Dynamic Bidirectional Pattern Memory: A Production-Scale Empirical Characterisation of Inference-Time Gating in Clinical NLP

Reasoning benchmarks measure clinical performance on clean inputs. We evaluate the step before reasoning: retrieval over real EHR notes, where negation, temporality, and family-versus-patient attribution can flip a correct answer to a wrong one. EpiKG carries an assertion label and a temporality tag with every fact in a patient knowledge graph, then routes retrieval by question intent. ClinicalBench is a 400-question test over 43 MIMIC-IV patients across 9 assertion-sensitive categories. A 7-condition ablation tests each piece of EpiKG across six LLMs (Claude Opus 4.6, GPT-OSS 20B, MedGemma 27B, Gemma 4 31B, MedGemma 1.5 4B, Qwen 3.5 35B). Three physicians blindly adjudicated 100 paired items. The author-blind primary endpoint, leave-author-out paired exact McNemar on 50 unanimous-strict items rated by two external physicians, yields +22.0 percentage points (95 percent Newcombe CI [+5.1, +31.5], p=0.0192). The architectural novelty, intent-aware KG-RAG over a Contriever dense-RAG baseline (C2b to C4g_kw on the change-excluded n=362 endpoint), is +8.84 percentage points (paired McNemar p=1.79e-3); +12.43 percentage points under oracle intent. Sensitivities agree directionally: three-rater physician majority +24.0 percentage points (subject to single-author circularity); deterministic keyword reproducibility proxy +39.5 percentage points. Across the six models, the gain shrinks as the LLM-alone baseline rises (beta=-1.123, r=-0.921, p=0.009). With n=6 this looks more like regression to the mean than encoding substituting for model size. Physician adjudication identified 56 percent of auto-generated reference answers as defective, a methodological finding indicating that NLP-pipeline clinical-QA benchmarks require physician adjudication to be usable. ClinicalBench, the frozen evaluator, three-rater adjudication data, and the EpiKG output stack are publicly released.

Patient-voiced clinical-triage benchmarks report high under-triage rates for consumer LLMs for constrained multiple-choice output, yet the same cases score differently with free-text. We ask whether output format changes the model's \emph{clinical representation} or only the mapping from a preserved representation to an answer. Using sparse-autoencoder (SAE) features in Gemma 3 4B/12B IT and Qwen3-8B, we find the same medical features fire on the shared clinical narrative under both formats but go {silent} at the multiple-choice decision token in all the cases at every model. Three independent methods (natural-language autoencoder verbalization, decision-token logit attribution, and top-feature characterization) agree that scaffold and format features, but not medical features, drive the decision logits. Behaviorally, the multiple-choice penalty inverts under both structured and natural-language input, option-order shuffle rules out positional bias, and the gap is dominated by off-by-one decision (the model picks an adjacent acuity letter to the gold answer) rather than knowledge failure. Thus, the failure originates in the output format and not in the clinical representation.

Reliably knowing when a language model is correct is almost as important as being correct. We introduce prover-verifier deliberation (PVD), an inference-time protocol grounded in interactive proof theory, as a mechanism for selective prediction: the protocol produces both an answer and a structured confidence verdict, allowing a system to report high-confidence answers while abstaining on uncertain cases. In each dialogue, a prover defends a candidate answer through checkable sub-claims while a verifier issues targeted challenges and returns \textsc{Accept}, \textsc{Challenge}, or \textsc{Reject}. Because frozen language models are imperfect provers and verifiers operating over a noisy channel, formal soundness and completeness guarantees do not transfer; instead, we characterize the protocol empirically through its coverage-precision behavior. Our main experiment uses Claude Sonnet 4.6 as prover and Claude Haiku 4.5 as verifier on GPQA Diamond. Questions accepted with no answer revision, which we call Accept + No Change (ANC), are reported as the high-confidence subset; we evaluate this subset by its precision and coverage. ANC separates reliable from unreliable answers, yielding a $\sim$30pp HC-Prec gap over the non-ANC complement. Robustness experiments with GPT and Gemini pairings show that high HC-Prec can transfer across model families, while verifier strictness and domain competence largely determine the size of the selection gap. On Humanity's Last Exam, weaker prover-verifier pairings can collapse or invert the ANC signal, illustrating a practical failure mode when the verifier operates outside its effective region. Comparisons with self-consistency, universal self-consistency, multi-agent debate, and Reflexion suggest that prover-verifier deliberation supplies a distinct argument-defensibility signal for selective prediction.