The Validity Gap in Health AI Evaluation: A Cross-Sectional Analysis of Benchmark Composition

Large language model (LLM) assistants are being deployed to clinicians across health systems, and judgments about their readiness rest largely on benchmark scores, most of them derived from examination questions or curated cases. A benchmark predicts performance in deployment only to the extent that its items resemble real use, yet whether benchmarks reflect the work these systems receive has rarely been measured. Here we analyze 127,833 queries sent by 6,342 physicians, advanced practice providers and nurses in 35 specialties to an institutional assistant during an eight-month roll-out. We characterize each query with RCQ-Map, a clinician-validated framework grounded in taxonomies of clinical questions and of LLM evaluation, which records its task, intent, answerability, missing information and potential harm. Documentation and administration (36.2%) and knowledge retrieval (28.9%) made up nearly two-thirds of use, and diagnosis 3.7%; more than a third of queries could not be answered well as posed. Applying RCQ-Map to 58 public benchmarks drawn from major evaluation suites and frontier model reports, which we assemble into the Clinical AI Benchmark Atlas, showed that the median benchmark contained no documentation requests and shared 31% of the task mix of real use, less than an even spread across task categories would. Benchmarks in suites designed to resemble clinical practice were individually no closer to real use than those used in frontier model reports. Benchmark scores therefore say little about how clinical AI performs on most of the work it is actually given, and evaluation should be matched to real clinical use.

Large language models are increasingly used for medical guidance, but women's health remains under-evaluated in benchmark design. We present the Women's Health Benchmark (WHBench), a targeted evaluation suite of 47 expert-crafted scenarios across 10 women's health topics, designed to expose clinically meaningful failure modes including outdated guidelines, unsafe omissions, dosing errors, and equity-related blind spots. We evaluate 22 models using a 23-criterion rubric spanning clinical accuracy, completeness, safety, communication quality, instruction following, equity, uncertainty handling, and guideline adherence, with safety-weighted penalties and server-side score recalculation. Across 3,102 attempted responses (3,100 scored), no model mean performance exceeds 75 percent; the best model reaches 72.1 percent. Even top models show low fully correct rates and substantial variation in harm rates. Inter-rater reliability is moderate at the response label level but high for model ranking, supporting WHBench utility for comparative system evaluation while highlighting the need for expert oversight in clinical deployment. WHBench provides a public, failure-mode-aware benchmark to track safer and more equitable progress in womens health AI.

Large language models (LLMs) are increasingly used to answer health-related questions and support healthcare workflows, yet evidence for their safety still relies heavily on static benchmarks that can rapidly become obsolete or be optimized against. Here we introduce a Dynamic, Automatic, and Systematic (DAS) red-teaming audit framework that continuously stress-tests LLMs for health across four safety-critical axes: robustness, privacy, bias/fairness, and hallucination/factual inaccuracies. Validated against board-certified clinicians with high concordance, a suite of adversarial agents autonomously mutates health-related test cases to uncover vulnerabilities in real time. Applying DAS to 15 proprietary and open-source LLMs revealed a profound gap between high static benchmark performance and low dynamic reliability--the "Benchmarking Gap". Despite median MedQA accuracy exceeding 80%, 94% of previously correct answers failed under dynamic robustness testing. This brittleness generalized to the realistic, open-ended HealthBench dataset, where top-tier models exhibited failure rates exceeding 70% and sharp shifts in model rankings across evaluations, suggesting that high scores on established static benchmarks may reflect superficial memorization. We observed similarly high failure rates across other domains: privacy leaks were elicited in 86% of scenarios, cognitive-bias priming altered recommendations in 81% of fairness tests, and hallucination rates exceeded 74% in widely used models. By converting LLM safety evaluation for health from a static checklist into a living adversarial audit, DAS provides a scalable framework for surfacing latent risks before such systems are deployed in consumer-facing health assistants, clinician-facing tools, and broader healthcare workflows. Code is available at https://github.com/JZPeterPan/DAS-Medical-Red-Teaming-Agents.