MedPAO-VL: Interpretable and Protocol-Compliant Agent for Structured Radiology Report Generation

arXiv:2610.21794 · cs.CV · Submitted 2026-10-15 · Read on arXiv

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Introduction to the show: ident: AI Radio. Generated commentary on the latest Artificial Intelligence papers.

Tom: I'm Tom.

Jane: And I'm Jane, here with Lu, Meng and our in-house large language model, Lalam.

Tom: We're looking at the paper: "MedPAO-VL: Interpretable and Protocol-Compliant Agent for Structured Radiology Report Generation".

Jane: The gist The MedPAO-VL agent shifts from monolithic generation to explainable, iterative,

Tom: First, who's behind it and why it matters.

Title and authors: Tom: So we’re looking at this paper today called "MedPAO-VL: Interpretable and Protocol-Compliant Agent for Structured Radiology Report Generation". It seems like they’re tackling a big problem in radiology where the current end-to-end models are just black boxes.

Jane: That's right, Tom. The title itself says it’s about making the generation of structured reports from medical images both interpretable and compliant with protocols. What that means for us is that we’re moving away from these opaque systems to something where we can actually see how the AI arrived at its conclusions.

Lu: What they are doing is shifting the entire process from a single, monolithic generation step to this iterative loop using a plan-act-observe cycle, which they call MedPAO-VL. It’s about building in explainability right into the generation process itself rather than just adding an explanation afterward.

Meng: I’m curious how that loop actually works in practice when you’re dealing with something as critical as a radiology report. Does it actually help it self-correct if it gets something wrong?

Lalam: It does, Meng. The Observe phase uses something called a Semantic Overlap Checker to compare what the AI has generated against its set of known concepts, and if there are discrepancies, the agent triggers a Re-Plan and Act cycle to fix that specific section until everything matches. It’s a self-correction mechanism built into the loop itself.

Tom: That sounds like they're trying to enforce protocol compliance step by step, which is crucial since radiology reports have very strict formatting rules we have to follow. They aren't just guessing the whole report at once; they are refining it based on what they see visually and conceptually.

Jane: And that visual perception part is key here. They introduce a Vision Concept Module designed with an uncertainty-aware labeling scheme, which gives them reliable visual recognition by predicting for each pathology whether it's present, absent, or uncertain. It’s trying to mirror how a clinician thinks about differential diagnosis.

Lu: That uncertainty awareness is interesting because it’s supposed to provide a visual grounding that reflects clinical epistemology better than just saying something is present or absent. They are using this output to drive the report generation process.

Meng: From an engineering standpoint, having that explicit uncertainty signal should help us debug where the model is struggling most when it doesn't know what to decide. It gives us a clearer error signal than just a final wrong answer.

Title and authors: Lalam: Yeah, and they use this concept-grounded approach for the report generator, which means instead of relying only on raw image features, it synthesizes the text using these derived concepts from the Vision Concept Module and grounding it in a curated concept vocabulary.

Tom: So instead of just letting a large model map pixels directly to words, they are forcing the AI to use these discrete, verifiable clinical findings as its foundation for writing the report. That traceability is something I think we need when deploying models in healthcare settings.

Jane: Exactly. And this grounding allows them to produce reports that are traceable back to those specific concepts, which makes auditing much easier for doctors and researchers alike. It moves it away from being a pure black box system.

Lu: They’ve also introduced some architectural tricks in the Vision Concept Module, specifically an Explainable Pathology Slot Module that uses scaled dot-product attention to get per-pathology spatial attention maps directly from the input feature map, without any post-hoc approximations.

Meng: That sounds efficient. Getting those per-pathology spatial maps directly should give us a very clear picture of *where* the model is looking when it decides on a finding, which is better than just looking at the final text output.

Tom: And to keep that attention focused and not letting it collapse into one area, they added a similarity loss term called Lsim to penalize redundant attention patterns across different pathology slots. It’s designed to encourage per-pathology spatial diversity.

Jane: That’s a smart move, Tom. If the model just focuses on one thing all the time, it can get stuck in a local minimum of its understanding. This loss function tries to keep the visual focus spread out across different potential findings in a way that makes sense anatomically.

Lalam: It helps prevent what they call representational collapse, which is when the attention patterns become too similar, and this loss term pushes them apart slightly while still allowing related findings to cluster near each other. It’s a delicate balance for representation learning.

