# When Confidence Fails: Overconfidence in LLMs under Uncertainty and Missing Clinical Information

arXiv: https://arxiv.org/abs/2608.09080 · HTML: https://mlsanity.com/paper/2608.09080/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 18 of its 26 references that are in the map.
- First posted on arXiv 10 Aug 2026.

## Builds on (most cited first, 18 of 18)

- [Language Models are Few-Shot Learners](https://mlsanity.com/paper/2005.14165/) (2020)
- [On Calibration of Modern Neural Networks](https://mlsanity.com/paper/1706.04599/) (2017)
- [Survey of Hallucination in Natural Language Generation](https://mlsanity.com/paper/2202.03629/) (2022)
- [Language Models (Mostly) Know What They Know](https://mlsanity.com/paper/2207.05221/) (2022)
- [Large Language Models Encode Clinical Knowledge](https://mlsanity.com/paper/2212.13138/) (2022)
- [A Survey on Hallucination in Large Language Models: Principles, Taxonomy, Challenges, and Open Questions](https://mlsanity.com/paper/2311.05232/) (2023)
- [Just Ask for Calibration: Strategies for Eliciting Calibrated Confidence Scores from Language Models Fine-Tuned with Human Feedback](https://mlsanity.com/paper/2305.14975/) (2023)
- [MedMCQA : A Large-scale Multi-Subject Multi-Choice Dataset for Medical domain Question Answering](https://mlsanity.com/paper/2203.14371/) (2022)
- [A Survey of Confidence Estimation and Calibration in Large Language Models](https://mlsanity.com/paper/2311.08298/) (2023)
- [Do Large Language Models Know What They Don't Know?](https://mlsanity.com/paper/2305.18153/) (2023)
- [What Large Language Models Know and What People Think They Know](https://mlsanity.com/paper/2401.13835/) (2024)
- [Do LLMs Know When to NOT Answer? Investigating Abstention Abilities of Large Language Models](https://mlsanity.com/paper/2407.16221/) (2024)
- [Overconfidence is Key: Verbalized Uncertainty Evaluation in Large Language and Vision-Language Models](https://mlsanity.com/paper/2405.02917/) (2024)
- [Mind the Confidence Gap: Overconfidence, Calibration, and Distractor Effects in Large Language Models](https://mlsanity.com/paper/2502.11028/) (2025)
- [Do Language Models Mirror Human Confidence? Exploring Psychological Insights to Address Overconfidence in LLMs](https://mlsanity.com/paper/2506.00582/) (2025)
- [Knowing When to Abstain: Medical LLMs Under Clinical Uncertainty](https://mlsanity.com/paper/2601.12471/) (2026)
- [The Confidence Paradox: Can LLM Know When It's Wrong](https://mlsanity.com/paper/2506.23464/) (2025)
- [A Survey of the State-of-the-Art in Conversational Question Answering Systems](https://mlsanity.com/paper/2509.05716/) (2025)

## Abstract (arXiv)

Large Language Models (LLMs) have achieved strong performance in medical question answering and clinical reasoning tasks. However, their reliability under uncertainty remains poorly understood which raises critical concerns for deployment in high-stakes clinical settings. In such environments, incorrect predictions are inherently risky, but confident incorrect predictions can be particularly harmful as they may mislead clinical decision-making. In this paper, we conduct a systematic behavioral analysis of LLMs under clinical information uncertainty. We propose an evaluation framework based on the MedMCQA dataset consisting of two complementary uncertainty settings. First, we introduce linguistic uncertainty cues through prompt modifications to simulate ambiguous clinical contexts. Second, we construct an answer removal setting, wherein the correct option is deliberately excluded mandating the model to recognize insufficient information and abstain. We analyze both model accuracy and confidence behavior using multiple calibration metrics including calibration gap, Expected Calibration Error (ECE), and Unsafe Confident Error Rate (UCER) across 500 medical questions. Our results reveal a consistent failure mode, i.e., although accuracy degrades under increasing uncertainty, model confidence remains misaligned with accuracy. This leads to a substantial increase in unsafe confident errors, indicating that model confidence remains largely insensitive to clinically meaningful information loss. Furthermore, we observe significant variation across models in their ability to abstain when the correct answer is unavailable, with some models persistently producing high confidence hallucinated answers. These findings expose critical limitations in the epistemic reliability of current LLMs and highlight the need for uncertainty aware evaluation methods prior to their deployment in clinical workflows.