Deployment-Centered Evaluation: Predicting Query-Level Rejection Risk in a Clinical LLM System
Authors: Alyssa Unell, Miguel Fuentes, Brenna Li, Bridget Lin, Meena Jagadeesan, Sanmi Koyejo, Nigam Shah
Abstract
Large language models (LLMs) are increasingly integrated into clinical systems, making it essential to evaluate the real-world utility of these systems. However, static benchmarks tend to measure correctness rather than user acceptance, aggregate performance across queries, and require densely annotated datasets -- leading to major blind spots for evaluating clinical systems. In this work, we perform a deployment-centered evaluation of an LLM system embedded within electronic health records at an academic medical center, where user feedback is sparse but closely reflects the deployment conditions. Specifically, we train a pre-response classifier that estimates the risk that a future interaction will result in the user rejecting the LLM response, based on query content and deployment-specific context available before generation. We conduct a prospective analysis of our model over 4.5 months of user feedback, finding that our prediction model achieves an AUROC of 0.719. Further, we estimate the benefit of such predictions in two downstream use cases (guardrail triggering and abstention). Our key conceptual insight is that making use of deployment-specific context (i.e., the provider type, department name, language model used for response), as opposed to only query content, improves the ability to predict whether the user will reject the system output. Altogether, our empirical case study demonstrates the feasibility of predicting user rejection using deployment-specific context, opening the door to targeted guardrails.
Large language model (LLM) applications are increasingly expected to satisfy deterministic institutional requirements while relying on probabilistic generative components. This mismatch makes ordinary post-hoc benchmarking insufficient for systems that must be safe, reliable, auditable, and economically useful. This paper contributes an evaluation-protocol extension for operational LLM systems grounded in acceptance-test-driven development, safety engineering, and business-centric validation. The extension translates stakeholder goals into executable behavioral contracts, release gates, monitoring signals, and evidence artifacts before prompt, model, retrieval, or agent changes are accepted. It adapts the red-green-refactor discipline of test-driven development to a red-train-green lifecycle: first define failing acceptance tests for desired behavior, then improve the LLM system through prompt changes, retrieval design, fine-tuning, guardrails, or data augmentation, and finally release only when multidimensional gates are satisfied. The contribution is a governance-oriented metric stack, reference architecture, and empirical protocol for comparing acceptance-test-driven LLM development against prompt-first and benchmark-after workflows.
Benchmarks are necessary for healthcare evaluation, but are not sufficient for predicting deployment performance. Our position is that the evaluation--deployment gap arises not because of poorly designed benchmarks, but from implicit assumptions about how users interact with models that cannot be surfaced from benchmarks alone. To make this precise, we propose a classification of assumptions into two categories: task, which can be tested from conversation data alone, and outcome, which requires outcome data and behavioral studies for testing. Critically, outcome assumptions depend on human behavior, something that even well-designed benchmarks cannot directly observe. To demonstrate the operationality of this framework, we retrospectively analyze a healthcare RCT as a case study and find that the gap naturally separates into task and outcome gaps of roughly equal size. To address this, we make two contributions: first, we propose BenchmarkCards, an artifact that documents assumptions, and second, we propose staged evaluation, a procedure that systematically tests assumptions and evaluates performance.
Naveen Raman, Santiago Cortes-Gomez, Mateo Dulce Rubio +2
Medical large language model (LLM) evaluations rely on simplified, exam-style benchmarks that rarely reflect the ambiguity of real-world medical inquiries. We introduce the CLinical Evaluation of Ambiguity and Reliability (CLEAR) framework, which assesses how decision-space presentation, ambiguity, and uncertainty affect LLMs' reasoning on medical benchmarks. CLEAR systematically perturbs (1) the number of plausible answer options, (2) the presence of a ground truth or abstention option, and (3) the semantic framing of answer options. Applying CLEAR on three benchmarks evaluated across 17 LLMs reveals three notable limitations of existing evaluation methods. First, increasing the number of plausible answers degrades a model's ability to identify the correct answer and abstain against incorrect ones. Second, this lack of caution intensifies as the framing of abstention shifts from assertive rejection like "None of the Above" to uncertainty admission like "I don't know" (IDK). Notably, just including IDK in the answer space increases incorrect answer selections. Lastly, we formalize the performance gap between identifying the correct answer and abstaining from incorrect ones as the humility deficit, which worsens with model scale. Our findings reveal limitations in standard medical benchmarks and underscore that scaling alone does not resolve LLM reliability issues.