Addressing disparities in academic medicine: What of the minority tax?

Abstract

Background
The proportion of black, Latino, and Native American faculty in U.S. academic medical centers has remained almost unchanged over the last 20 years. Some authors credit the "minority tax"¿the burden of extra responsibilities placed on minority faculty in the name of diversity. This tax is in reality very complex, and a major source of inequity in academic medicine.DiscussionThe ¿minority tax¿ is better described as an Underrepresented Minority in Medicine (URMM) faculty responsibility disparity. This disparity is evident in many areas: diversity efforts, racism, isolation, mentorship, clinical responsibilities, and promotion.SummaryThe authors examine the components of the URMM responsibility disparity and use information from the medical literature and from human resources to suggest practical steps that can be taken by academic leaders and policymakers to move toward establishing faculty equity and thus increase the numbers of black, Latino, and Native American faculty in academic medicine.

Full text

D E B A T E Open Access
Addressing disparities in academic medicine:
what of the minority tax?
José E Rodríguez
1*
, Kendall M Campbell
1
and Linda H Pololi
2
Abstract
Background: The proportion of black, Latino, and Native American faculty in U.S. academic medical centers has
remained almost unchanged over the last 20 years. Some authors credit the "minority tax"—the burden of extra
responsibilities placed on minority faculty in the name of diversity. This tax is in reality very complex, and a major
source of inequity in academic medicine.
Discussion: The “minority tax”is better described as an Underrepresented Minority in Medicine (URMM) faculty
responsibility disparity. This disparity is evident in many areas: diversity efforts, racism, isolation, mentorship, clinical
responsibilities, and promotion.
Summary: The authors examine the components of the URMM responsibility disparity and use information from
the medical literature and from human resources to suggest practical steps that can be taken by academic leaders
and policymakers to move toward establishing faculty equity and thus increase the numbers of black, Latino, and
Native American faculty in academic medicine.
Keywords: Underrepresented minority, Black, Latino, Hispanic, Native american, Minority tax
Background
The proportion of black, Latino, and Native American
faculty in U.S. academic medical centers increased
slightly over the last 20 years (7% vs. 8%) [1] Multiple
medical organizations, including the American Medical
Association (AMA), the American Association of Medical
Colleges (AAMC) and the National Medical Association
(NMA) have been working to increase the representation
of those in racial/ethnic groups that are underrepresented
in medicine. Although progress has been made in increasing
the numbers of medical students and faculty from URMM
backgrounds, the proportions of URMM faculty and
URMM students remain basically unchanged since the
numbers of positions has increased. The unchanged
proportion is far below the targets set by the AMA, the
AAMC and the NMA.
Our review of the literature identified factors that
affect minority faculty in academic medicine. These
factors have been colloquially called the “minority tax”or
“cultural tax”. The minority tax has been defined as the
tax of extra responsibilities placed on minority faculty in
the name of efforts to achieve diversity [2,3]—but this
unfair tax is, in reality, complex. For the purposes of this
article, we will focus on those who are Underrepresented
Minorities in Medicine (URMM), including blacks,
Latinos, and Native Americans/Alaskans. Other minorities,
particularly Asians, may not be underrepresented in
medicine, but still suffer many, if not all, of the disparities
addressed. Unlike taxes, (which are theoretically shared by
all) the following responsibilities are not shared equally by
all faculty, and disproportionately burden URMM faculty.
The URMM faculty responsibility “tax”or disparity includes
the following categories: responsibility for achieving
diversity efforts, racism, isolation, mentorship, clinical,
and promotion inequities.
