Abstract
BACKGROUND: Diagnostic pathology depends on complex, structured reasoning to interpret clinical, histologic, and molecular data. Replicating this cognitive process algorithmically remains a significant challenge. As large language models (LLMs) gain traction in medicine, it is critical to determine whether they have clinical utility by providing reasoning in highly specialized domains such as pathology. METHODS: We evaluated the performance of four reasoning LLMs (OpenAI o1, OpenAI o3-mini, Gemini 2.0 Flash Thinking Experimental, and DeepSeek-R1 671B) on 15 board-style open-ended pathology questions. Responses were independently reviewed by 11 pathologists using a structured framework that assessed language quality (accuracy, relevance, coherence, depth, and conciseness) and seven diagnostic reasoning strategies. Scores were normalized and aggregated for analysis. We also evaluated inter-observer agreement to assess scoring consistency. Model comparisons were conducted using one-way ANOVA and Tukey's Honestly Significant Difference (HSD) test. RESULTS: Gemini and DeepSeek significantly outperformed OpenAI o1 and OpenAI o3-mini in overall reasoning quality (p < 0.05), particularly in analytical depth and coherence. While all models achieved comparable accuracy, only Gemini and DeepSeek consistently applied expert-like reasoning strategies, including algorithmic, inductive, and Bayesian approaches. Performance varied by reasoning type: models performed best in algorithmic and deductive reasoning and poorest in heuristic and pattern recognition. Inter-observer agreement was highest for Gemini (p < 0.05), indicating greater consistency and interpretability. Models with more in-depth reasoning (Gemini and DeepSeek) were generally less concise. CONCLUSION: Advanced LLMs such as Gemini and DeepSeek can approximate aspects of expert-level diagnostic reasoning in pathology, particularly in algorithmic and structured approaches. However, limitations persist in contextual reasoning, heuristic decision-making, and consistency across questions. Addressing these gaps, along with trade-offs between depth and conciseness, will be essential for the safe and effective integration of AI tools into clinical pathology workflows.