BIT.UA-AAUBS at ArchEHR-QA 2026: Evaluating Open-Source and Proprietary LLMs via Prompting in Low-Resource QA

Automated question answering (QA) over electronic health records (EHRs) demands precise evidence retrieval, faithful answer generation, and explicit grounding of answers in clinical notes. In this work, we present Neural1.5, our method for the ArchEHR-QA 2026 shared task at CL4Health@LREC 2026, which comprises four subtasks: question interpretation, evidence identification, answer generation, and evidence alignment. Our approach decouples the task into independent, modular stages and employs DSPy"s MIPROv2 optimizer to automatically discover high-performing prompts, jointly tuning instructions and few-shot demonstrations for each stage. Within every stage, self-consistency voting over multiple stochastic inference runs suppresses spurious errors and improves reliability, while stage-specific verification mechanisms (e.g., self-reflection and chain-of-verification for alignment) further refine output quality. Among all teams that participated in all four subtasks, our method ranks second overall (mean rank 4.00), placing 4th, 1st, 4th, and 7th on Subtasks 1-4, respectively. These results demonstrate that systematic, per-stage prompt optimization combined with self-consistency mechanisms is a cost-effective alternative to model fine-tuning for multifaceted clinical QA.

Open-response evaluation provides stronger clinical validity than multiple-choice benchmarks but creates a scoring bottleneck that motivates automated LLM-asa-Judge approaches. Whether such evaluators replicate clinical calibration and caution, however, remains untested. We introduce MedQADE, the first standardised open-response clinical benchmark for German, a major clinical language lacking native evaluation infrastructure, comprising 3,800 items annotated by ten practising physicians and nine Large Language Model (LLM) evaluators. The top-performing evaluator model, Gemini 3 Flash, reached alignment consistent with the physician ceiling (\k{appa} = 0.694 vs. \k{appa} = 0.709), though wide confidence intervals limit interpretation. Despite this statistical alignment, automated evaluators exhibited near-absent clinical metacognition: physicians scaled abstention with item difficulty, while frontier models assigned definitive scores in every case. We additionally quantified systematic lineage-dependent biases, where models preferentially scored architectural siblings, an effect independent of language. These results show that statistical alignment does not ensure clinical caution, and that evaluator independence requires explicit verification.

Practitioners deploying small open-weight large language models (LLMs) for medical question answering face a recurring design choice: invest in a domain-fine-tuned model, or keep a general-purpose model and inject domain knowledge at inference time via retrieval-augmented generation (RAG). We isolate this trade-off by holding model size, prompt template, decoding temperature, retrieval pipeline, and evaluation protocol fixed, and varying only (i) whether the model has been domain-adapted (Gemma 3 4B vs. MedGemma 4B, both 4-bit quantized and served via Ollama) and (ii) whether retrieved passages from a medical knowledge corpus are inserted into the prompt. We evaluate all four cells of this 2x2 design on the full MedQA-USMLE 4-option test split (1,273 questions) with three repetitions per question (15,276 LLM calls). Domain fine-tuning yields a +6.8 percentage-point gain in majority-vote accuracy over the general 4B baseline (53.3% vs. 46.4%, McNemar p < 10^-4). RAG over MedMCQA explanations does not produce a statistically significant gain in either model, and in the domain-tuned model the point estimate is slightly negative (-1.9 pp, p = 0.16). At this scale and on this benchmark, domain knowledge encoded in weights dominates domain knowledge supplied in context. We release the full experiment code and JSONL traces to support replication.