Catherine Price

Jiaqing Zhang, Sandeep Elluri, Bhanu Cherukuvada et al.

Multimodal large language models (LLMs) are increasingly explored as automated evaluators in clinical settings, yet their scoring behavior on ordinal clinical scales remains poorly understood. We benchmark three frontier LLM families against supervised deep learning models for scoring Clock Drawing Test (CDT) images on two public datasets using the Shulman rubric. While fully fine-tuned Vision Transformers achieve the best calibration (MAE 0.52, within-1 accuracy 91%), zero-shot LLMs remain competitive on tolerance-based agreement (GPT-5 MAE 0.67, within-1 accuracy 92%) despite higher absolute error. However, per-score analysis reveals that all three LLM families exhibit a pronounced central tendency effect (systematic endpoint compression): predictions are systematically compressed toward the middle of the scale, with over-prediction at the low end (score 0 to 1) and under-prediction at the high end (score 5 to 4). This effect disproportionately affects the clinically critical extremes where accurate scoring most impacts screening decisions for cognitive impairment. Targeted ablations show that neither few-shot exemplars spanning the full score range nor removing clinical terminology from the prompt eliminates the effect. Our findings extend the LLM-as-a-judge bias literature from NLP evaluation to clinical assessment, and highlight the need for calibration-aware evaluation and post-hoc calibration before deploying LLM-based raters in high-stakes screening workflows.

Sabyasachi Bandyopadhyay, Jiaqing Zhang, Ronald L. Ison et al.

The association between preoperative cognitive status and surgical outcomes is a critical, yet scarcely explored area of research. Linking intraoperative data with postoperative outcomes is a promising and low-cost way of evaluating long-term impacts of surgical interventions. In this study, we evaluated how preoperative cognitive status as measured by the clock drawing test contributed to predicting length of hospital stay, hospital charges, average pain experienced during follow-up, and 1-year mortality over and above intraoperative variables, demographics, preoperative physical status and comorbidities. We expanded our analysis to 6 specific surgical groups where sufficient data was available for cross-validation. The clock drawing images were represented by 10 constructional features discovered by a semi-supervised deep learning algorithm, previously validated to differentiate between dementia and non-dementia patients. Different machine learning models were trained to classify postoperative outcomes in hold-out test sets. The models were compared to their relative performance, time complexity, and interpretability. Shapley Additive Explanations (SHAP) analysis was used to find the most predictive features for classifying different outcomes in different surgical contexts. Relative classification performances achieved by different feature sets showed that the perioperative cognitive dataset which included clock drawing features in addition to intraoperative variables, demographics, and comorbidities served as the best dataset for 12 of 18 possible surgery-outcome combinations...