Searcharxiv⌕ Search
Home/Archive/arXiv

arXiv · 2609.34112

Unknown is not normal: separating language-model extraction from rule-based decision logic for clinical risk scores

Nicolás Vera Zúñiga
View original source ↗Read source document ↗Export metadata ↓

Abstract

Large language models (LLMs) are increasingly used to compute clinical risk scores from free-text notes. Notes are often incomplete, and treating undocumented findings as normal can silently misclassify patients. We test whether separating three-state extraction (present, absent or unknown, by an LLM) from decision logic (deterministic code computing score bounds over unknown inputs) lets a system ask only questions that can change the decision. On 1,200 synthetic emergency cases across six calculators (HEART, CURB-65, qSOFA, PERC, Wells, Cockcroft-Gault), with a simulated clinician answering questions, we compared this bounds policy with asking for every missing input, a missing-equals-normal schema, and an end-to-end LLM agent (Claude Opus 5.5). With Claude Haiku 4.5 as extractor, the bounds policy matched ask-all accuracy (99.4% vs 99.4%) with half the questions (0.92 vs 1.78 per case) and no irrelevant ones. Treating missing as normal dropped accuracy to 91.2% and under-triaged 8.5% of patients (95% CI 7.1-10.2), and under-triage persisted under messy notes and a noisy clinician. The agent was equally accurate under ideal conditions (99.6%) but 9.5% of its questions were irrelevant; with a noisy clinician it was less accurate than the bounds policy (83.5% vs 87.0%, p<0.001) and committed prematurely in 2.7% of cases (bounds: 0%). A 9B local model as extractor reached oracle-level accuracy (99.8%). In 584 real case reports from MedCalc-Bench, only 52% contained enough information to determine the category (HEART 13%). Routing decisions through code that reasons explicitly about unknowns avoids premature commitment and irrelevant questions, halves the questions asked, and works with small local models.

Explore related subjects

cs.CLcs.AI

Keep this discovery

Explore connections, maps & timelines

BibTeXRIS

Nicolás Vera Zúñiga. 2026-09-28. Unknown is not normal: separating language-model extraction from rule-based decision logic for clinical risk scores. https://arxiv.org/abs/2609.34112

Cite the original work for its findings. Save a collection to share your selection of sources.

KEEP EXPLORING

Related papers

arXiv2026

LaSEr-Edit: Localized Span-level Error Editing with Energy-based Localization

As large language models (LLMs) are widely adopted in real-world applications, it has become critical to ensure LLMs satisfy safety constraints, such as non-toxicity and logical consistency, as well as task- and situation-specific constraints. Controlling the output through instructions is a simple and tempting approach; however, it remains brittle, is opaque in how it influences model behavior, and thus cannot reliably ensure constraint satisfaction. Moreover, most recent controlled text generation (CTG) methods require access to the internal components of language models--such as weights or logits--making them incompatible with popular API-based LLMs. In this work, we propose LaSEr-Edit, a constraint-satisfying text revision method that can be applied to any LLMs, black- or white-box. We first find that lightweight, task-specific energy-based models (EBMs) achieve error-localization performance competitive with or even better than that of much larger LLMs, while operating substantially faster. Based on this finding, we propose two variants of text revision methods that incorporate energy-based error localization: LaSEr-LLM Edit, which instructs an LLM to edit text given EBM-predicted error spans, and LaSEr-EBM Edit, which uses the EBM not only for localization but also for editing by reranking edit candidates. Through experiments in diverse single-constraint control tasks, we show that LaSEr-LLM Edit controls text better than plain LLM-based editing in most of the tasks. We also find that LaSEr-EBM Edit further improves the control performance of LaSEr-LLM Edit and achieves among the strongest controllability across all tasks. Furthermore, we find that LaSEr-Edit, especially LaSEr-EBM Edit, performs well even when multiple constraints are controlled simultaneously.

cs.CL↗
arXiv2026

No Free Labels: Limitations of LLM-as-a-Judge Without Human Grounding

Reliable evaluation of large language models (LLMs) is critical as their deployment rapidly expands, particularly in high-stakes domains such as business and finance. The LLM-as-a-Judge framework, which uses prompted LLMs to evaluate response quality, is appealing due to its scalability, low cost, and strong correlations with human stylistic preferences. However, it remains unclear how accurately these methods can assess response quality in domains where correctness matters more than style. To address this gap, we introduce the Business and Finance Fundamentals Benchmark (BFF-Bench), a dataset of 160 challenging questions and long-form responses authored by financial professionals. These experts subsequently evaluated the correctness of 1,200 responses generated by a diverse set of LLMs on both BFF-Bench and a challenging subset of MT-Bench. With this expert-annotated dataset of judgments (VERDICTS), we analyze the agreement between a suite of automated grading methods and human experts. While we observe that LLM Judges are more reliable than other grading methods, our findings reveal a clear pattern in LLM Judge performance: when not provided with a correct reference, judges show high agreement with human experts only on questions the judges were able to correctly answer themselves. We demonstrate that providing the judges with expert-written references largely mitigates this issue, highlighting the limits of using LLM-as-a-Judge without any form of human verification.

cs.CL↗
arXiv2026

Adaptive Activation Steering for Efficient LLM Reasoning via Closed-Loop PID Control

Reasoning LLMs trained with long chain-of-thought often overthink: they spend tokens on redundant reflection and transitions that inflate cost without improving accuracy. Static activation steering (e.g.\ SEAL) suppresses such content with a fixed vector, but applies the same strength regardless of how redundant the current chunk actually is. We describe PID-steering, a training-free, decoding-time method that modulates the steering strength with a PID controller driven by a lightweight chunk-level redundancy classifier. On a subset of GSM8K with DeepSeek-R1-Distill-Qwen-1.5B, the method improves accuracy from 85.7\% to 89.6\% (+3.9 pp) while cutting average output length from 1026 to 790 tokens ($-$23\%). We report it as a small-scale proof of concept rather than a benchmark result.

cs.CL↗