Implicit Framing in Obstetric Counseling Notes: A Grounded LLM Pipeline on a VBAC-Eligible Cohort

The application of large language models (LLMs) to personalized medical assistants has garnered growing interest. However, existing medical benchmarks largely rely on static question answering with pre-selected evidence, leaving unclear whether LLMs can make reliable clinical decisions from real longitudinal electronic health records (EHRs). To bridge this gap, we introduce ObGynLongBench, a rule-grounded long-context EHR benchmark for obstetric and gynecologic decision-making, comprising 1,500 clinical decision-point cases from 976 real pregnancy EHR histories and traceable rules. Each case is anchored to a patient, a pregnancy-timeline point, and a pre-decision information boundary, enabling Evidence-only, Visit-level EHR, and History-level EHR evaluation. Evaluating 17 LLMs reveals a substantial Evidence-to-EHR Gap: models perform well when evidence is directly provided, but accuracy drops when evidence must be extracted from same-day records or full pre-decision EHR histories. Further analyses identify evidence utilization as a key bottleneck: performance decreases with longer EHR contexts and more complex evidence requirements, and earlier failures often predict later failures within the same patient history. Finally, active-search agents perform best among EHR access strategies, highlighting patient-specific evidence utilization as a central challenge for reliable personalized medical assistants. Resources are available at https://github.com/xiangjun2003/ObgynLongbench.

We introduce FramingQA, a benchmark that measures the model sensitivity to question framing across law, medicine, finance, and robotic simulations. Large language models (LLMs) often change their responses to subtle rephrasings that align with an implied stance by users. This can leave users with advice tainted by how they happened to phrase a question rather than by the underlying facts, and the consequences are highly costly in high-stakes domains. Because in the realistic scenarios, both expert practitioners and non-expert users frequently ask LLMs questions containing incomplete or misleading assumptions, models are highly susceptible to those framings. To test this, we inject the framing bias across three nested levels: a framing-biased question phrasing (root), an injected framing-biased premise prepended to a neutral question (propositional), and a premise paired with a framing-biased question (global). Evaluating nine open models (3.8B-70B) across four families, we find that strong per-variant accuracy does not guarantee the robustness across differently phrased questions under the fixed factual information.

Large language models (LLMs) are increasingly used for clinical text tasks such as summarization and revision. While most studies evaluate the fluency and coherence of LLM-generated text, whether LLMs correctly preserve diagnostic uncertainty remains underexplored. In clinical practice, phrases such as ``possible pneumonia'' communicate the strength of available evidence and directly guide decisions about follow-up testing and treatment. Altering these uncertainty expressions can change the clinical meaning entirely. In this paper, we systematically evaluated this problem in two steps. First, we constructed a benchmark of 1,200 clinical documents with 9,184 uncertainty annotations across five levels. Second, we evaluated three LLMs on this benchmark. Our results show that (1) LLMs preserve the original uncertainty cues poorly, often less than half the time; (2) LLMs struggle with nuanced distinctions between adjacent levels. This work reveals a failure mode not captured by standard evaluation metrics and provides implications for the safe deployment of LLMs in clinical workflows.