Discussion
Diversity efforts disparity
Many underrepresented URMM faculty feel an obligation
to the communities they represent and to future generations
of minority students [2]. As a result, they choose to spend
more of their time working in community efforts, and they
are often asked to take on committee work in the area of
* Correspondence: jose.rodriguez@med.fsu.edu
1
The Center for Underrepresented Minorities in Academic Medicine at The
Florida State University College of Medicine, 1115 West Call Street#3210 M,
Tallahassee, FL 32306, USA
Full list of author information is available at the end of the article
© 2015 Rodríguez et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Rodríguez et al. BMC Medical Education (2015) 15:6
DOI 10.1186/s12909-015-0290-9

diversity [4]. URMM faculty are disproportionately
represented in institutions’diversity efforts, illustrating
the disparity that exists in this area. These diversity-related
pursuits have been devalued in some institutions, and
not taken seriously as promotion-earning activities
[4]. Importantly, these efforts are time consuming and
result in URMM faculty having less time to engage in
pursuits that are more valued by their institutions. Some
URMM faculty find that this extra work presents a con-
flict of interest because the institution’s espoused goals for
diversity and care of the underserved are not aligned
with the reality of what is rewarded and supported by
the organization [4]. In one study, URMM faculty in
institutions where the majority of faculty were from
URMM groups felt more values alignment than URMM
faculty in traditional medical schools [5].
Racism disparity
Numerous studies of URMM faculty have reported
racism, discrimination and inequity in academic medicine
as a major problem [2,4-8]. Racism has been cited as a
major cause of job dissatisfaction. URMM faculty have
gone so far as to publish responses to discrimination
[6,8,9]. URMM faculty also feel that there is racism or bias
in the promotions process [8], a course of action that
seems to favor non-URMM faculty over URMM faculty
[2]. Racism has also been named as a reason URMM
faculty feel that they have to constantly prove their value,
worth and ability [6], thus diverting their energies from
more meaningful activities. URMM faculty agree that
although racism has become subtler [4,6,7], it remains
harmful and can have lasting effects. URMM faculty have
to expend more effort to combat racism than their
non-URMM peers as they have not only to defend them-
selves against racism but also take more responsibility for
righting the injustice of racism generally.
Isolation disparity
URMM faculty feel excluded [10], invisible [4,6,11], isolated
[5], and of poor fit [11,12]. They report that a sense of
belonging to the institution is essential for success [6]
and career satisfaction. They also feel the isolation
derives in part, from the fact that there are few or no
other persons in their departments or institutions that
look like them [4]. This isolation additionally impacts
minority faculty by limiting opportunity for collaboration
and scholarly activity.
Stereotypic thinking by colleagues acts as a barrier to
potential collaboration. For example, URMM faculty are
often viewed as lacking skills in literature review,
research, writing and publication, or URMM faculty are
sometimes seen as similar to “uneducated minority
patients or other people of color in service roles”.[4]
Often the expertise of URMM faculty members is not
fully recognized by non-URMM colleagues, and URMM
are not readily identified as valuable collaborators. This
is unfortunate as diverse perspectives enrich research
collaboration and would enhance outcomes, and benefit
health care and the institution.
Mentorship disparity
URMM faculty believe that having mentors and role
models is crucial for their success [2,8,10,11,13,14].
URMM faculty at individual institutions and in national
samples express that there are inadequate numbers of
mentors for URMM faculty [15]. Mentors are indispensable
in helping URMM faculty feel that they belong [2] to the
academic institution and to help them navigate the
complex process of academic promotion and tenure.
The absence of mentors may contribute to URMM
underrepresentation in academic medicine [4,6]. Func-
tional mentoring relationships are also associated with
career satisfaction [2].
URMM faculty also serve as role models for URMM
students and house staff, and act as mentors for them.
URMM faculty thus become mentors without the benefit
of having mentoring and guidance for themselves. Non-
URMM faculty need to receive training in mentoring
URMM faculty and students, to help alleviate this
disparity. Mentoring is a teachable skill.
Clinical disparity
This aspect of the tax is subtler than other contributing
factors. URMM faculty spend more of their time in com-
munity work [4] and caring for underserved populations
[5], and clinical activities [7,16,17] than non-URMM fac-
ulty. There is an inverse relationship between clinical time
and scholarly productivity: as clinical time increases, time
for scholarly productivity decreases, resulting in less time
for promotion related activities. This may contribute to the
presence of fewer URMM faculty in senior positions, such
as full professor or department chair [18]. URMM faculty
tend to care for poorer patients [18], making their
clinical revenues less than those of their peers. This
further disadvantages URMM faculty with respect to
promotion since they have not only less time for
scholarship but also need more time for clinical care
to generate revenue comparable to their non-URMM
counterparts.