Tom: So, in terms of results, they claim that this hybrid architecture produces clinically sound reports that are factually consistent and protocol-compliant along with that interpretable vision module. They achieved an expert-rated accuracy score of three point five out of five and a structural score of four point three out of five on their evaluation set.

Title and authors: Jane: Those scores, especially the structural score, tell us a lot about adherence to the required report format which is usually where these systems fail in the real world. They also achieved a CheXbert-F1 of zero point six one seven on the MIMIC-CXR dataset for the 50K variant.

Lu: The fact that they set a new benchmark for chest X-ray report generation, especially achieving that CheXbert-F1 score, shows how effective this concept grounding and iterative refinement strategy is at improving clinical accuracy compared to traditional VLMs.

Meng: I wonder about the infrastructure cost here. They used MedGemma-4B quantized in four-bit NormalFloat with LoRA for fine-tuning on a fifty thousand report subset. That sounds like a very resource-intensive setup to get that level of fine-grained control over the generation process.

Tom: It is resource intensive because they are training it on that large subset and using parameter-efficient fine-tuning techniques like LoRA, which keeps the memory footprint manageable while still allowing them to adapt the base model for clinical grounding.

Jane: So, what does this mean for someone just listening to the show? It means we’re talking about an AI system that doesn't just spit out text; it has a verifiable internal reasoning process that follows rules and corrects itself based on visual evidence.

Lu: It means the architecture successfully bridges the gap between deep vision features and actual clinical interpretability through this transparent design and agentic reasoning capabilities in MedPAO-VL.

Meng: That bridging is important because if we can trust the reasoning trace, we can actually deploy it where high stakes decisions are made, even if it’s still constrained by that vocabulary of two hundred thirty-six concept groups.

Lalam: And they address the vocabulary limitation by planning to dynamically expand that clinical vocabulary in future work, which is a necessary step for making these tools truly general-purpose for any anomaly.

Tom: So to wrap up this segment, MedPAO-VL is showing us how an agentic system can move toward generating structured reports iteratively and explainably by using visual uncertainty and self-correction loops.

Jane: It’s a big step in making AI tools for radiology more trustworthy by forcing them to follow protocol and show their work along the way. Next up, we’ll look at some other interesting papers from arXiv.

The paper's summary: Tom: So, MedPAO-VL is essentially taking radiology report generation and making it work like an actual agent that plans, acts, and checks its own work against visual evidence to ensure it follows all the rules for writing a structured report.

Jane: Right, so instead of just throwing a big model at the image and getting text back that might be wrong or messy, this system uses an iterative loop where it looks at what it wrote, compares it to the actual image, finds the mismatches, and then fixes those specific parts until everything lines up.

Lu: The core idea they are pushing is moving away from that monolithic generation approach to something transparent where you can see exactly *why* the AI chose a certain finding or structure in its report.

Meng: From what I’m hearing, they’re focusing heavily on making sure the output isn't just fluent text, but it has to map back to discrete, verifiable clinical findings.

Tom: Exactly. They use this concept-grounded approach where the report generation is based on these specific concepts derived from an image analysis module rather than just letting the model guess words from raw pixels.

Jane: And they’re making that visual analysis smarter by introducing a way to label things as present, absent, or uncertain for each potential finding, which tries to mimic how a doctor thinks about what they might see.

Lu: They’ve also put some specific architectural tweaks in the vision module, like a similarity loss term called Lsim. That loss term is there to stop the attention maps from just collapsing onto one area and instead encourage diversity across all the different pathology slots they are looking at.

Meng: So, it’s not just about getting a report; it’s about ensuring that every piece of information in that report has a traceable source back to what was actually in the image, and that the AI is actively trying to be thorough by checking its own work.

Tom: That self-correction mechanism using the semantic overlap checker is what really makes this agentic loop effective; if it sees a gap in the expected concepts, it doesn't just try again blindly; it re-plans and acts on that specific section until the required information is present.

Jane: So for someone who just listens, think of it like an AI writer who has to follow a strict checklist. It doesn't just write a story; it checks its work against the original source material repeatedly until every box on that checklist is ticked in the right order.

Lu: The results they are showing, like that expert-rated accuracy score of three point five out of five and the structural score of four point three out of five suggest this iterative refinement is working well to get reports that look clinically sound and follow those required formats much better than previous methods.

Meng: Those scores against models like MedGemma-27B show that this approach is actually setting a new bar for how accurate the structure of the report itself can be, which is huge because format matters in real clinical workflows.

