Gated Activation Steering for Reducing Sycophancy & Hallucination in Medical Question Answering

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.

Large language models often produce unsupported claims. We frame this as a misclassification error at the output boundary, where internally generated completions are emitted as if they were grounded in evidence. This motivates a composite intervention that combines instruction-based refusal with a structural abstention gate. The gate computes a support deficit score, St, from three black-box signals: self-consistency (At), paraphrase stability (Pt), and citation coverage (Ct), and blocks output when St exceeds a threshold. In a controlled evaluation across 50 items, five epistemic regimes, and three models, neither mechanism alone was sufficient. Instruction-only prompting reduced hallucination sharply, but still showed over-cautious abstention on answerable items and residual hallucination for GPT-3.5-turbo. The structural gate preserved answerable accuracy across models but missed confident confabulation on conflicting-evidence items. The composite architecture achieved high overall accuracy with low hallucination, while also inheriting some over-abstention from the instruction component. A supplementary 100-item no-context stress test derived from TruthfulQA showed that structural gating provides a capability-independent abstention floor. Overall, instruction-based refusal and structural gating show complementary failure modes, which suggests that effective hallucination control benefits from combining both mechanisms.

Sycophancy, the tendency of large language models to favour user-affirming responses over critical engagement, has been identified as an alignment failure, particularly in high-stakes advisory and social contexts. While prior work has documented conversational features correlated with sycophancy, we lack a systematic understanding of what provokes or prevents AI sycophancy. Here, we present a set of controlled experimental studies where we first isolate how input framing influences sycophancy, and second, leverage these findings to develop mitigation strategies. In a nested factorial design, we compare questions to various non-questions where we vary three orthogonal factors: epistemic certainty (statement, belief, conviction), perspective (I- vs user-perspective), and affirmation vs negation. Measuring expressed sycophancy, how sycophantically a model phrases its free-text response, we show that (1) sycophancy is substantially higher in response to non-questions compared to questions. Additionally, we find that (2) sycophancy increases monotonically with epistemic certainty conveyed by the user, and (3) is amplified by I-perspective framing. Building on this, we show that asking a model to convert non-questions into questions before answering significantly reduces sycophancy. Importantly, this effect is stronger than a simple baseline prompt asking models "not to be sycophantic". In a follow-up experiment, we show that these framing effects generalise to choice sycophancy, which answer a model commits to, in a more context-rich, personalised setting: when a model is given extensive knowledge of a user and must select between forced binary choices, the same question vs. statement framing shapes how often it picks the answer aligned with the user's stance. Our work offers a practical and effective input-level mitigation that both developers and users can easily adopt.