Nigam Shah

Rebecca Handler, Suhana Bedi, Nigam Shah

Premature closure, or committing to a conclusion before sufficient information is available, is a recognized contributor to diagnostic error but remains underexamined in large language models (LLMs). We define LLM premature closure as inappropriate commitment under uncertainty: providing an answer, recommendation, or clinical guidance when the safer response would be clarification, abstention, escalation, or refusal. We evaluated five frontier LLMs across structured and open-ended medical tasks. In MedQA (n = 500) and AfriMed-QA (n = 490) questions where the correct choice had been removed, models still selected an answer at high rates, with baseline false-action rates of 55-81% and 53-82%, respectively. In open-ended evaluation, models gave inappropriate answers on an average of 30% of 861 HealthBench questions and 78% of 191 physician-authored adversarial queries. Safety-oriented prompting reduced premature closure across models, but residual failure persisted, highlighting the need to evaluate whether medical LLMs know when not to answer.

Alyssa Unell, Natalie Dullerud, Naomi Boneh et al.

LLM judges are used to reduce the need for costly human labor in evaluating open-ended text generation. However, the reliability of these judges depends critically on their alignment with human raters -- a property that itself depends on costly human annotations. In this work, we develop a method (Metric Match) for estimating correlation-based reliability metrics of LLM judges from limited annotations. Metric Match selects a subset of samples for human annotation such that the subset matches the population reliability metric with respect to acquired synthetic labels. We empirically show that Metric Match achieves a win-rate of 0.838 against random subset selection across four different correlation metrics and 15 datasets, with an 18.7% decrease in average estimation error and reduces annotation needs by 32.5%. We provide a cost model and highlight a medical case study where our method saves $1,041.67 compared to random selection for expert annotation. Further, we shift our task from reliability estimation to reliability classification of whether a given judge is above a deployment threshold, outperforming random selection with Metric Match. All project code is publicly available, and we additionally provide an installable package for ease of use.

Alyssa Unell, Miguel Fuentes, Brenna Li et al.

Large language models (LLMs) are increasingly integrated into clinical systems, making it essential to evaluate the real-world utility of these systems. However, static benchmarks tend to measure correctness rather than user acceptance, aggregate performance across queries, and require densely annotated datasets -- leading to major blind spots for evaluating clinical systems. In this work, we perform a deployment-centered evaluation of an LLM system embedded within electronic health records at an academic medical center, where user feedback is sparse but closely reflects the deployment conditions. Specifically, we train a pre-response classifier that estimates the risk that a future interaction will result in the user rejecting the LLM response, based on query content and deployment-specific context available before generation. We conduct a prospective analysis of our model over 4.5 months of user feedback, finding that our prediction model achieves an AUROC of 0.719. Further, we estimate the benefit of such predictions in two downstream use cases (guardrail triggering and abstention). Our key conceptual insight is that making use of deployment-specific context (i.e., the provider type, department name, language model used for response), as opposed to only query content, improves the ability to predict whether the user will reject the system output. Altogether, our empirical case study demonstrates the feasibility of predicting user rejection using deployment-specific context, opening the door to targeted guardrails.