# Translating Inference-Time Control to Radiology Vision-Language Models: Activation Steering for Pneumonia Classification on Chest X-rays

arXiv: https://arxiv.org/abs/2606.20852 · HTML: https://mlsanity.com/paper/2606.20852/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in Medical vision-language models, one of 16 directions in Multimodal LLMs / vision-language models.
- Builds on 9 of its 14 references that are in the map.
- First posted on arXiv 18 Jun 2026.

## Placed in

- Multimodal LLMs / vision-language models / [Medical vision-language models](https://mlsanity.com/mllm/medical-vision-language-models/)
- Mechanistic interpretability / [Interpreting biomedical and science models](https://mlsanity.com/mechinterp/interpreting-biomedical-and-science-models/)

## Builds on (most cited first, 9 of 9)

- [CheXpert: A Large Chest Radiograph Dataset with Uncertainty Labels and Expert Comparison](https://mlsanity.com/paper/1901.07031/) (2019)
- [Inference-Time Intervention: Eliciting Truthful Answers from a Language Model](https://mlsanity.com/paper/2306.03341/) (2023)
- [Refusal in Language Models Is Mediated by a Single Direction](https://mlsanity.com/paper/2406.11717/) (2024)
- [MIMIC-CXR-JPG, a large publicly available database of labeled chest radiographs](https://mlsanity.com/paper/1901.07042/) (2019)
- [NLP Evaluation in trouble: On the Need to Measure LLM Data Contamination for each Benchmark](https://mlsanity.com/paper/2310.18018/) (2023)
- [Analyzing the Generalization and Reliability of Steering Vectors](https://mlsanity.com/paper/2407.12404/) (2024)
- [Increasing Probability Mass on Answer Choices Does Not Always Improve Accuracy](https://mlsanity.com/paper/2305.14596/) (2023)
- [A Reasoning-Enabled Vision-Language Foundation Model for Chest X-ray Interpretation](https://mlsanity.com/paper/2604.00493/) (2026)
- [Suppressing Prior-Comparison Hallucinations in Radiology Report Generation via Semantically Decoupled Latent Steering](https://mlsanity.com/paper/2602.23676/) (2026)

## Abstract (arXiv)

Inference-time engineering can alter model behavior without fine-tuning. However, its utility for improving diagnostic performance in medical vision-language models (VLMs) remains unclear. We aim to evaluate whether Contrastive Activation Addition (CAA) can improve pneumonia classification in chest radiograph VLMs without updating model weights. Three frozen chest radiograph VLMs (MedGemma-4B-IT, NV-Reason-CXR-3B, and CheXOne-3B) were evaluated on the public Kermany pneumonia test set. Classification was based on the logits of the tokens Yes and No under a binary prompt. Steering vectors included a 30-pair answer-bias control, a 30-pair pneumonia text contrast, and an image-conditioned contrast derived from 30 pneumonia and 30 normal development images. A deterministic 200-image development set was used for layer and scale selection (100 images) and threshold calibration (100 images). Performance was assessed using ROC-AUC, PR-AUC, F1 score, threshold analyses, reverse-vector controls, random-vector controls, and conditional bootstrap confidence intervals. Fixed-threshold F1 improvements were frequently observed but did not consistently indicate improved diagnostic performance. For MedGemma-4B-IT. NV-Reason-CXR-3B showed the strongest benefit: calibrated F1 improved from 0.7692 in the zero-shot setting to 0.8619 with pneumonia-text steering and to 0.8727 with image-conditioned steering. For CheXOne-3B, pneumonia-text steering increased calibrated F1 from 0.8528 to 0.8666, although the confidence interval crossed zero. On this public pneumonia benchmark, CAA substantially altered prediction score distributions and operating characteristics without fine-tuning. Meaningful performance gains were observed in one of three evaluated VLMs, suggesting that activation steering may serve as a lightweight approach for adapting medical VLM behavior.