Promotion disparity
It is well documented that a promotion disparity exists
between URMM and non-URMM faculty [16,19,20].
URMM faculty are more frequently found in junior faculty
positions than leadership positions [1]. They are promoted
at lower rates than their non-URMM counterparts [21]
(Table 1). Spending more time on diversity efforts and in
clinical activities, lacking effective mentors and conscious
Rodríguez et al. BMC Medical Education (2015) 15:6 Page 2 of 5

and non-conscious bias all contribute to promotion
inequity. Because salary is dependent on academic rank in
many institutions, this disparity ensures that URMM
faculty are paid less than their peers [16].
Summary
The sum of these disparities presents a considerable
barrier to success for URMM faculty, as illustrated in
Figure 1.
The inequities described make it very difficult for them
to remain and advance in academic medicine. It is also a
regressive disparity—URMM faculty that have “extra”
responsibilities are more likely to be found in the lowest
paying ranks.
The relative absence of URMM faculty and especially
in leadership roles has a negative effect on all medical
students and house staff, but particularly URMM
trainees. These negative effects include: less research
regarding the health care needs of minority patients,
limited exposure to underserved populations, and
fewer mentors for URMM students. URMM faculty are
essential to pipeline programs, and they provide sup-
port for URMM students in the form of role models,
educators and mentors [2]. Since URMM faculty
teach students to care for underserved/minority patients
by caring for those patients themselves, their relative
absenceamongthefacultyalsohasanegativeeffect
on patient care. As the US population becomes more
diverse, educators need to ensure that our physician
workforce is willing and committed to caring for diverse
patients. Increasing the numbers of URMM faculty is an
important part of that effort. Since URMM faculty are
also more likely to engage in health disparities research
than their non-URMM counterparts [5], increasing the
proportion of faculty from URMM groups would also
benefit the nation’s research agenda to eliminate health
care disparities.
Addressing the URMM responsibility disparity
We can learn of effective ways to eliminate these disparities
affecting URMM faculty from our colleagues in human
resources. Among possible interventions are:
Table 1 Promotion rates for black, Latino and white faculty
Study author and year Assistant to Associate Associate to Full
Black Latino White Black Latino White
Nunez-Smith et al. (2012) [21] 21.7% 26.2% 30% 18.8% 23.5% 30.2%
Fang et al. (2000) [19] URM* 30% 46% URM 36% 50%
*URM refers to black, Mexican American, Mainland Puerto Rican and Native American faculty members.
Figure 1 Additive effect of the minority tax.
Rodríguez et al. BMC Medical Education (2015) 15:6 Page 3 of 5

1. Value diversity effort fairly [22]
a. Recognize that the URMM responsibility
disparity exists and adjust assignment of
responsibilities accordingly
b. Work to ensure that clinical and community
endeavors are counted toward promotion
c. Assign promotion value to work in the area of
diversity
2. Employ rules that are in harmony with the
institution’s stated service goals and mission [22]
a. Increase awareness and avoidance of mission
drift, i.e. institutional departure from the service
mission [18]
b. Fund stated institutional diversity commitments.
3. Eliminate all forms of discrimination
a. Institute policies and procedures that address and
correct bias [6]
i. Move beyond compliance with the Americans
with Disabilities Act and Title VII to establish
robust accountability systems for acts of
discrimination by including it in annual
evaluations.
b. Facilitate and support relationship formation
among faculty, administrators, and learners [23].
c. Encourage positive curiosity when encountering
“otherness”and recognize differences in faculty as
benefitting our institutions [23].
i. Seek training in unconscious bias for all
faculty to help recognize its role in
discrimination.
4. Ensure clear, frank, honest communication between
administration and faculty to avoid faculty
discouragement.
a. Develop transparent communication in the
promotion and tenure process.
b. Develop opportunities for explicit conversations
(i.e. professionally moderated retreats) about
personal values to amplify the meaning faculty
find in the practice of medicine and in their
careers [23].
