Organizations: Department of Basic and Translational Research, BC Cancer Research Institute, Vancouver, BC, Canada · Department of Radiology, University of British Columbia, Vancouver, BC, Canada · Departments of Physics and Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada · Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada · Vector Institute, Canada · Institute of Nuclear Medicine, Bethesda, MD, United States
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.