Evaluation of Multiple Generative Large Language Models on Neurology Board-style Questions
Abstract
Objective: To compare the performance of eight large language models (LLMs) with neurology residents on board-style multiple-choice questions across seven subspecialties and two cognitive levels. Methods: In a cross-sectional benchmarking study, we evaluated Bard, Claude, Gemini v1, Gemini 2.5, ChatGPT-3.5, ChatGPT-4, ChatGPT-4o, and ChatGPT-5 using 107 text-only items spanning movement disorders, vascular neurology, neuroanatomy, neuroimmunology, epilepsy, neuromuscular disease, and neuro-infectious disease. Items were labeled as lower- or higher-order per Bloom's taxonomy by two neurologists. Models answered each item in a fresh session and reported confidence and Bloom classification. Residents completed the same set under exam-like conditions. Outcomes included overall and domain accuracies, guessing-adjusted accuracy, confidence–accuracy calibration (Spearman ρ), agreement with expert Bloom labels (Cohen κ), and inter-generation scaling (linear regression of topic-level accuracies). Group differences used Fisher exact or χ2 tests with Bonferroni correction. Results: Residents scored 64.9%. ChatGPT-5 achieved 84.1% and ChatGPT-4o 81.3%, followed by Gemini 2.5 at 77.6% and ChatGPT-4 at 68.2%; Claude (56.1%), Bard (54.2%), ChatGPT-3.5 (53.3%), and Gemini v1 (39.3%) underperformed residents. On higher-order items, ChatGPT-5 (86%) and ChatGPT-4o (82.5%) maintained superiority; Gemini 2.5 matched 82.5%. Guessing-adjusted accuracy preserved rank order (ChatGPT-5 78.8%, ChatGPT-4o 75.1%, Gemini 2.5 70.1%). Confidence–accuracy calibration was weak across models. Inter-generation scaling was strong within the ChatGPT lineage (ChatGPT-4 to 4o R2 = 0.765, p = 0.010; 4o to 5 R2 = 0.908, p < 0.001) but absent for Gemini v1 to 2.5 (R2 = 0.002, p = 0.918), suggesting discontinuous improvements. Conclusions: LLMs—particularly ChatGPT-5 and ChatGPT-4o—exceeded resident performance on text-based neurology board-style questions across subspecialties and cognitive levels. Gemini 2.5 showed substantial gains over v1 but with domain-uneven scaling. Given weak confidence calibration, LLMs should be integrated as supervised educational adjuncts with ongoing validation, version governance, and transparent metadata to support safe use in neurology education.
