Douglas Kondziolka

Krithik Vishwanath, Anton Alyakin, Mrigayu Ghosh et al.

The Congress of Neurological Surgeons Self-Assessment for Neurological Surgeons (CNS-SANS) questions are widely used by neurosurgical residents to prepare for written board examinations. Recently, these questions have also served as benchmarks for evaluating large language models' (LLMs) neurosurgical knowledge. This study aims to assess the performance of state-of-the-art LLMs on neurosurgery board-like questions and to evaluate their robustness to the inclusion of distractor statements. A comprehensive evaluation was conducted using 28 large language models. These models were tested on 2,904 neurosurgery board examination questions derived from the CNS-SANS. Additionally, the study introduced a distraction framework to assess the fragility of these models. The framework incorporated simple, irrelevant distractor statements containing polysemous words with clinical meanings used in non-clinical contexts to determine the extent to which such distractions degrade model performance on standard medical benchmarks. 6 of the 28 tested LLMs achieved board-passing outcomes, with the top-performing models scoring over 15.7% above the passing threshold. When exposed to distractions, accuracy across various model architectures was significantly reduced-by as much as 20.4%-with one model failing that had previously passed. Both general-purpose and medical open-source models experienced greater performance declines compared to proprietary variants when subjected to the added distractors. While current LLMs demonstrate an impressive ability to answer neurosurgery board-like exam questions, their performance is markedly vulnerable to extraneous, distracting information. These findings underscore the critical need for developing novel mitigation strategies aimed at bolstering LLM resilience against in-text distractions, particularly for safe and effective clinical deployment.

Krithik Vishwanath, Anton Alyakin, Daniel Alexander Alber et al.

Large language models (LLMs) have the potential to transform medicine, but real-world clinical scenarios contain extraneous information that can hinder performance. The rise of assistive technologies like ambient dictation, which automatically generates draft notes from live patient encounters, has the potential to introduce additional noise making it crucial to assess the ability of LLM's to filter relevant data. To investigate this, we developed MedDistractQA, a benchmark using USMLE-style questions embedded with simulated real-world distractions. Our findings show that distracting statements (polysemous words with clinical meanings used in a non-clinical context or references to unrelated health conditions) can reduce LLM accuracy by up to 17.9%. Commonly proposed solutions to improve model performance such as retrieval-augmented generation (RAG) and medical fine-tuning did not change this effect and in some cases introduced their own confounders and further degraded performance. Our findings suggest that LLMs natively lack the logical mechanisms necessary to distinguish relevant from irrelevant clinical information, posing challenges for real-world applications. MedDistractQA and our results highlights the need for robust mitigation strategies to enhance LLM resilience to extraneous information.

Anton Alyakin, Jaden Stryker, Daniel Alexander Alber et al.

General-purpose vision-language models (VLMs) demonstrate impressive capabilities, but their opaque training on uncurated internet data posse critical limitations for high-stakes decision-making, such as in neurosurgery. We present CNS-Obsidian, a neurosurgical VLM trained on peer-reviewed neurosurgical literature, and demonstrate its clinical utility compared with GPT-4o in a real-world setting. We compiled 23,984 articles from Neurosurgery Publications journals, yielding 78,853 figures and captions. Using GPT-4o and Claude Sonnet-3.5, we converted these image-text pairs into 263,064 training samples across three formats: instruction fine-tuning, multiple-choice questions, and differential diagnosis. We trained CNS-Obsidian, a fine-tune of the 34-billion parameter LLaVA-Next model. In a blinded, randomized deployment trial at NYU Langone Health (Aug 30-Nov 30, 2024), neurosurgeons were assigned to use either CNS-Obsidian or GPT-4o as a diagnostic co-pilot after patient consultations. Primary outcomes were diagnostic helpfulness and accuracy. CNS-Obsidian matched GPT-4o on synthetic questions (76.13% vs 77.54%, p=0.235), but only achieved 46.81% accuracy on human-generated questions versus GPT-4o's 65.70% (p<10-15). In the randomized trial, 70 consultations were evaluated (32 CNS-Obsidian, 38 GPT-4o) from 959 total consults. CNS-Obsidian received positive ratings in 40.62% of cases versus 57.89% for GPT-4o (p=0.230). Both models included correct diagnosis in approximately 60% of cases (59.38% vs 65.79%, p=0.626). Domain-specific VLMs trained on curated scientific literature can approach frontier model performance in specialized medical domains despite being orders of magnitude smaller and less expensive to train. However, low clinical utilization suggests chatbot interfaces may not align with specialist workflows, indicating need for alternative AI integration strategies.

Yifan Li, Garrett Yoon, Mustafa Nasir-Moin et al.

Numerous COVID-19 clinical decision support systems have been developed. However many of these systems do not have the merit for validity due to methodological shortcomings including algorithmic bias. Methods Logistic regression models were created to predict COVID-19 mortality, ventilator status and inpatient status using a real-world dataset consisting of four hospitals in New York City and analyzed for biases against race, gender and age. Simple thresholding adjustments were applied in the training process to establish more equitable models. Results Compared to the naively trained models, the calibrated models showed a 57% decrease in the number of biased trials, while predictive performance, measured by area under the receiver/operating curve (AUC), remained unchanged. After calibration, the average sensitivity of the predictive models increased from 0.527 to 0.955. Conclusion We demonstrate that naively training and deploying machine learning models on real world data for predictive analytics of COVID-19 has a high risk of bias. Simple implemented adjustments or calibrations during model training can lead to substantial and sustained gains in fairness on subsequent deployment.

Brian Murphy, Mustafa Nasir-Moin, Grace von Oiste et al.

The prognosis for patients with epithelial ovarian cancer remains dismal despite improvements in survival for other cancers. Treatment involves multiple lines of chemotherapy and becomes increasingly heterogeneous after first-line therapy. Reinforcement learning with real-world outcomes data has the potential to identify novel treatment strategies to improve overall survival. We design a reinforcement learning environment to model epithelial ovarian cancer treatment trajectories and use model free reinforcement learning to investigate therapeutic regimens for simulated patients.