Artificial intelligence has driven rapid progress in medical imaging research, producing increasingly sophisticated algorithms and steady improvements on benchmark tasks. However, this algorithm-centric trajectory has also revealed a growing imbalance: while computational methods advance rapidly, the conceptual foundations that define imaging tasks, evaluation metrics, and clinical meaning sometimes remain underexamined. In this Perspective, we distinguish algorithmic innovation, which focuses on improving computational implementations and performance within a fixed problem definition, from conceptual innovation, which reframes what problems are posed, how success is measured, and why an approach is clinically relevant. We argue that prevailing incentive structures, training pathways, and publication norms disproportionately reward algorithmic novelty, particularly for early-career researchers, while at times undervaluing conceptual contributions that are essential for scientific maturation and clinical translation. Through representative examples from medical imaging AI, we show how insufficient conceptual grounding can lead to misaligned objectives, fragile generalization, and limited real-world impact. We conclude with actionable recommendations for researchers, mentors, reviewers, and journals to better recognize, support, and integrate conceptual innovation alongside algorithmic advances.

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