Auditing Multimodal LLM Raters: Central Tendency Bias in Clinical Ordinal Scoring

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.

Evaluating medical AI systems using expert clinician panels is costly and slow, motivating the use of large language models (LLMs) as alternative adjudicators. Here, we evaluate an LLM Jury, composed of three frontier AI models, for scoring 3334 diagnoses on 300 real-world low- and middle-income country (LMIC) hospital cases. Both LLM- and clinician-generated diagnoses are scored against expert panel diagnoses across four dimensions: diagnosis, differential diagnosis, clinical reasoning, and negative treatment risk. The LLM Jury scores are compared with expert and independent re-scoring panel scores to assess error metrics, inter-rater agreement, severe-risk errors, and the effect of post hoc calibration using isotonic regression. In our data, we find that: (i) the uncalibrated LLM Jury scores preserve ordinal agreement with the expert clinician panel scores, but are systematically lower; (ii) the probability of severe-risk errors is lower for the LLM Jury than the human expert re-score panels; (iii) the LLM Jury combined with LLM diagnoses can be used to identify diagnoses at high risk of error, enabling targeted expert review and improved panel efficiency; (iv) the calibrated LLM Jury scores and rankings of diagnosing agents show excellent agreement with those of the primary expert panels; (v) LLM Jury models show no self-preference bias, they did not score diagnoses generated by their own underlying model or models from the same vendor more (or less) favourably than those generated by other models. Together, these results provide evidence that a calibrated LLM Jury is a trustworthy and reliable proxy for expert clinician evaluation in medical AI benchmarking. Confirming these findings in other clinical settings is an important direction for future work.

LLMs now sit on every side of evaluation: as examinees scored on benchmarks, judges of other models' outputs, and raters of human-generated content. Each paradigm can be viewed as a measurement problem, where a latent property of an object is probed with items from an instrument (e.g., benchmark) by judges or raters. Standard evaluation practices often neglect the contributions of each core component to the end result, limiting our understanding of what is being measured. Rasch measurement theory (RMT) is well-suited to this problem. RMT decomposes ordinal ratings into separable facets on a common scale. It further provides a battery of diagnostics that can identify miscalibrated measurements and rater biases. We present a case study of RMT applied to the LLM-as-rater paradigm using the Measuring Hate Speech corpus, whose construct was itself built under RMT. We fit a series of many-facet Rasch models to annotations from nine LLMs spanning families and capability levels. Our analyses show that LLMs systematically differ from human raters in severity, item-level calibration, question-order robustness, target-identity sensitivity, and rating scale use, all of which standard evaluation practice would largely obscure. Overall, we argue that RMT belongs in the toolkit for evaluating LLM-as-examinee, -judge, and -rater paradigms.