ER-Reason: A Benchmark Dataset for LLM Clinical Reasoning in the Emergency Room

Abstract

Existing benchmarks for evaluating the clinical reasoning capabilities of large language models (LLMs) often lack a clear definition of "clinical reasoning" as a construct, fail to capture the full breadth of interdependent tasks within a clinical workflow, and rely on stylized vignettes rather than real-world clinical documentation. As a result, recent studies have found significant discrepancies between LLM performance on stylized benchmarks derived from medical licensing exams and their performance in real-world prospective studies. To address these limitations, we introduce ER-Reason, a benchmark designed to evaluate LLM reasoning as clinical evidence accumulates across decision-making tasks spanning the full workflow of emergency medicine. ER-Reason comprises 25,174 de-identified clinical notes from 3,437 patients, supporting evaluation across all stages of the emergency department workflow: triage intake, treatment selection, disposition planning, and final diagnosis. Crucially, evaluation in ER-Reason extends beyond diagnostic accuracy to include stepwise Script Concordance Test (SCT)-style questions grounded in real patient cases, which assess whether LLMs update their diagnostic beliefs in the correct direction and magnitude as clinical evidence accumulates, scored against 2,555 emergency physician annotations. We evaluate reasoning and non-reasoning LLMs on ER-Reason, and show that our tasks provide a more nuanced view of how LLM reasoning fails on real patient cases than existing benchmarks allow.