Table 2.
Qualitative Code Definitions, Frequencies, Percentages, and Representative Examples (N = 123)
| Brief definition | Frequency (%) | Representative example | |
|---|---|---|---|
| Clue | Race or immigration status is mentioned in the question stem to guide the user toward the correct answer choice. | 55 (44.7) | A patient with exertional dyspnea is described as Black to suggest a diagnosis of longstanding hypertension. |
| Distraction | Race or immigration status is mentioned in the question stem to guide the user toward an incorrect answer choice. | 15 (12.2) | A Black patient with cough, fatigue, and shortness of breath is initially treated with high-dose corticosteroids for sarcoidosis, but this treatment actually exacerbates the histoplasmosis infection that is causing his symptoms. The answer explanation indicates that sarcoidosis is a reasonable diagnosis given the patient’s symptoms and race but notes that histoplasmosis is the most likely diagnosis. |
| Descriptive | Race or immigration status is included in the question stem with no clear rationale or link to the answer choices or explanation. | 22 (17.9) | A patient with shortness of breath is described as African American and all answer choices relate to malignancies that have not been previously linked to Black race. |
| Race and ethnicity | |||
| White norm | White/“Caucasian” race is used specifically in the question stem without clear rationale or link to the answer choices or explanation. | 16 (13.0) | Descriptions include a 64-year-old White female with nausea and a 35-year-old “Caucasian” male with aplastic anemia. |
| Epidemiology | Racial differences in disease prevalence. | 41 (32.5) | Systemic lupus erythematosus is described as occurring most commonly in African American, Hispanic, and Asian women. |
| Ancestry | References to “ancestry” or “descent.” | 12 (9.8) | Links are made between Mediterranean ancestry and beta-thalassemia and between ulcerative colitis and Ashkenazi Jewish descent. |
| Racial differences in risk | Race is treated as a risk factor for a disease condition. | 11 (8.1) | Black race is listed as a risk factor for prostate cancer in a chart comparing prostate cancer and benign prostatic hyperplasia. |
| Racial genetics | Associations with racial groups and genetic risks for disease. | 9 (7.3) | Increased prevalence of kidney disease in Black patients is linked to variants in the APOL1 gene. |
| Race-based management | Descriptions of variations in treatment (or lack of treatment) based on a patient's race. | 8 (6.5) | Sodium restriction is described as more effective in Black patients. |
| Socio-structural | Mention of a patient’s race is contextualized within their social or structural support system or vulnerability. | 1 (0.8) | An immigrant patient is described as having few social supports. |
| Immigration status | |||
| Endemic | Migration from a specific area (e.g., country or region) in which an infectious disease is endemic | 10 (8.1) | An immigrant’s prior residence in Southeast Asia, a region where tuberculosis is endemic, suggests a diagnosis of miliary tuberculosis. |
| Global | Descriptions of endemic areas that supersede continental boundaries (e.g., “Latin America, Asia, and Africa”), generally referring to a global population that excludes Europe and North America. | 7 (5.7) | Mitral stenosis is described as a common cause of rheumatic heart disease among patients who have migrated from Latin America, Africa, or Asia. |
| Developing country | Specific use of the phrase “developing country/ies” or “developing world.” | 6 (4.8) | Tuberculosis is described as a common cause of constrictive pericarditis in “developing countries.” |
| Immigrant–inadequate care | Mentions of immigrants from other countries and absence of prior care or vaccination. | 7 (5.6) | A question featuring a 26-year-old pregnant woman mentions that she immigrated to the USA 6 years ago and includes titer information signifying her lack of immunization for measles, mumps, and rubella. |
| Cultural/behavioral | Attributions of disease risk to cultural practices, beliefs, or behaviors. | 7 (5.6) | Migration from North Africa is linked to niacin deficiency due to presumed primary subsistence on corn products |
| Total | 226 segments (123 questions) | ||
iFull code definitions are available in Supplemental Materials
iiFrequency, or count, of code and percent representation of all questions in QBank data. Note that the numerators for the percent representation values may differ from the frequency value due to potential code repetition within questions