Beyond Algorithms: Conceptual Innovation in Medical Imaging AI

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.

Methodological progress in artificial intelligence (AI) for electronic health records (EHRs) depends on our ability to determine which algorithms work better, and under which conditions. However, such progress is thought to be hindered by difficulties in reproducibility and in defining clinically meaningful evaluation tasks. We empirically study these barriers by re-implementing 12 historical and recent algorithms within a shared evaluation framework and evaluating them on two clinical datasets, MIMIC-IV and NWICU. We compare two complementary task families: expert-authored clinically meaningful tasks and generated tasks defined from randomly sampled event codes and prediction horizons. We ask whether relative algorithms comparisons transfer across task families and datasets, whether residual task heterogeneity contains useful methodological structure, and what a controlled comparison reveals about progress over the last decade. We find that aggregate pairwise comparisons transfer strongly across evaluation settings, including from randomly generated tasks to clinically meaningful tasks and across datasets. At the same time, clinically meaningful tasks exhibit greater task-method interaction, providing preliminary evidence that task properties can help explain when particular modeling choices are advantageous. Finally, newer algorithms do not consistently outperform earlier approaches: gradient-boosted trees remain highly competitive when paired with a modern, wide and sparse representation of the EHR. Together, these results suggest that useful methodological knowledge may require less task engineering than commonly assumed, while highlighting the importance of understanding the structured heterogeneity that remains across tasks and methods.

Autonomous agents are increasingly expected to support end-to-end medical-AI research workflows, moving beyond isolated prediction tasks or short-form clinical question answering. However, existing medical agent benchmarks primarily evaluate final outputs, providing limited visibility into agent behavior within the research process. To address this gap, we present AutoMedBench, a workflow-aware benchmark for autonomous medical-AI research across diverse medical imaging and multimodal inference tasks, organizing agent execution into a unified five-stage workflow (S1-S5): Plan, Setup, Validate, Inference, and Submit. It comprises long-horizon tasks with each run averaging 33 agent turns, spanning five research tracks: segmentation, image enhancement, visual question answering (VQA), report generation, and lesion detection. Each task is evaluated under two difficulty tiers, Lite and Standard, which use the same data and metrics but differ in the amount of task-brief scaffolding, and each run is scored using both final task performance and S1-S5 stage scores, enabling stage-level analysis from the initial task brief to the final submitted artifact. Across thousands of recorded runs, stage-level scoring reveals that Validate is the weakest workflow stage on average, whereas Setup is the strongest, suggesting that current agents are better at making pipelines executable than at verifying their reliability. Post-run error analysis further shows that verification and submission failures dominate tagged errors, accounting for 37.7% and 38.1% of fired codes respectively, whereas task-understanding errors are rare at 0.9%, and runs with one fired error code have a 48% lower overall score than runs with no error code on average.