5. Develop an employee retention strategy [22]
a. This could take the form of faculty development
that focuses on:
i. Institutional culture
ii. Networking
iii. Professional skill development
1. Understanding the prevalence and
acceptance of unconscious bias
2. Teaching acceptable institution specific
behaviors to address silent racism.
3. Dealing with micro-aggressions and
stereotype threat [24]
4. Avoiding isolation and marginalization
iv. Mentoring [13]
6. Develop and implement organizational
culture-change activities in medical schools
involving broad participation to provide the
experience (for faculty and leadership) of learning
and collaborating in an inclusive and humanistic
culture [25,26].
The authors propose that these changes could make a
career in academic medicine much more attractive to
URMM faculty, and can, in effect, begin to alleviate the
URMM faculty responsibility disparity, and make academic
medicine a more equitable career choice for graduating
URMM residents. Similarly to repealing taxes, addressing
these disparities requires political stamina, negotiation
and coalition building. It requires a champion in the
ruling body who is willing to use political capital to
establish faculty equity. Diversifying academic leader-
ship can help alleviate the URMM responsibility dis-
parity. In addition to the cited proven institutional
change programs, further research on interventions to
address the URMM faculty responsibility disparity is
necessary to evaluate their effectiveness. These inter-
ventions once implemented, can hopefully help create
a healthy, diverse, and inclusive environment that will
benefit all members of the academic community and
improve health care.
Ethics
The Human Subjects Committee at the Florida State
University Institutional Review Board (IRB) does not re-
quire ethics approval for manuscripts using data that has
already been published. Since this paper only uses that type
of data, it is exempt from IRB review.
Abbreviation
URMM: Underrepresented Minorities in Medicine.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
JR: Conducted and revised the literature review, structured the paper,
and produced the first draft. KM: Conducted and revised the literature
review, structured the paper, saw and edited the draft and added
sections to the paper. LP: Substantially revised document critically for
intellectual content and flow. All authors read and approved the final
manuscript.
Acknowledgements
The authors would like to thank Tana J. Welch PhD for her valuable review
of our work throughout the process of writing this paper. We would also like
to acknowledge Jodi Slade, who created the figure illustrating the minority
faculty disparity.
Author details
1
The Center for Underrepresented Minorities in Academic Medicine at The
Florida State University College of Medicine, 1115 West Call Street#3210 M,
Tallahassee, FL 32306, USA.
2
Women’s Studies Research Center, Mailstop 079,
Waltham, MA 02454-9110, USA.
Rodríguez et al. BMC Medical Education (2015) 15:6 Page 4 of 5

Received: 10 June 2014 Accepted: 9 January 2015
References
1. Guevara J, Adanga E, Avakame E, Carthon M. Minority Faculty Development
Programs and Underrepresented Minority Faculty Representation at US Medical
Schools. JAMA. 2013;310(21):8.
2. Mahoney MR, Wilson E, Odom KL, Flowers L, Adler SR. Minority faculty
voices on diversity in academic medicine: perspectives from one school.
Acad Med. 2008;83(8):781–6.
3. Sánchez JP, Peters L, Lee-Rey E, Strelnick H, Garrison G, Zhang K, et al. Racial
and ethnic minority medical students' perceptions of and interest in careers
in academic medicine. Acad Med. 2013;88(9):1299–307.
4. Pololi L, Cooper LA, Carr P. Race, disadvantage and faculty experiences in
academic medicine. J Gen Intern Med. 2010;25(12):1363–9.
5. Pololi LH, Evans AT, Gibbs BK, Krupat E, Brennan RT, Civian JT. The
experience of minority faculty who are underrepresented in medicine, at 26
representative U.S. medical schools. Acad Med. 2013;88(9):1308–14.
6. Carr PL, Palepu A, Szalacha L, Caswell C, Inui T. 'Flying below the radar': a
qualitative study of minority experience and management of discrimination
in academic medicine. Med Educ. 2007;41(6):601–9.
