Unmasking True Clinical Competence: The Importance of Adaptive and Open-Ended Evaluation for Large Language Models in Cardiology

Background Large language models (LLMs) achieve impressive accuracy on multiple-choice (MC) medical examinations, but this performance alone may not accurately reflect their clinical reasoning abilities. MC evaluations of LLMs risk inflating apparent competence by rewarding recall rather than genuine clinical adaptability, particularly in specialized medical domains such as cardiology. Aim To rigorously evaluate the clinical reasoning, contextual adaptability, and answer-reasoning consistency of a state-of-the-art reasoning-based LLM in cardiology using MC, open-ended, and clinically modified question formats. Methods We assessed GPT o1-preview using 185 board-style cardiology questions from the American College of Cardiology Self-Assessment Program (ACCSAP) in MC and open-ended formats. A subset of 66 questions underwent modifications of critical clinical parameters (e.g., ascending aorta diameter, ejection fraction) to evaluate model adaptability to context changes. The model’s answer and reasoning correctness were graded by cardiology experts. Statistical differences were analyzed using exact McNemar tests. Results GPT o1-preview demonstrated high baseline accuracy on MC questions (93.0% answers, 92.4% reasoning). Performance significantly decreased with open-ended questions (80.0% answers, 80.5% reasoning; p<0.001). For modified MC questions, accuracy decreased significantly (answers: 93.9% to 66.7%; reasoning: 93.9% to 71.2%; both p<0.001), as well as answer-reasoning concordance (93.9% to 66.7%, p<0.001). Conclusions Using existing MC question formats substantially overestimates the performance and clinical reasoning capabilities of GPT o1-preview. Incorporating open-ended, clinically adaptive questions and evaluating answer-reasoning concordance are essential for accurately assessing the real-world clinical decision-making competencies of LLMs in cardiology.