Tom: And they’ve also shown that they can do this with a model that's been fine-tuned on a fifty thousand-report subset using techniques like LoRA and NF4 quantization, which shows it’s actually feasible to get this level of grounded performance on current hardware setups.

Jane: It bridges the gap between complex deep vision features and actual clinical interpretability by giving us those reasoning traces, which is a big deal for building trust in AI tools in medicine.

Lu: The real limitation they point out is that right now, their vocabulary is constrained to two hundred thirty-six concept groups, so it can’t document some of the rarer anomalies yet, but they have a plan to expand that clinical vocabulary dynamically later on.

Meng: That means for now, if you're looking at something super rare in an X-ray and it falls outside those two hundred thirty-six concepts, the AI won't be able to document it correctly through this system.

Tom: So, MedPAO-VL is proving that by combining a perception module that understands uncertainty with an agentic loop that enforces protocol compliance, we can get structured report generation that is both accurate and auditable.

Jane: It’s a step toward AI tools for healthcare where the reasoning isn't just a final answer, but an open process of checking and refining based on visual evidence.

Lu: The implication is that we are moving toward AI systems that don't just predict outcomes, but generate verifiable narratives grounded in explicit visual evidence.

Meng: For deployment at scale, the dynamic concept cache they built to skip slow ontology mapping tools is a practical win because it keeps the inference time down and makes it much faster to actually use this thing in a busy hospital setting.

The paper's improvements: Tom: So, MedPAO-VL has some specific tweaks they suggest to make it even better, focusing on those architectural details we talked about earlier.

Jane: Right, so beyond just the core loop they’ve outlined, they are pushing improvements in how the system actually perceives and grounds that visual information.

Lu: They introduce this Explainable Pathology Slot Module, or PSM. This module uses a scaled dot-product attention mechanism where the softmax is applied over the patch dimension to get per-pathology spatial attention maps directly from the input feature map, which they say gives them faithful grounding without any extra post-hoc math.

Meng: That sounds like a neat way to get that visual data—they’re not just looking at a general image; they’re getting specific attention maps for each pathology right away.

Tom: And to keep those attention patterns from collapsing onto one spot, they added this similarity loss term called Lsim. This penalizes redundant attention patterns across the slots, which is supposed to encourage per-pathology spatial diversity.

Jane: That’s smart because it stops the model from getting lazy and just focusing on one area of the image instead of looking at all the potential findings in a balanced way.

Lu: The Concept Grounded Report Generator also uses a MedGemma-4B model, but they fine-tune it using Parameter-Efficient Fine-Tuning via LoRA, which helps them produce reports that are truly traceable to those discrete, verifiable clinical findings they talked about <ref:2610.21794#pg2>.

Meng: That’s good for production because LoRA keeps the memory footprint reasonable while still letting you adapt a big model to be this specific and grounded in a structured way.

Tom: And for interpretability, they have the "Concept Extractor" which outputs both discrete concepts and their corresponding source sentences, which serves as explainable reasoning traces that doctors can use for auditing.

Jane: That’s the key—it gives you a reason *why* the AI said something by linking it back to a specific sentence in its report that was grounded in a concept.

Lu: They also mention using an Ontology Mapper to ground those extracted concepts within standardized medical ontologies like SNOMED CT, giving you detailed info like matched surface and ancestors for every finding.

Meng: That makes the traceability much stronger than just saying "the model said this"; it gives you the actual medical code context for that finding.

Tom: The dynamic concept cache they built for ABCDEF protocol categorization is another big improvement because it lets the agent bypass high-latency calls to tools like Ontology Mapping when there’s a hit in the cache, cutting that inference time down significantly from two hundred ninety-five seconds to one hundred sixty-three seconds in warm conditions.

Jane: That latency reduction is huge for practical use; if you have a real workflow running, you don't want every step of the report generation waiting around for a database lookup.

Lu: The final result is that they show this architecture can produce reports that conform to predefined reporting protocols with ninety percent of structure scores reaching four or five out of five on radiologist evaluations, which is better than seventy percent for MedGemma-27B.

Meng: That ninety percent compliance score against human experts tells you the system is actually getting close to being a reliable tool for clinical use in terms of formatting and structure.

Tom: So, the improvements focus on making the visual grounding more precise, ensuring conceptual diversity in attention, and optimizing the processing speed through caching to make this iterative loop practical.

