As communities of color continue to be disproportionately decimated by COVID-19 and the brutal impact of racism and other longstanding systemic inequalities, academic medicine finds itself at a critical inflection point in defining its role in addressing social injustices not only for its patients but also for its academic workforce.  In the aftermath of George Floyd’s killing, many medical schools and teaching hospitals released statements condemning racial injustice and vowed long-term commitments to diversity and inclusion initiatives.  The heightened engagement on diversity represents an unprecedented opportunity for change, but simultaneously an exacerbation of a longstanding workforce phenomenon colloquially termed the “minority tax.”

The minority tax is defined as the burden of extra responsibilities placed on the underrepresented minority in medicine (UIM) to achieve diversity (e.g., participating in pipeline programs, leading recruitment, and mentorship efforts).  Layered on these efforts is the gratitude tax: the feeling of indebtedness of UIMs to an academic institution that stimulates a desire to pay back the perceived debt for being given the opportunity to be a physician. The weight of such taxes promulgate a power dynamic where agreeing to participate in diversity initiatives is expected and UIMs become an outsourced workforce for what should be institutional work, despite being grossly lacking at all levels of academic medicine (3.6 percent Black, 5.5 percent Hispanic). These “extra duties” reduce the time for academic productivity, often without counting toward promotion, which can compromise career advancement resulting in job dissatisfaction and UIM faculty attrition.  Any loss of UIM faculty will deplete their small numbers across medical schools and academic medical centers.

Across the country, UIM faculty are debating what it would mean to deliberately default on their ‘taxes’ or leave academic medicine altogether.  In addition to continuing the work of increasing the pipeline of UIMs in medical schools, systemic and institutional change is necessary to move toward health equity for communities of color, and it must start with UIM faculty retention and leadership in academic medicine. Several strategies can be employed to achieve this goal:

1. Institutions need to engage all faculty, not just UIMs, in diversity efforts to begin to achieve health equity. Diversity and social justice in medicine should be a collective responsibility in academic medicine. Institutional mission statements, by-laws, policies, community benefits programs, and philanthropy should be aligned to reflect this collective mission. Having leadership support a demonstration of White Coats for Black Lives or social media posts about the separation of Latinx parents from their children rings empty without reframing mission/vision statements to support these efforts.

2. UIM diversity and inclusion efforts need to move from a voluntary effort to one that “counts” by providing allocated time and a way to work toward promotion for these efforts. Annual evaluations and promotion criteria/tracks for all faculty participating in health equity efforts may reduce attrition among minority faculty, and also recruit non-UIMs to participate in many of these initiatives. This shift allows for a greater focus, dialogue, and promotion of health equity for patient care and research initiatives in minority populations.

3. Institutions should create internal grant programs, research, and education to fund scholarly work related to diversity and health equity. Areas for focus should include interventions and programmatic initiatives to facilitate patient trust, cultural competency, recruitment and retention in research, and elimination of health inequities for underrepresented minority patients. These grants’ findings will provide the preliminary data necessary to apply for large-scale, federal, and foundation funding.

4. UIM faculty should have a clear path toward reporting racist behavior or addressing policies that propagate academic medicine disparities. These behaviors are often hidden in the form of microaggressions, promotion, or career advancement, or in hiring or leadership positions. Institutions should implement existing anti-bias policies that explain to patients their duty to treat providers with respect at the initiation of care and for health care workers, who are in positions of authority with the power to exert influence on patients’ long-lasting health outcomes. To mitigate potential microaggressions towards patients, universal implicit bias training at all levels of medical schools and teaching hospitals should be initiated.

5. Institutions should have adequately resourced and staffed language and cultural services such that UIM faculty are not asked to fill gaps in services working below the level of their licenses. An example is Latinx physicians being asked to “play interpreter” for another provider because there are not enough translators or asked to translate medical documents because it is “easier than getting it formally translated.”

6. Institutions should make policies that promote diversification in all fields a priority, including robust recruitment packages, loan forgiveness, etc. While increasing the numbers of UIMs in primary care has clear value, addressing UIMs in subspecialties also warrants the specific investment. UIMs grossly lack in the majority of medical and surgical subspecialties, which contributes to health disparities that we see in many of these fields.

7. UIM faculty should be given sponsors, not just mentors. Non-UIM faculty and executives must commit to the idea of sponsorship. Sponsors have protégés and promote these protégés directly, using their influence and networks to connect them to high-profile assignments and promotions. Most UIM faculty mentors are not able to be a sponsor, as evidenced by their relative scarcity in medical school and academic health center leadership.

8. The concept of giving an UIM a “seat at the table” needs to be modernized. Having a “token minority” at the table to check a box is no longer sufficient to impact health equity. UIMs need meaningful and impactful leadership roles and opportunities to be the “head of the table” to promote ideas and policies that directly affect minority populations. Prioritizing the hiring of strategic leaders as chief equity officers in the executive suite (focus on service and delivery system performance) and chief diversity officers (internal recruiting, retention, and inclusion programs) for patients is critically important.  Finally, leadership training alongside diversity and inclusion initiatives can groom UIMs for leadership positions, which helps align the mission, vision, and goals of an academic institution toward reducing disparities both for those in academic medicine and for patients of color.

Keila Lopez is a pediatric cardiologist. Jean Raphael is a pediatric hematologist-oncologist.

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