Precision Recall Controllable Radiology Report Generation via Hybrid Natural Language and Clinical Reward Learning
Authors: Ling Chen, Ruinan Jin, Jun Luo, Hanliang Chen, Quirin Strotzer, Rongkai Yan, Yuan Xue, Luciano Prevedello, +1 more
Organizations: The Ohio State University, Columbus, OH 43221, USA · University Medical Center Regensburg, Regensburg, Germany
Abstract
Automated radiology report generation (RRG) has gained increasing attention because it can reduce the heavy workload of clinical report writing. However, most existing methods mainly optimize for natural language generation (NLG) metrics that focus on language fluency, while providing little control over clinically important factors such as precision and recall. As consequence, generated reports may be fluent but not well aligned with different clinical needs. To address this challenge, we propose a reinforcement learning framework for precision recall controllable RRG, where a control parameter explicitly adjusts the trade-off between clinical precision and recall during inference. This design allows the model to flexibly generate reports according to different clinical requirements. To ensure clinical correctness, we introduce a clinical reward into the training objective, which helps improve clinical efficacy (CE) beyond standard language-based optimization. In addition, we apply a group-relative training strategy that normalizes rewards within each training group, reducing reward variance and improving training stability. Extensive experiments on the MIMIC-CXR dataset show that our method consistently outperforms state-of-the-art approaches in both NLG and CE evaluation metrics, while providing reliable control over the CE precision recall trade-off.
Chest X-ray (CXR) radiology report generation (RRG) models have shown rapid progress on automated metrics, yet their clinical utility remains uncertain due to limited qualitative evaluation by radiologists. We present CXRMate-2, a state-of-the-art CXR RRG model that enables tractable reinforcement learning (RL) through structured multimodal temporal embeddings and high-resolution visual feature compression, for efficient, unified conditioning of an LLM decoder on visual, textual, and temporal context from a study and its prior. This enables group relative policy optimisation (GRPO), where a proposed reward function is used to improve semantic alignment with radiologist reports. Across the MIMIC-CXR, CheXpert Plus, and ReXgradient datasets, CXRMate-2 achieves statistically significant improvements over strong benchmarks, including gains of 11.2% and 24.4% in GREEN and RadGraph-XL, respectively, on MIMIC-CXR relative to MedGemma 1.5 (4B). To directly compare CXRMate-2 against radiologist reporting, we conduct a blinded, randomised qualitative retrospective evaluation. Three consultant radiologists compare generated and radiologist reports across 120 studies from the MIMIC-CXR test set. Generated reports were deemed acceptable (defined as preferred or rated equally to radiologist reports) in 45% of ratings, with no statistically significant difference in preference rates for seven of the eight analysed findings. Preferences for radiologist reports were driven primarily by higher recall, while generated reports were consistently preferred for readability. Together, these results define a clear pathway to clinically acceptable CXR RRG. Improving recall and the detection of subtle findings represents the primary remaining barrier to non-inferiority with radiologist reporting, positioning CXR RRG for prospective evaluation in assistive, radiologist-led workflows.
Aaron Nicolson, Elizabeth J. Cooper, Hwan-Jin Yoon +7
Medical imaging interpretation is a foundational pillar of modern clinical diagnostics, yet the manual generation of radiology reports remains a time-consuming process prone to interpretation inconsistencies. Within the field of medical AI, automating these descriptions through deep learning promises to streamline clinical workflows and standardise diagnostic output. However, accurate disease detection and precise report generation remain significant challenges due to limitations in capturing fine-grained visual features and ensuring clinical coherence. To address these issues, we propose RL-ACRGNet, an improved encoder-decoder model that integrates a pre-trained DenseNet encoder with a multilevel LSTM decoder within an off-policy reinforcement learning framework. Using a dual-network approach to refine visual-semantic embeddings through a metric-based reward mechanism, we demonstrate that RL-ACRGNet consistently outperforms state-of-the-art baselines on the IU-Xray dataset, achieving quantitative improvements in BLEU-4 (0.47%), METEOR (0.17%) and ROUGE-L (0.518). Furthermore, comprehensive evaluations on the large-scale MIMIC-CXR data set confirm the robust generalisation of the model and its ability to generate high-quality, clinically relevant reports
While multi-task learning based automatic radiology report generation (RRG) is widely adopted to ensure clinical consistency, most focus on architectural designs yet remain limited to coarse linear scalarization strategies. These strategies cannot effectively balance the hard constraints of discriminative clinical supervision with the smoothness requirements of report generation. To address these problems, we analyze the failure mechanism of linear scalarization from the perspective of gradient dynamics, utilizing the stochastic differential equation (SDE) framework to characterize it as a "Double Dilemma" of drift term deviation and diffusion term decay. Based on this, we propose a backbone-agnostic optimizer named Conflict-Averse Magnitude-Enhanced Gradient Descent (CAME-Grad). Through conflict-averse direction rectification and magnitude-enhanced energy injection, the algorithm not only ensures geometric validity, but also avoids local optimal solutions. Then, the adaptive gradient fusion mechanism is used to establish a dynamic balance between the theoretical optimal direction and the task-specific inductive bias. Experiments show that as a universal plug-and-play optimizer, CAME-Grad brings substantial and consistent improvements across eight diverse RRG methods, elevating overall clinical efficacy performance by an average of 2.3% on MIMIC-CXR and 1.9% on IU X-Ray. Our code is available at https://github.com/vpsg-research/CAME-Grad.