ClinConsensus: A Physician-Calibrated Benchmark for Evaluating Clinical Rubric Coverage in Chinese Medical LLMs

LLM-as-a-Judge frameworks are increasingly trusted to automate evaluation in place of human experts, yet their reliability in high-stakes medical contexts remains unproven. We stress-test this assumption for detecting incomplete patient-facing medical responses, evaluating three rubric granularities (General-Likert, Analytical-Rubric, Dynamic-Checklist) and three backbone models across two clinician-annotated datasets, including HealthBench, the largest publicly available benchmark for medical response evaluation. LLM Judges discriminate complete from incomplete responses at and slightly above near chance (AUC $0.49$--$0.66$); at the threshold required to recall $90\%$ of incomplete responses, clinicians must still review the vast majority of the dataset, offering no triage utility. Even when model and clinician verdicts agree, they rarely cite the same explanation; and when they diverge, false positives stem from over-flagging non-essential gaps while false negatives reflect outright detection failures. These results reveal that LLM Judges and clinicians apply fundamentally different completeness standards; a finding that undermines their use as autonomous evaluators or triage filters in clinical settings.

Hallucinations can undermine clinician trust in LLMs, making it important that evaluation methods capture clinically relevant errors. Rubric-based evaluation has become the leading approach for assessing LLMs in medicine, but it is unclear whether rubric scores reflect such errors. We first study this in a controlled setting using MedHallu, finding that more specific rubrics better distinguish correct from hallucinated responses. To test this systematically, we develop a taxonomy of medical hallucination types and a clinician-validated error-injection pipeline that creates matched correct and error-injected responses. Across HealthBench, HealthBench Professional, and LiveMedBench, our clinically relevant hallucinations are missed by rubrics, often leaving scores unchanged. We find that rubrics are most effective when explicitly checking facts, and are less effective for additional or unexpected errors they do not anticipate. A preliminary retrieval-based factuality check recovers some of the rubric-blind errors, suggesting a complementary approach. These findings reveal systematic blind spots in current medical evaluation of LLMs and suggest that rubric scores alone are insufficient to establish clinical reliability, potentially undermining clinician trust and confidence in clinical deployment.

Objective. Clinical AI documentation systems require evaluation methodologies that are clinically valid, economically viable, and sensitive to iterative changes. Methods requiring expert review per scoring instance are too slow and expensive for safe, iterative deployment. We present a case-specific, clinician-authored rubric methodology for clinical AI evaluation and examine whether LLM-generated rubrics can approximate clinician agreement. Materials and Methods. Twenty clinicians authored 1,646 rubrics for 823 clinical cases (736 real-world, 87 synthetic) across primary care, psychiatry, oncology, and behavioral health. Each rubric was validated by confirming that an LLM-based scoring agent consistently scored clinician-preferred outputs higher than rejected ones. Seven versions of an EHR-embedded AI agent for clinicians were evaluated across all cases. Results. Clinician-authored rubrics discriminated effectively between high- and low-quality outputs (median score gap: 82.9%) with high scoring stability (median range: 0.00%). Median scores improved from 84% to 95%. In later experiments, clinician-LLM ranking agreement (tau: 0.42-0.46) matched or exceeded clinician-clinician agreement (tau: 0.38-0.43), attributable to both ceiling compression and LLM rubric improvement. Discussion. This convergence supports incorporating LLM rubrics alongside clinician-authored ones. At roughly 1,000 times lower cost, LLM rubrics enable substantially greater evaluation coverage, while continued clinical authorship grounds evaluation in expert judgment. Ceiling compression poses a methodological challenge for future inter-rater agreement studies. Conclusion. Case-specific rubrics offer a path for clinical AI evaluation that preserves expert judgment while enabling automation at three orders lower cost. Clinician-authored rubrics establish the baseline against which LLM rubrics are validated.