# Reporting Practice Matters: The Impact of Reference Choice on Chest X-ray Report Evaluation

arXiv: https://arxiv.org/abs/2609.19093 · HTML: https://mlsanity.com/paper/2609.19093/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 20 of its 34 references that are in the map.
- First posted on arXiv 16 Sep 2026.

## Builds on (most cited first, 20 of 20)

- [Llama 2: Open Foundation and Fine-Tuned Chat Models](https://mlsanity.com/paper/2307.09288/) (2023)
- [BERTScore: Evaluating Text Generation with BERT](https://mlsanity.com/paper/1904.09675/) (2019)
- [Generating Radiology Reports via Memory-driven Transformer](https://mlsanity.com/paper/2010.16056/) (2020)
- [CheXbert: Combining Automatic Labelers and Expert Annotations for Accurate Radiology Report Labeling Using BERT](https://mlsanity.com/paper/2004.09167/) (2020)
- [RadGraph: Extracting Clinical Entities and Relations from Radiology Reports](https://mlsanity.com/paper/2106.14463/) (2021)
- [MAIRA-2: Grounded Radiology Report Generation](https://mlsanity.com/paper/2406.04449/) (2024)
- [GREEN: Generative Radiology Report Evaluation and Error Notation](https://mlsanity.com/paper/2405.03595/) (2024)
- [CheXpert Plus: Augmenting a Large Chest X-ray Dataset with Text Radiology Reports, Patient Demographics and Additional Image Formats](https://mlsanity.com/paper/2405.19538/) (2024)
- [Improving the Factual Correctness of Radiology Report Generation with Semantic Rewards](https://mlsanity.com/paper/2210.12186/) (2022)
- [A Vision-Language Foundation Model to Enhance Efficiency of Chest X-ray Interpretation](https://mlsanity.com/paper/2401.12208/) (2024)
- [RaTEScore: A Metric for Radiology Report Generation](https://mlsanity.com/paper/2406.16845/) (2024)
- [Towards a clinically accessible radiology foundation model: open-access and lightweight, with automated evaluation](https://mlsanity.com/paper/2403.08002/) (2024)
- [Libra: Leveraging Temporal Images for Biomedical Radiology Analysis](https://mlsanity.com/paper/2411.19378/) (2024)
- [ReXGradient-160K: A Large-Scale Publicly Available Dataset of Chest Radiographs with Free-text Reports](https://mlsanity.com/paper/2505.00228/) (2025)
- [ReXrank: A Public Leaderboard for AI-Powered Radiology Report Generation](https://mlsanity.com/paper/2411.15122/) (2024)
- [Automated Structured Radiology Report Generation](https://mlsanity.com/paper/2505.24223/) (2025)
- [Scaling medical imaging report generation with multimodal reinforcement learning](https://mlsanity.com/paper/2601.17151/) (2026)
- [CRIMSON: A Clinically-Grounded LLM-Based Metric for Generative Radiology Report Evaluation](https://mlsanity.com/paper/2603.06183/) (2026)
- [Lunguage: A Benchmark for Structured and Sequential Chest X-ray Interpretation](https://mlsanity.com/paper/2505.21190/) (2025)
- [Gla-AI4BioMed at RRG24: Visual Instruction-tuned Adaptation for Radiology Report Generation](https://mlsanity.com/paper/2412.04954/) (2024)

## Abstract (arXiv)

Radiologists follow heterogeneous reporting practices. Two radiologists examining the same image and identifying the same clinical findings might nevertheless compose superficially distinct reports, varying in terminology, shorthand, formatting, and level of detail. These variations in reporting norms represent an under-appreciated obstacle in efforts to evaluate AI-based radiology report generation (RRG) models, where machine-generated reports are typically assessed based on their concordance with human-generated references. In this paper, we quantify the sensitivity of established evaluation metrics to variations in reporting practices, revealing impacts large enough to alter the rankings of models. We introduce a radiologist-informed taxonomy of variations in radiology reporting practice and a method (ReRef) that rewrites reference reports along the axes of our taxonomy while preserving clinical interpretation. For instance, when comparing the performance of nine RRG models on MIMIC-CXR using RadCliQ-v1, condensing the discussion of normal findings in the reference reports causes Libra to drop from first to second place while CheXOne rises from third to first. Our results suggest that many current metrics fail to decouple clinical interpretation from conformity to reporting practices and that choosing the ``right'' references that accurately reflect the desired reporting practices can be important in practice. To support future research, we release MIMIC-CXR-Ext-ReRef, a radiologist-validated dataset of 120 (original, alternative) reference report pairs derived from MIMIC-CXR.