Ambient clinical scribes increasingly combine Automatic Speech Recognition with Large Language Models to automate documentation. However, traditional metrics like Word Error Rate mask systemic safety degradation. We present a paired acoustic stress test to isolate the causal impact of noise on clinical reasoning. For the same dialogues, we inject diverse noise types while keeping the downstream model configuration frozen. Crucially, we uncover a dangerous disconnect between signal fidelity and clinical safety. Stationary ambient noise increased the Word Error Rate by a negligible 0.71 percentage points yet nearly doubled the rate of unsafe outputs. Our analysis reveals that minor acoustic perturbations can invert clinical meaning without substantially inflating error rates. Furthermore, we demonstrate a lightweight mitigation strategy that mitigates safety degradation under noisy conditions without requiring model fine tuning.
Automatic Speech Recognition systems are notoriously both sensitive to adversarial and benign perturbations. While this has been repeatedly demonstrated using reference datasets, detecting such behaviors in deployed systems is incredibly challenging, due to the absence of oracle knowledge of the true transcription. We demonstrate that employing a certification-inspired mechanism can significantly decrease WER, increase recall, and decrease the Spearman correlation between confidence and WER. We achieve this through a dual-gate diagnostic pipeline: a Two-Sided Atomic Audit that accumulates statistical wealth to certify both token existence and adversarial exclusion, and a Rank-Based Tournament that selects the winning sequence. Our evaluations across four diverse architectures demonstrate up to a 55% relative reduction in Word Error Rate, while also providing granular word- and sentence-level certifications to enhance acoustic security.
Large language models (LLMs) are entering clinical practice based on benchmark accuracy that may fail to detect safety-relevant failure modes. Here we present AI-MASLD, a stress-audit framework that adapts the logic of metabolic stress testing from hepatology to the evaluation of clinical LLMs. Using 240 clinical cases across six narrative perturbation probes, we subjected seven models to double-stress testing and quantified performance through three indices: metabolic index (MI), perturbation flip rate (PFR), and counterfactual fairness index (CFI). Under clean baseline conditions, all models performed uniformly well. Under realistic narrative stress, performance diverged sharply, revealing two distinct stress-response phenotypes. Quantized models exhibited pseudonormalization, in which low flip rates hid functional collapse. Medical supervised fine-tuning systematically degraded logical stability, fairness, and information extraction. An open-weight model matched or exceeded proprietary alternatives on every safety dimension. These findings establish narrative stress auditing as a necessary complement to accuracy-based evaluation.
Automatic speech recognition replaces typing only when correction costs less than manual entry - a threshold determined by error types, not counts: fixing a misrecognized domain term costs far more than inserting a comma. Word error rate (WER) fails on two fronts: it collapses distinct error categories into a single scalar, and it structurally penalizes agglutinative languages where valid sandhi merges inflate scores. We introduce SCRIBE, a diagnostic framework offering categorical error decomposition into lexical, punctuation, numeral, and domain-entity rates via sandhi-tolerant alignment with domain vocabulary injection. Human validation confirms SCRIBE aligns with expert judgment where WER does not. We release SCRIBE, an LLM curation pipeline, benchmarks, and open-weight rich transcription models for Hindi, Malayalam, and Kannada.