Are We Grading Properly? Understanding Failure Modes in Medical Benchmarks

Hallucinations can undermine clinician trust in LLMs, making it important that evaluation methods capture clinically relevant errors. Rubric-based evaluation has become the leading approach for assessing LLMs in medicine, but it is unclear whether rubric scores reflect such errors. We first study this in a controlled setting using MedHallu, finding that more specific rubrics better distinguish correct from hallucinated responses. To test this systematically, we develop a taxonomy of medical hallucination types and a clinician-validated error-injection pipeline that creates matched correct and error-injected responses. Across HealthBench, HealthBench Professional, and LiveMedBench, our clinically relevant hallucinations are missed by rubrics, often leaving scores unchanged. We find that rubrics are most effective when explicitly checking facts, and are less effective for additional or unexpected errors they do not anticipate. A preliminary retrieval-based factuality check recovers some of the rubric-blind errors, suggesting a complementary approach. These findings reveal systematic blind spots in current medical evaluation of LLMs and suggest that rubric scores alone are insufficient to establish clinical reliability, potentially undermining clinician trust and confidence in clinical deployment.

As Large Language Model (LLM) alignment evolves from simple completions to complex, highly sophisticated generation, Reward Models are increasingly shifting toward rubric-guided evaluation to mitigate surface-level biases. However, the community lacks a unified benchmark to assess this evaluation paradigm, as existing benchmarks lack both the discriminative complexity and the ground-truth rubric annotations required for rigorous analysis. To bridge this gap, we introduce RubricBench, a curated benchmark with 1,147 pairwise comparisons specifically designed to assess the reliability of rubric-based evaluation. Our construction employs a multi-dimensional filtration pipeline to target hard samples featuring nuanced input complexity and misleading surface bias, augmenting each with expert-annotated, atomic rubrics derived strictly from instructions. Comprehensive experiments reveal a substantial capability gap between human-annotated and model-generated rubrics, indicating that even state-of-the-art models struggle to autonomously specify valid evaluation criteria, lagging considerably behind human-guided performance.

We propose a rubric for assessing expressed clinical reasoning in model responses, drawing on three bodies of work: medical education assessment frameworks (ART, SCT, Key Feature Problems and OSCE); clinical LLM benchmarks (MedR-Bench, HealthBench, TIMER-Bench, DR. BENCH, PrIME-LLM and PatientSafeBench); and general LLM reasoning evaluation research, including the Factuality-Validity-Coherence-Utility taxonomy, FaithCoT-Bench and C2-Faith. We use groundedness as a clinically oriented adaptation of the taxonomy's factuality category. The rubric brings these concepts together in a multidimensional framework for scoring free-text responses to gold-standard clinical vignettes. It includes provisional behavioural anchors, applicability rules and a separate flag for case-specific safety-critical errors. General-domain frameworks inform its design but are not treated as validated clinical instruments. The rubric does not replace case-specific reference criteria or the task-specific metrics of existing benchmarks. It has not yet been tested for inter-rater reliability, construct validity or clinical utility. Its immediate purpose is to make evaluation decisions explicit and open to scrutiny before empirical testing.