---
type: source
title: "JMIR 2025 Systematic Review: Knowledge-Practice Performance Gap in Clinical LLMs — Only 5% of 761 Studies Used Real Patient Data"
author: "JMIR authors (systematic review team)"
url: https://www.jmir.org/2025/1/e84120
date: 2025-11-01
domain: health
secondary_domains: [ai-alignment]
format: research-paper
status: processed
priority: medium
tags: [clinical-ai-safety, benchmark-performance-gap, llm-evaluation, knowledge-practice-gap, real-world-deployment, belief-5, systematic-review]
claims_extracted:
- "five-adverse-sdoh-independently-predict-hypertension-risk-food-insecurity-unemployment-poverty-low-education-inadequate-insurance"
- "never-skilling-is-structurally-invisible-because-it-lacks-pre-ai-baseline-requiring-prospective-competency-assessment"
---

## Content

Published in *Journal of Medical Internet Research* (JMIR), 2025, Vol. 2025, e84120. Available in PMC as PMC12706444. Systematic review of 761 LLM evaluation studies across clinical medicine, analyzing 39 benchmarks.

**Key findings:**
- **Only 5%** of 761 LLM evaluation studies assessed performance on real patient care data
- Remaining 95%: relied on medical examination questions (USMLE-style) or case vignettes
- Traditional knowledge-based benchmarks show saturation: leading models achieve 84-90% accuracy on USMLE
- **Conversational frameworks:** Diagnostic accuracy drops from 82% on traditional case vignettes to 62.7% on multi-turn patient dialogues — **a 19.3 percentage point decrease**
- LLMs demonstrate "markedly lower performance on script concordance testing (evaluating clinical reasoning) than on medical multiple-choice benchmarks"
- Review conclusion: "Recent audits reveal substantial disconnects from clinical reality and foundational gaps in construct validity, data integrity, and safety coverage"

**Related findings (npj Digital Medicine benchmark study):**
- Six LLMs evaluated: average total score 57.2%, safety score 54.7%, effectiveness 62.3%
- **13.3% performance drop in high-risk scenarios** vs. average scenarios

## Agent Notes

**Why this matters:** This is the methodological foundation under both the Oxford/Nature Medicine RCT (94.9% → 34.5% deployment gap) and the broader claim that OE's USMLE 100% benchmark performance doesn't predict clinical outcomes. The systematic review establishes that the benchmark-to-reality gap is systematic across the field, not anomalous. The 5% real-patient-data figure is particularly striking: 95% of clinical AI evaluation is done with questions that would never fool a medical student, not with actual clinical workflows.

**What surprised me:** The 19.3 percentage point drop from case vignettes to multi-turn dialogues. This is the conversational complexity gap — the same model that answers discrete questions well fails in the back-and-forth of real clinical interaction. OE users query OE in conversational clinical language, making this gap directly relevant.

**What I expected but didn't find:** Any indication that the field is systematically correcting this — moving toward real-patient-data evaluation. The review documents the problem but doesn't identify a trend toward better evaluation practices.

**KB connections:**
- Methodological foundation for the Oxford/Nature Medicine RCT deployment gap finding
- Directly explains why OE's USMLE 100% benchmark performance (cited in Session 9) doesn't predict clinical safety
- Connects to NOHARM's finding that real clinical scenario evaluation (31 LLMs, complex vignettes) shows 22% severe error rates — vs. USMLE saturation at 84-90%
- The 13.3% performance drop in high-risk scenarios (npj Digital Medicine) maps to NOHARM's finding that omissions cluster in complex, high-acuity scenarios

**Extraction hints:**
- Primary claim: "95% of clinical LLM evaluation uses medical examination questions rather than real patient care data — a systematic evaluation methodology gap that makes benchmark performance (84-90% USMLE) uninterpretable as a clinical safety signal"
- Secondary: "Conversational frameworks reveal 19.3pp accuracy drop vs. case vignettes, demonstrating that LLMs fail in the back-and-forth interaction that defines actual clinical use"
- This could merge with the Oxford/Nature Medicine source as a unified "benchmark saturation and real-world deployment gap" claim

**Context:** JMIR is a leading peer-reviewed journal in digital health and health informatics. Systematic review of 761 studies is a large corpus. The PMC availability confirms peer review.

## Curator Notes
PRIMARY CONNECTION: Belief 5 — clinical AI safety evaluation methodology gap
WHY ARCHIVED: Provides systematic evidence that the KB's reliance on benchmark performance data (e.g., "OE scores 100% on USMLE") is epistemically weak — and establishes that the Oxford RCT deployment gap finding is part of a systematic pattern
EXTRACTION HINT: Extract the 5%/95% finding as a standalone methodological claim about the clinical AI evaluation field; pair with Oxford Nature Medicine RCT as empirical confirmation
