vary depending on the study and the question asked, a
general basic starting point around 1000 images per class will have a
good chance of training a classifier accurately. This is based largely on
the ImageNet database which contained around 1000 images per class.
There are many factors that can reduce this requirement including
using different architecture types, how representative of the population
your training data is, how distinguishable the different classes are, and
the methods you employ for regularization.
Medical data has historically been difficult to amass due to concerns
about patient confidentiality and the cost of obtaining high quality
ground-truth annotated data [22,23]. However, the efforts of large data

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S. Mutasa, et al.
Fig. 4. Data augmentation: Artificially increase the size of a training dataset by
creating image variants from the original dataset such as flipping, rotation,
cropping, skewing without straying too far from the original label.
archives, such as the Cancer Imaging Archive (TCIA), are making de-
identified, public medical imaging data more accessible to researchers
around the world [24]. A recent Google AI project utilized the National
Lung Cancer Screening Trial (NSLT) data, including 42,000 CT cases
[16]. The 2019 RSNA AI Challenge for Intracranial Hemorrhage De-
tection and Classification assembled a dataset of over 25,000 annotated
brain CTs [25]. The success of these recent large dataset studies will
undoubtedly foster future efforts to provide large data to AI researchers.
3.1. Technical solutions
Researchers have also developed several creative workarounds to
efficiently use limited training data and prevent overfitting. One
strategy, data augmentation, can artificially increase the size of a
training dataset by creating image variants from the original dataset.
This can involve random rigid affine transformations, such as flipping,
rotation, cropping, skewing, or even the introduction of artifacts to
diversify the images without straying too far from the original label, as
shown in Fig. 4 [22,26].
Kim et al., in their effort to detect fractures, used this technique to
create 11,112 training images from an original dataset of only 1389
images [27]. Warped images, while providing variation, do not prove
the same degree of data enrichment that additional, separate examples
do.
In a study using CNN to predict breast cancer molecular subtype
published in 2019 [15], Ha et al. used this augmentation technique to
increase sample size (Fig. 5). Images of a single input example of an
enhancing mass with multiple random affine warps applied for data
augmentation. This technique alters the mass slightly utilizing a rigid
transformation effectively making additional unique samples of the
Fig. 5. Images of a single input example of an enhancing mass with multiple
random affine warps applied for data augmentation.
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Clinical Imaging 65 (2020) 96–99
same mass to be inputted to the network.
Another strategy is transfer learning, which involves the use of a
network that is already trained on a different dataset, such as the
ImageNet collection, and then fine-tuning it with the addition of a small
amount of training data to direct the network to a specific task [11].
This utilizes the concept that visual tasks require similar processing, for
example, the recognition of edges and simple shapes. Similarly, deep
features, or off-the-shelf features, can be extracted from pre-trained
CNNs, and then applied to a new task [29]. Several groups have all
demonstrated increased performance using transfer learning [30–32].
Typically transfer learning works best when the data that the original
network was trained on is similar to the new data. As such, there is no
current consensus that networks trained to recognize cats and dogs
perform consistently better when fine-tuned on medical images than
networks trained from random initializations.
On the other hand, another approach to limit overfitting is modify
the learning algorithm in a way that the model will generalize better,
known as regularization [33,34]. One such technique, dropout, can
limit the capacity of the network.
3.2. Digging deeper
Dropout is based on the insight that an ensemble of neural net-
works, each trained on the same data but with slightly different con-
siderations, generalizes better. Dropout allows us to have a large
number of different network architectures while training by randomly
removing nodes during training. The theory behind this is that the ar-
chitecture of a neural network can compensate for individual nodal
deficiencies. However, this is not reproducible to unseen data, and
disrupting the architecture slightly by dropping random nodes will re-
move this compensation effect [35].
Another technique for regularization is called L1/L2 regularization.
As a neural network learns each feature, each feature is given a weight
to determine how significant that feature is. We can limit the magnitude
of our weights through L1/L2 regularization so that no single feature
overwhelms others [36]. This has the effect of encouraging the agree-
ment of many input features when coming to a certain conclusion as
opposed to preferring the input of a few overwhelming features.
Batch normalization (BN), initially developed to mitigate a game of
“broken telephone” which can occur when layers in a neural network
are unable to learn simultaneously, has a small regularizing effect. The
theoretical motivation for batch normalization is outside the scope of
this paper; however it functions by forcing normalization of the acti-
vation maps to a learned mean and standard deviation. This has the
effect of introducing noise to the input of each layer in the neural
network, which introduces a regularization effect [37].
4. Importance of external validation
The exciting results of recent AI radiology studies certainly generate
much anticipation towards a future where radiologists utilize AI to
better save lives [38]. However, the pitfall of overfitting really high-
lights the need for external validation of AI before clinical im-
plementation. There have been cases of neural network performance
being affected by data from a different institution [39,40]. To prove to
clinicians the validity of results, deep neural networks need to de-
monstrate performance on external data different from its training data.
Some researchers have even emphasized the need for prospective,
multi-center, cohort studies [41] and to hold AI technology to the same
level of scrutiny as new clinical drugs. Undoubtedly, the field of AI in
medical imaging is still in its infancy, as studies achieving that level of
validation are extremely rare [42].
5. Conclusion
Overfitting is a common pitfall in which AI models capture noise or
S. Mutasa, et al.
superficial information rather than truly distinguishing disease. Models
that are overfitted will have a high training performance but will have
severely decreased accuracy upon encountering new data. This can be
overcome by increasing the amount of training data, data augmenta-
tion, or several other techniques such as regularization and dropout.
Before AI algorithms can be incorporated into clinical use, external
validation will be necessary to ensure generalizability.
Declaration of competing interest
No disclosures. No conflict of interest.
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