Counterfactual Cultural Cues Reduce Medical QA Accuracy in LLMs: Identifier vs Context Effects

Abstract

Engineering sustainable and equitable healthcare requires medical language models that do not change clinically correct diagnoses when presented with non-decisive cultural information. We introduce a counterfactual benchmark that expands 150 MedQA test items into 1650 variants by inserting culture-related (i) identifier tokens, (ii) contextual cues, or (iii) their combination for three groups (Indigenous Canadian, Middle-Eastern Muslim, Southeast Asian), plus a length-matched neutral control, where a clinician verified that the gold answer remains invariant in all variants. We evaluate GPT-5.2, Llama-3.1-8B, DeepSeek-R1, and MedGemma (4B/27B) under option-only and brief-explanation prompting. Across models, cultural cues significantly affect accuracy (Cochran's Q, $p<10^-14$), with the largest degradation when identifier and context co-occur (up to 3-7 percentage points under option-only prompting), while neutral edits produce smaller, non-systematic changes. A human-validated rubric ($\kappa=0.76$) applied via an LLM-as-judge shows that more than half of culturally grounded explanations end in an incorrect answer, linking culture-referential reasoning to diagnostic failure. We release prompts and augmentations to support evaluation and mitigation of culturally induced diagnostic errors.