Jane: It shows that for these complex multimodal tasks, success isn't just about a big model; it’s about designing an agentic loop that forces the system to check its work repeatedly against known concepts and visual evidence.

Lu: And while they noted the limitation on the vocabulary size right now, their plan to dynamically expand it means this framework is built for continuous growth in handling new or rare findings.

Conclusion: Tom: So, to wrap up on "MedPAO-VL: Interpretable and Protocol-Compliant Agent for Structured Radiology Report Generation," we’re talking about an AI system that uses a plan act observe loop to iteratively refine radiology reports until they are both accurate and follow the required clinical structure.

Jane: Exactly, so what this means for us is that we are moving toward AI tools in medicine where the reasoning isn't just a final answer, but an open process of checking and refining based on visual evidence while strictly adhering to protocol.

Lu: The implication is that we are building systems where the output isn't just text; it’s a verifiable narrative grounded in explicit visual evidence that can be traced back to its source concepts.

Meng: For deployment at scale, the dynamic concept cache they built to skip slow ontology mapping tools is a practical win because it keeps the inference time down and makes it much faster for these systems to actually use in a busy hospital setting.

Lalam: I'm pretty sure this version of MedPAO-VL is very sure of its own answer; the self-correction loop ensures that every vision-derived concept is incorporated into the final report, which means we don’t have to worry about the AI forgetting something critical mid-generation.

Tom: It really shows how combining a perception module with this kind of agentic self-correction can move us closer to systems that are trustworthy enough for high-stakes environments.

Jane: And while they noted the limitation on the vocabulary size right now, their plan to dynamically expand that clinical vocabulary means this framework is built for continuous growth in handling new or rare findings.

Lu: The architecture successfully bridges the gap between deep vision features and actual clinical interpretability through its transparent design and agentic reasoning capabilities in MedPAO-VL.

Meng: I just hope we see more of these systems being deployed where they can handle those rarer anomalies without needing a huge vocabulary expansion immediately.

Tom: So, that’s the gist of MedPAO-VL; it’s a solid piece of work showing how iterative refinement can enforce structure and interpretability in complex medical text generation.

Jane: It really sets a good standard for what structured, protocol-compliant AI should look like when dealing with critical data like radiology reports.

Lu: Next week, we’re going to look at some other papers from arXiv that are tackling different challenges in the agent space.

Shrish Shrinath Vaidya, Gowthamaan Palani, Minmini Selvam, Gokulraja Srinivasaraja, Ganapathy Krishnamurthi

Department of Data Science and Artificial Intelligence, Indian Institute of Technology Madras · TANUH – The AI Centre of Excellence in Healthcare, Indian Institute of Science, Bengaluru · Department of Radiology (Division of Interventional Radiology), Ramaiah Medical College and Memorial hospital, Bengaluru

cs.CV

Submitted: 2026-10-15

Updated: 2026-10-15

Comments: The paper has been accepted at ECCV BISCUIT Workshop, 2026

Code: https://github.com/MiRL-IITM/medpao-vl

License: http://creativecommons.org/licenses/by-nc-sa/4.0/

Importance score: 91/100

The gist: The gist The MedPAO-VL agent shifts from monolithic generation to explainable, iterative, protocol-compliant structured report generation by integrating multimodal perception with an agentic

Key concepts

Agentic Plan-Act-Observe Loop: This is a self-correcting reasoning cycle where the AI first plans an action (generating a report), then observes the result, identifies any errors or discrepancies using a semantic checker, and then replans or acts to fix those errors. This iterative approach allows the system to continuously refine its output until it aligns with visual evidence.
Vision Concept Module: This module uses a novel uncertainty-aware labeling scheme to analyze chest X-rays. It doesn't just guess pathology; it predicts for each potential disease whether the finding is 'present,' 'absent,' or 'uncertain.' This mirrors how a clinician forms a differential diagnosis, providing an explainable visual foundation for the report.
Concept Grounded Report Generator: This component synthesizes the final report using a curated vocabulary of medical concepts instead of relying solely on raw image pixels. By basing the text generation on these discrete, verifiable clinical findings, the model ensures that every statement in the report is traceable back to a specific concept extracted from the image.

