ClinDet-Bench: Beyond Abstention, Evaluating Judgment Determinability of LLMs in Clinical Decision-Making

Clinical decision-making often begins with underspecified information and requires not only gathering missing information but also knowing when to stop. This calls for judging determinability (whether the available information is sufficient for a decision) by considering whether missing information could change the conclusion, not simply the amount of available decision-relevant information. Reliance on this amount as a cue for determinability, which we term factor coverage bias, could undermine the trustworthiness of large language models (LLMs) through premature conclusions or excessive information gathering, such as unnecessary invasive tests. Yet whether LLMs exhibit this bias remains insufficiently studied. To address this gap, we construct a controlled pairwise benchmark in which LLMs identify the determinable case within each determinable--undeterminable pair. We add a decision-relevant factor to either side while keeping each case's determinability unchanged, and similarly add irrelevant text to distinguish this bias from context-length effects. Adding a relevant factor made LLMs more likely to select the augmented case as determinable even when it remained undeterminable, an effect that persisted with increased reasoning effort, while adding irrelevant text made them less likely to select the augmented case, an effect that reasoning substantially reduced. These findings identify factor coverage bias as a failure mode distinct from context-length effects and a potential risk to LLM trustworthiness. Our work provides an evaluation framework for LLM trustworthiness under underspecification.

Medical large language model (LLM) evaluations rely on simplified, exam-style benchmarks that rarely reflect the ambiguity of real-world medical inquiries. We introduce the CLinical Evaluation of Ambiguity and Reliability (CLEAR) framework, which assesses how decision-space presentation, ambiguity, and uncertainty affect LLMs' reasoning on medical benchmarks. CLEAR systematically perturbs (1) the number of plausible answer options, (2) the presence of a ground truth or abstention option, and (3) the semantic framing of answer options. Applying CLEAR on three benchmarks evaluated across 17 LLMs reveals three notable limitations of existing evaluation methods. First, increasing the number of plausible answers degrades a model's ability to identify the correct answer and abstain against incorrect ones. Second, this lack of caution intensifies as the framing of abstention shifts from assertive rejection like "None of the Above" to uncertainty admission like "I don't know" (IDK). Notably, just including IDK in the answer space increases incorrect answer selections. Lastly, we formalize the performance gap between identifying the correct answer and abstaining from incorrect ones as the humility deficit, which worsens with model scale. Our findings reveal limitations in standard medical benchmarks and underscore that scaling alone does not resolve LLM reliability issues.

Large language models (LLMs) are increasingly used for decision support in healthcare, but clinical evidence is often incomplete or evolving. When the available information is insufficient to support a reliable answer, models should request clarification or abstain rather than provide unsupported responses. Existing medical benchmarks, however, typically assume that complete information is available upfront. We introduce Safe-Psych, a sequential benchmark for evaluating how LLMs handle evolving diagnostic uncertainty in clinical psychiatry. Safe-Psych contains over 1,000 real-world psychiatric clinical notes segmented to simulate incremental evidence disclosure, with psychiatrist-derived action labels at each stage: DIAGNOSE, CLARIFY, or ABSTAIN. We evaluate multiple state-of-the-art LLMs in full-information and sequential settings. Our findings show that capability does not ensure calibration: even strong models struggle under incomplete clinical information, with under-abstention exceeding 60% for most models and safety-aware prompting reducing premature commitment only by shifting errors toward excessive abstention. In sequential evaluation, models frequently diagnose before sufficient evidence is available and rarely seek clarification unless explicitly prompted; these premature diagnoses are less accurate than on-time diagnoses. Overall, Safe-Psych reveals a limitation across the evaluated models: recognizing when clinical evidence is incomplete and additional information is needed. We release Safe-Psych to support research on improving LLM safety in healthcare.