Unmentioned Checklist Findings Change How Reinforcement Learning Appears to Improve Chest Radiograph Report Checking

Automated checks of radiology reports may rely on AI-generated checklists that leave findings unmentioned. We used reinforcement learning to train a vision-language model to fill in a 12-finding checklist from a chest radiograph without seeing the sentence under test; a separate checking model judged the sentence from the checklist. On held-out patients, a rule-based check and an independent medical checker, neither used in training, measured discrimination gains (Youden index) of 12.6% and 11.8%; only the rule-based check met the prespecified false-alarm criterion. Switching to the training format, which fixes finding order and enters unmentioned findings as absent, raised the training checker's measured gain and lowered the independent checker's, a prespecified comparison that yielded 6.2% (95% interval 2.0% to 10.5%) and, post hoc on held-out patients, 7.7%. Across 8 checking models, acceptance of a label-consistent negative statement about an unmentioned finding ranged from 1.0% to 97.0%. Labels were report-derived, not radiologist-adjudicated.