Over 100 years since the 1910 Flexner Report resulted in the closure of all but two predominantly Black medical schools, underrepresented minority (URM) medical students and faculty still struggle to surface amid the rising currents of medical education. While overall medical school enrollment has increased and the proportion of URMs in the overall United States population has grown steadily to approximately 30 percent, the representation of male and female URMs in both medical education and academic medicine has remained largely stagnant; 11 percent of graduating medical students in 2015 were Black or Hispanic, while the proportion of URM faculty has only very recently edged eight percent.
The benefits of diversity in the medical profession cannot be understated. Studies in behavioral science have shown that teams composed of diverse individuals operate with increased creativity and promote cross-cultural competence. These benefits, especially the latter, are important; the 2002 Institute of Medicine Unequal Treatment report stated unequivocally that minorities receive worse care, in terms of fewer recommended treatments and worse outcomes, even when controlling for a variety of socioeconomic factors. URM physicians, on the other hand, are more likely to dedicate their careers to providing care to underserved communities and performing research in areas specific to minority health, thereby providing a counterbalance to this trend. Furthermore, the presence of a “critical mass” — a percentage of minorities large enough to deter individual isolation — of minority faculty strengthens the mentorship network available for budding Black and brown physicians because many minority faculty members are interested in addressing the numerous disparities in representation within medical education.
However, for the vast majority of American medical schools, achieving a critical mass amongst minority faculty (now an LCME accreditation standard) remains a dream deferred. A plethora of challenges in recruiting and retaining minority medical students into academic medicine further puncture an already very leaky URM educational pipeline. A study of AAMC matriculation and graduation questionnaires showed that URM medical students are, during the course of their medical education, significantly less likely to gain interest in pursuing academic medicine than their non-URM counterparts and are significantly more likely to lose interest in an academic career path by the time they graduate. Cited reasons include lack of awareness of the nature of academic medicine, concerns of fairness in the academic promotion process and a lack of mentorship and pipeline opportunities to prepare for careers in academia. Additionally, plans to practice in underserved areas and high levels of debt are individually associated with a decreased interest in academic medicine; minority students, too, lead in both of these areas.
These barriers exacerbate the dearth of male and female minorities who teach, research and administrate within our hospitals and medical schools. Yet, for the few that do trickle out of the academic pipeline, further hardships await. Black and brown faculty bear the burden of the “minority tax,” — an array of additional duties, expectations and challenges that accompany being an exception within white male-dominated institutional environments. Aside from experiencing instances of racism, implicit bias and isolation from mentors and colleagues with similar backgrounds, minority faculty are often asked — or mandated — to serve as mentors themselves for minority trainees and to contribute to diversity initiatives. While these extra responsibilities are both important and necessary for the expansion of diversity in a training program, they are intensive and often detract from the time spent on traditional promotion-granting activities: research and publication. These contributions to diversity and inclusion are exceptionally taxing because they are rarely regarded on an equal plane as scholarly productivity.
The resulting effect on faculty advancement is significant. URM faculty are less likely than their white counterparts to be promoted, receive NIH research grants and hold senior faculty and administrative positions. This is the vicious cycle imposed by the minority tax; time and effort spent pulling talent up the ladder hinder one’s own ascent along it. Even when controlling for attributes such as research productivity and desire to progress in rank, disparities in academic advancement persist, suggesting that bias still comprises a considerable part of the burden.
Underrepresented medical students and aspiring academic physicians standing at the foot of this very ladder confront an even harsher and sobering reality: the minority tax is not just for faculty. It is exacted on us, as trainees, as well. When given the opportunity, we advocate for diversity in our programs and provide valuable service to our communities. We work to combat health disparities, administrate pipeline programs and serve as mentors and recruiters for those who follow the path behind us. For many of us, this is much more than an option or even an obligation; it is a mission. One that we carry out with duty, enthusiasm and sacrifice. Our individual interests and successes are not always the priority, even when the current score-centric cultures of medical education and residency selection demand that they should be. As we balance our scholastic responsibilities with these efforts, we do so while shouldering the burdens of implicit bias and stereotype threat. And we do all of the above while holding ourselves to high standards of excellence, in the face of those who would justify any instance of weakness or failure as a means against pro-diversity and affirmative-action policies.
For these efforts, we often receive thanks in private, behind closed doors, if at all. We are greeted with the reality that bias still permeates many levels of both undergraduate and graduate medical education, from medical school admissions to AOA selection to residency evaluations. We process all this, and with gritted teeth, return to the foray, our mission clearly undone. Yet, a small voice remains to ask: at what point is our own success subject to sacrifice?
It is impossible to articulate a specific solution that will alleviate the minority tax. We all can begin by acknowledging its existence and pinpointing the factors that perpetuate its effect. Most importantly, we can support our fellow students, colleagues and faculty members who bear its burden. And as we look to bolster the outflow of the minority academic pipeline from a trickle to a stream, we must ensure that the “revenue” from this tax is duly reinvested in furthering the advancement of current minority students and faculty — for if we fail to nurture the seeds of diversity in our programs, we will merely be pouring water on sand.