Summary

The gist The MedPAO-VL agent shifts from monolithic generation to explainable, iterative, protocol-compliant structured report generation by integrating multimodal perception with an agentic Plan-Act-Observe loop to ensure clinical correctness and transparency. <ref:2610.21794#pg6>

How it works

MedPAO-VL is a multimodal agent designed to generate structured radiology reports through an iterative refinement process, shifting the paradigm from opaque end-to-end mapping to transparent reasoning <ref:2610.21794#pg4>. It functions as a goal-oriented agent with a Plan-Act-Observe loop that first perceives the Chest X-Ray through an explainable vision module designed to capture inherent diagnostic uncertainty <ref:2610.21794#pg6> and then iteratively refines the generated report by observing semantic discrepancies and self-correcting its generation for better alignment with visually detected clinical findings <ref:2610.21794#pg6>.

The architecture consists of three core components:

Vision Concept Module: This module employs a novel uncertainty aware labeling scheme to provide reliable and explainable visual recognition that more faithfully reflects clinical epistemology <ref:2610.21794#pg6>. It predicts a label from the set of present, absent, uncertain for each pathology, mirroring clinical differential diagnosis <ref:2610.21794#pg6>.
Concept Grounded Report Generator: This multimodal model synthesizes a fluent, unstructured report by receiving both the CXR image and semantic constraints derived from the Vision Concept Module <ref:2610.21794#pg6>. It adopts a concept-driven approach, using observed concepts to ground the generation on a curated concept vocabulary rather than raw image features alone <ref:2610.21794#pg6>.
Agentic PAO Loop: This iterative loop handles report correction and structuring through self-correction, where the Observe phase employs a Semantic Overlap Checker to compute semantic similarity against the concept list <ref:2610.21794#pg6>. If discrepancies are found, the agent triggers a Re-Plan and Act cycle to refine the specific section containing the discrepancy until all vision-derived concepts are present in the generated narrative <ref:2610.21794#pg6>.

Key Architectural Innovations

The Vision Concept Module utilizes an Explainable Pathology Slot Module (PSM) which instantiates pathology-specific slots, each designed to extract features relevant to its corresponding pathology from the input feature map <ref:2610.21794#pg6>. The PSM uses a scaled dot-product attention mechanism where softmax is applied over the patch dimension, yielding per-pathology spatial attention maps that are an inherent product of the forward pass, providing faithful, pathology-specific visual grounding without any post-hoc approximation <ref:2610.21794#pg6>. To enforce per-pathology spatial diversity and prevent representational collapse, a similarity loss (Lsim) is introduced to penalize redundant attention patterns across slots <ref:2610.21794#pg6>.

The Concept Grounded Report Generator uses a finetuned MedGemma-4B model, quantized in 4-bit NormalFloat (NF4) with Parameter-Efficient Fine-Tuning (PEFT) via Low-Rank Adaptation (LoRA) <ref:2610.21794#pg6>. This module is trained on a 50,000-report subset and is fine-tuned to produce reports that are traceable to discrete, verifiable clinical findings <ref:2610.21794#pg6>.

Evaluation and Results

The framework demonstrates improved performance over traditional VLMs by achieving an expert-rated accuracy score of 3.5/5 and a structural score of 4.3/5 <ref:2610.21794#pg6>. The Concept Grounded Report Generator sets a new benchmark for clinical accuracy in chest X-ray report generation, achieving a CheXbert-F1 of 0.617 on the MIMIC-CXR dataset for the 50K variant <ref:2610.21794#pg6>. Furthermore, the structured report evaluation metrics show that MedPAO-VL achieves a Combined Mean Accuracy score of 3.18 ± 0.36 and a Structure Score of 3.98 ± 0.24 against the MedGemma-27B model <ref:2610.21794#pg6>.

Interpretability and Clinical Fidelity

The system's interpretability is enhanced through several mechanisms, including the Concept Extractor which outputs both discrete concepts and their corresponding source sentences, serving as explainable reasoning traces for clinical auditing <ref:2610.21794#pg6>. The Ontology Mapper grounds extracted concepts within standardized medical ontologies like SNOMED CT, providing detailed information such as matched surface and ancestors for each finding <ref:2610.21794#pg6>. Latent Orthogonality analysis shows that the PSM encodes clinically meaningful differentials as directional structure in embedding space, with related findings clustering near the reference axis while opposing pathologies are displaced into the negative half-space <ref:2610.21794#pg6>.

