Trajectory-Guided Steering: Mitigating Spurious Feature Bias in Clinical Classification

Longitudinal clinical notes contain rich evidence of how patients evolve over time, but converting this signal into training supervision for clinical prediction remains challenging. We extend Foresight Learning to clinical prediction by converting time-ordered MIMIC-III notes into examples consisting of past patient context, a natural-language question about a possible future event, and a label resolved from later documentation. This process yields 6,900 prediction examples from 702 admissions across medications, procedures, organ support, microbiology, and mortality. A small LoRA adapter trained on these examples improves over the prompted base model, reducing expected calibration error from 0.1269 to 0.0398 and Brier score from 0.199 to 0.145, while slightly outperforming GPT-5 point estimates on held-out questions. The approach enables reusable clinical prediction supervision from longitudinal notes without hand-engineered structured features or endpoint-specific classifiers.

Language models encode task-relevant knowledge in internal representations that far exceeds their output performance, but whether mechanistic interpretability methods can bridge this knowledge-action gap has not been systematically tested. We compared four mechanistic interpretability methods -- concept bottleneck steering (Steerling-8B), sparse autoencoder feature steering, logit lens with activation patching, and linear probing with truthfulness separator vector steering (Qwen 2.5 7B Instruct) -- for correcting false-negative triage errors using 400 physician-adjudicated clinical vignettes (144 hazards, 256 benign). Linear probes discriminated hazardous from benign cases with 98.2% AUROC, yet the model's output sensitivity was only 45.1%, a 53-percentage-point knowledge-action gap. Concept bottleneck steering corrected 20% of missed hazards but disrupted 53% of correct detections, indistinguishable from random perturbation (p=0.84). SAE feature steering produced zero effect despite 3,695 significant features. TSV steering at high strength corrected 24% of missed hazards while disrupting 6% of correct detections, but left 76% of errors uncorrected. Current mechanistic interpretability methods cannot reliably translate internal knowledge into corrected outputs, with implications for AI safety frameworks that assume interpretability enables effective error correction.

Clinical language models can achieve strong in-hospital accuracy yet fail under deployment shifts because they exploit note-specific artifacts (e.g., templates, separators, boilerplate) that do not reflect patient state. We propose CAST (Concept-guided Artifact Suppression Tuning), an SAE-based framework for auditable clinical text classification. CAST uses Sparse Autoencoders to expose sparse, human-auditable features from intermediate Transformer activations, labels SAE latents with an LLM-assisted interpretation pipeline and ICD-10 retrieval constraints, suppresses verified artifact latents via residual subtraction during fine-tuning, and provides post-hoc per-concept attributions for auditing model decisions. On MIMIC-IV discharge-note mortality prediction, CAST improves over its corresponding fine-tuned encoder baselines and remains competitive with strong LLM baselines, while producing a feature-level audit trail of the clinical concepts that support each prediction and the artifact concepts suppressed during training.