Leadership in Medical Education: The Minority Tax on U.S. Medical Students

By Michael Gisondi (@MikeGisondi)

Overview

This post summarizes the results of a study published in August 2022 by Kamceva et al. in the Journal of Wellness, “More Work, Less Reward: The Minority Tax on Medical Students.” Several medical students are co-authors of this study. I’ll eventually explain why I think this it deserves the attention of medical school leaders… but first, a review of the topic and the main study findings.

Minority Tax

Medical schools have been addressing issues of diversity, equity, and inclusion (DEI) in earnest in only the last several years. The U.S. physician workforce looks nothing like the general population that we care for in this country and it will take generations to correct that. This follows decades of systemic racism and bias in U.S. medical schools that have led to the socially and culturally challenging learning environments experienced today by those underrepresented in medicine. Efforts to correct demographic diversity are not enough, and must be paired with inclusive policies, programming, and practices to affect meaningful change in our classrooms and on our wards. This ‘diversity work’ has historically been relegated to faculty members who are underrepresented in medicine or to the medical school programs, offices, or initiatives they support.

Minority tax is the burden of time and resources placed upon faculty members in representation of their minority communities¹, resulting in less time for academic pursuits. This tax likely contributes to the low number of minority faculty in medical school leadership and advanced professoriate ranks². In short, these faculty members are spending their time and talents on DEI work to the benefit of their institutions, often at the request of their institutions, and at the expense of the scholarly and administrative work necessary to get ahead in academic medicine^3,4. Additional factors associated with minority tax and thought to hinder career advancement include discrimination, cultural isolation, lack of mentorship, and disparities in clinical and other responsibilities⁵.

Study Objective

Minority tax has been previously defined in the literature based on studies of the experiences of medical school faculty members alone. However, the student authors of this study were anecdotally subjected to a similar tax on their time and efforts, and they wanted to examine whether other medical students experienced such burdens. Therefore, this study was designed to determine if a minority tax exists for medical students, and if so, to characterize its features.

Study Findings

• The main study finding is simple: medical students who are from groups underrepresented in medicine or historically excluded from medicine experience a minority tax that is similar to that of faculty members.

• Among the study cohort, students’ diversity and advocacy work averaged to the equivalent of two extra 40-hour work weeks per year in addition to their academic work.

• Based on the experiences of the study participants, the authors define the minority tax on medical students differently than it has been defined for faculty members, though there is a clear overlap in themes.

The defining characteristics of the minority tax on medical students are:

• the additional hours worked on DEI initiatives by students at the expense of other work,
• an underappreciation of time and efforts invested by students in DEI activities,
• instances of discrimination and microaggressions experienced by students,
• decreased cultural alignment between students and schools,
• increased feelings of social isolation by students, and
• negative effects on student stress, mental health, and wellbeing.
• The synergy of these stressors affects coursework and burnout.

The study participants described their experiences of minority tax and recommended interventions to address it. Six themes were evident:

1. minoritized medical students feel obligated to do DEI work,
2. a minority tax is experienced by students doing DEI work,
3. the minority tax negatively affects student mental health,
4. changes to the learning environment can mitigate the effects of minority tax,
5. there is a demand for increased representation and improved DEI education to address minority tax, and
6. increased money budgeted for DEI work would reduce the minority tax for medical students.

The study participants felt that minority tax could be mitigated if:

• students were compensated for their hours spent working on DEI initiatives,
• residency directors were to value DEI work as they might research efforts, and
• schools took meaningful actions to better diversify their faculties.

My Thoughts

It is common for schools to rely on medical students to do their DEI work, and that is the reason for this study and this post. Medical school leaders should take pause at these study findings, as it is clear that DEI work impacts the lived experiences of our medical students.

In an ideal world, schools would hire qualified staff members to do this work instead of relying on medical students. Until then, we must listen to our students about the demands on their time, compensate them for their efforts, be conscious of the minority tax experienced by them, and be intentional about trying to mitigate it.

To end, I must disclose that I am the senior author of the research study discussed in this post, which was designed by a group of students at several U.S. medical schools. I’m proud of them and believe that their study findings should be of interest to you.

References

1.Rodríguez JE, KM Campbell, LH Pololi. Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ. 2015;15(1):6.

2. Pololi LH, AT Evans, BK Gibbs, E Krupat, RT Brennan, JT Civian. The experience of minority faculty who are underrepresented in medicine, at 26 representative U.S. medical schools. Acad Med. 2013; 88(9):1308- 14.

3. Williamson T, CR Goodwin, PA Ubel. Minority Tax Reform – Avoiding Overtaxing Minorities When We Need Them Most. N Engl J Med. 2021;384(20):1877-79.

4. Rodríguez JE, MH Wusu, T Anim, KC Allen, JC Washington. Abolish the Minority Woman Tax! J Womens Health (Larchmt). 2021;30(7):914–5.

5. Campbell KM, JE Rodríguez. Addressing the Minority Tax: Perspectives from Two Diversity Leaders on Building Minority Faculty Success in Academic Medicine. Acad Med. 2019;94(12):1854–7.

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About the Author: Michael A. Gisondi, MD is an emergency physician, medical educator, and education researcher who lives in Palo Alto, California. Michael serves as the Vice Chair of Education in the Department of Emergency Medicine at Stanford University. Twitter: @MikeGisondi

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