Organizations: Virginia Tech · Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine · Emory University
Abstract
Large language models can answer a medical question correctly and still abandon that answer when a user pushes back. We study this failure as medical sycophancy and ask when models are most likely to give in. Across five open-weight models, 500 MedQuAD questions, and 1.2 million trials, we use a fully crossed design over four conversational factors: user role, user evidence, interaction structure, and grounding. Medical sycophancy is nearly three times more common when users challenge an answer the model has already given than when the false claim appears in the initial query. Models are also more susceptible to users presented as physicians or medical students. Most strikingly, fabricated evidence has opposite effects across interaction structures. It increases sycophancy in single-turn interactions but reduces it after the model has already answered. Grounding helps, but does not eliminate the behavior. Sycophancy varies more across medical questions than across models, making question selection an important part of benchmark design. Reasoning traces suggest that multi-turn failures are associated with models turning back toward their own prior answer, while fabricated evidence receives more scrutiny after an initial response. Together, the results show that medical sycophancy depends as much on how a model is challenged and evaluated as on which model is tested.
When a language model agrees with a user's false belief, is it failing to detect the error, or noticing and agreeing anyway? We show the latter. Across twelve open-weight models from five labs, spanning small to frontier scale, the same small set of attention heads carries a "this statement is wrong" signal, whether the model is evaluating a claim on its own or being pressured to agree with a user. Silencing these heads flips sycophantic behavior sharply while leaving factual accuracy intact, so the circuit controls deference rather than knowledge. Edge-level path patching confirms that the same head-to-head connections drive sycophancy, factual lying, and instructed lying. Opinion-agreement, where no factual ground truth exists, reuses these head positions but writes into an orthogonal direction, ruling out a simple "truth-direction" reading of the substrate. Alignment training leaves this circuit in place: an RLHF refresh cuts sycophantic behavior roughly tenfold while the shared heads persist or grow, a pattern that replicates on an independent model family and under targeted anti-sycophancy DPO. When these models sycophant, they register that the user is wrong and agree anyway.
Large language models (LLMs) are increasingly used for health-related advice. Existing research measures their safety with static questions rather than pressured patient-facing conversations. We introduce MedPRESS, a multi-turn benchmark for measuring patient-pressure-induced sycophancy in LLMs. MedPRESS contains 600 medically grounded five-turn dialogues across three scenario families: medication and treatment demand, personal health self-care, and symptom triage and care resistance. Each dialogue begins with a health query and escalates through personal experience, social proof, external evidence claims, and direct adversarial challenge. We evaluate 20 LLMs across general, medical-domain, lightweight, large, open-weight, and proprietary families using structured judging and safety-focused metrics. Results show that models frequently shift toward unsafe agreement under repeated patient pressure, with substantial variation across model families, model scale, and prompt type. Anti-sycophancy prompting improves robustness for several models, but does not eliminate unsafe agreement. MedPRESS highlights a critical gap in medical LLM evaluation: safe medical knowledge is not enough unless models can maintain it under conversational pressure.
We propose a novel perspective for probing LLM sycophancy in a direct and neutral way, mitigating various forms of uncontrolled bias, noise, or manipulative language, deliberately injected to prompts in prior works. A key novelty of our approach is the use of an LLM-as-a-judge in a zero-sum betting game. Within this framework, sycophancy serves one individual (the user) while explicitly incurring cost on another. Comparing 11 leading models we find that while most models exhibit significant sycophantic tendencies in the common setting, in which sycophancy is self-serving to the user and incurs no cost on others, seven of the models exhibit ``moral remorse'', five of which significantly over-compensate for their sycophancy in case it explicitly harms a third party. We refer to this phenomenon as `anti-sycophancy' bias and discuss possible causes for this shift.