7. Peterson NB, Friedman RH, Ash AS, Franco S, Carr PL. Faculty self-reported
experience with racial and ethnic discrimination in academic medicine.
J Gen Intern Med. 2004;19(3):259–65.
8. Price EG, Gozu A, Kern D, Powe NR, Wand GS, Golden S, et al. The role of
cultural diversity climate in recruitment, promotion and retention of faculty
in academic medicine. J Gen Intern Med. 2005;20:565–71.
9. Price EG, Powe NR, Kern DE, Golden SH, Wand GS, Cooper LA. Improving
the diversity climate in academic medicine: faculty perceptions as a catalyst
for institutional change. Acad Med. 2009;84(1):95–105.
10. Cora-Bramble D, Zhang K, Castillo-Page L. Minority faculty members' resilience
and academic productivity: are they related? Acad Med. 2010;85(9):1492–8.
11. Elliott BA, Dorscher J, Wirta A, Hill DL. Staying connected: Native American
women faculty members on experiencing success. Acad Med. 2010;85(4):675–9.
12. Pololi LH, Jones SJ. Women faculty: an analysis of their experiences in
academic medicine and their coping strategies. Gend Med. 2010;7(5):438–50.
13. Daley SP, Broyles SL, Rivera LM, Brennan JJ, Lu ER, Reznik V. A conceptual
model for faculty development in academic medicine: the underrepresented
minority faculty experience. J Natl Med Assoc. 2011;103(9-10):816–21.
14. Wingard DL, Reznik VM, Daley SP. Career experiences and perceptions of
underrepresented minority medical school faculty. J Natl Med Assoc.
2008;100(9):1084–7.
15. Lewellen-Williams C, Johnson VA, Deloney LA, Thomas BR, Goyol A,
Henry-Tillman R. The POD: a new model for mentoring underrepresented
minority faculty. Acad Med. 2006;81(3):275–9.
16. Palepu A, Carr PL, Friedman RH, Ash AS, Moskowitz MA. Specialty choices,
compensation, and career satisfaction of underrepresented minority faculty
in academic medicine. Acad Med. 2000;75(2):157–60.
17. Campbell KM. A letter to the editor: under-represented minority faculty in
academic medical centers. J Health Care Poor Underserved. 2013;24(1):viii-ix.
18. Richert A, Campbell K, Rodríguez J, Borowsky IW, Parikh R, Colwell A. ACU
Workforce Column: expanding and supporting the health care workforce.
J Health Care Poor Underserved. 2013;24(4):1423–31.
19. Fang D, Moy E, Colburn L, Hurley J. Racial and ethnic disparities in faculty
promotion in academic medicine. JAMA. 2000;284(9):1085–92.
20. Palepu A, Carr PL, Friedman RH, Amos H, Ash AS, Moskowitz MA. Minority
faculty and academic rank in medicine. JAMA. 1998;280(9):767–71.
21. Nunez-Smith M, Ciarleglio MM, Sandoval-Schaefer T, Elumn J, Castillo-Page L,
Peduzzi P, et al. Institutional variation in the promotion of racial/ethnic minority
faculty at US medical schools. Am J Public Health. 2012;102(5):852–8.
22. Kleiman M. Hiring Wisdom: Top 10 Ways to Guarantee Your Best People Will
Quit. 2013. Accessed April 17, 2013.
23. Pololi L. In reply to Rodríguez and Campbell. Acad Med. 2013;88(11):1591–2.
24. Stroessner S, Good C, Webster L. Reducing Stereotype Threat. 2014;
http://www.reducingstereotypethreat.org/definition.html. Accessed February
11, 2015.
25. Pololi LH, Krupat E, Schnell ER, Kern DE. Preparing culture change agents for
academic medicine in a multi-institutional consortium: the C - change
learning action network. J Contin Educ Health Prof. 2013;33(4):244–57.
26. Krupat E, Pololi L, Schnell ER, Kern DE. Changing the culture of academic
medicine: the C-Change learning action network and its impact at participating
medical schools. Acad Med. 2013;88(9):1252–8.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Rodríguez et al. BMC Medical Education (2015) 15:6 Page 5 of 5