Rethinking Artificial Intelligence in Medical Imaging: Assumptions, Reality, and Reframing

Medical imaging has served as primary proving ground for clinical artificial intelligence (AI), yet a decade of intense research has not translated into proportionate bedside impact. We argue that this gap is not primarily a product of insufficient algorithmic performance, inadequate regulation, or limited explainability. Rather, it reflects a structural misalignment, between how AI systems are designed and evaluated, and how clinical decisions are made. This Perspective identifies six interconnected dimensions of this misalignment: the dominance of pixel-only models in a multimodal clinical world; the erosion of physician trust through opaque and inflexible systems; the unfulfilled promise of foundation models in data-sparse medical domains; the persistent bottleneck of non-shareable, under-curated datasets; the gap between validated algorithms and deployable clinical platforms; and the failure of prediction-centric AI to generate actionable clinical guidance. For each dimension, we reframe the problem and propose a path forward, culminating in a vision of agentic, physician-aligned AI that extends, rather than replaces, clinical judgment.

Retrieval, not hallucinations, will be the limiting factor for LLM-based clinical AI tools

Discussions around large language model (LLM) errors in clinical artificial intelligence (AI) generally center around precision errors like hallucinations. This perspective, targeting both clinicians and AI researchers, seeks to shift that discussion to recall errors, particularly in retrieval of patient-level data needed for many clinical AI tools. The perspective outlines types of errors and mitigation strategies, describes research directions in LLMs and retrieval, and provides an overview of retrieval evaluation.