The Agentic PAO Loop's efficiency is managed by a Dynamic Concept Cache for ABCDEF protocol categorization, which allows the agent to bypass high-latency Ontology Mapping and Categorizer tool invocations on cache hits, reducing inference time from 295s to 163s in the warm-cache condition <ref:2610.21794#pg6>. The system's self-correction loop effectively handles diagnostic uncertainty by triggering genuine re-planning when the Semantic Overlap Checker identifies missing concepts, ensuring that all vision-derived concepts are incorporated into the final report <ref:2610.21794#pg6>.

The final structured report generation is guided by a prompt conditioned on the ABCDEF protocol, which ensures clinical completeness and constrains the model to avoid hallucinating information not present in the input concepts <ref:2610.21794#pg6>. The system's ability to generate reports that conform to predefined reporting protocol is validated by radiologist evaluations, where 90% of structure scores reached the threshold of 4 or 5 for MedPAO-VL <ref:2610.21794#pg6>.

The system's current diagnostic reach is constrained by a predefined vocabulary of 236 concept groups, which limits the documentation of ultra-rare anomalies, but future work plans to address this limitation by dynamically expanding the clinical vocabulary <ref:2610.21794#pg6>. The MedPAO-VL architecture successfully bridges the gap between deep vision features and clinical interpretability through its transparent design and agentic reasoning capabilities. <ref:2610.21794#pg6>

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The system's ability to generate reports that conform to predefined reporting protocol is validated by radiologist evaluations, where 90% of structure scores reached this threshold versus 70% for MedGemma-27B <ref:2610.21794#pg6>. The system's current diagnostic reach is constrained by a predefined vocabulary of 236 concept groups, limiting the documentation of ultra-rare anomalies, but future work will address this limitation by dynamically expanding the clinical vocabulary and extending the agentic framework to accommodate multi-modal imaging and broader diagnostic workflows <ref:2610.21794#pg6>. The MedPAO-VL architecture successfully bridges the gap between deep vision features and clinical interpretability through its transparent design and agentic reasoning capabilities. <ref:2610.21794#pg6>

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Improvements for AI systems

Improved AI system can generate explainable, protocol-compliant structured radiology reports by shifting from monolithic generation to explainable, iterative, protocol-compliant structured report generation. This is achieved through a plan-act-observe loop that allows the agent to iteratively refine its generation based on observing semantic discrepancies and self-correcting its generation for better alignment with visually detected clinical findings.
The system incorporates a novel mechanism to mitigate implicit negative bias by formulating pathology prediction as a three-class problem: Given a CXR image x, the model predicts a label from three-class problem. Given an input CXR image x, the model predicts a label from one of 'present, absent, uncertain' for each of n target pathologies. This explicitly distinguishes true absence from reporting omission, enhancing clinical trust.
The system enhances spatial interpretability by introducing a Similarity Loss to regularize attention maps against representational collapse and encourage per-pathology spatial diversity. This is done via the loss term: To penalize only redundancy while permitting benign anti-correlation between anatomically distinct pathologies, ReLU is applied exclusively to offdiagonal entries: L sim = (1/n(n-1)) sum over i,j != i of ReLU(M ij).
The system enables verifiable reasoning traces by utilizing a Concept Grounded Report Generator that synthesizes reports based on curated concept vocabulary rather than raw image features alone, allowing outputs to be traceable to discrete, verifiable clinical findings.

Abstract

Despite the remarkable generalization capabilities of Large Language Models, generating clinically accurate and structured radiology reports from medical images remains a significant challenge. Current end-to-end approaches function as black boxes, prone to factual hallucinations and generating ungrounded findings. This lack of reliability and failure to adhere to domain-specific structuring protocols, fundamentally limits their clinical utility. We present MedPAO-VL, a multimodal agent that shifts the paradigm from monolithic generation to explainable, iterative, protocol-compliant structured report generation. Unlike deterministic models, our plan-act-observe loop functions as a goal-oriented agent: it first perceives the Chest X-Ray through an explainable vision module designed to capture inherent diagnostic uncertainty, then iteratively refines the generated report by observing semantic discrepancies and self-correcting its generation for better alignment with visually detected clinical findings. Evaluation of our framework demonstrates that this agentic reasoning improves clinical correctness and completeness, achieving an expert-rated accuracy score of 3.5/5 and a structural score of 4.3/5. By prioritizing pathology specific explainability and iterative refinement over opaque end-to-end mapping, MedPAO-VL offers a transparent and clinically viable alternative for automated structured radiology report generation.