In early 2015, we, 2 underrepresented minority in medicine (URMM) men in senior positions, published an article elucidating the multiple disparities that impact the recruitment and retention of URMM faculty in academic medicine, commonly referred to as the minority tax.1 URMMs generally include blacks or African Americans, Latinos/Hispanics, Native Americans, and Pacific Islanders. For the purposes of this Invited Commentary, we will focus on underrepresented racial/ethnic minorities when referring to URMMs, using the former, widely accepted definition.2 The minority tax encompasses disparities in the areas of isolation, mentorship, diversity efforts, and clinical assignments as defined in our previous article.1
In addition to the previously elucidated aspects of the minority tax, another one that impacts URMM faculty is the gratitude tax. The gratitude tax is the feeling of obligation that URMM faculty have to the academic institution and to future generations of URMMs for being given the opportunity to be a physician. It is a feeling of indebtedness to the institution and others that can at times diminish one’s sense of accomplishment and stimulate a desire to pay back the perceived debt. Payment could take the form of staying at one’s institution when academic advancement could be experienced elsewhere or not seeking better opportunities to advance one’s career. It is also the feeling that one must dedicate more time to clinical efforts than one’s peers because of being given a chance or opportunity at employment. Sharing experiences is a meaningful way of providing examples for other URMM faculty to follow, as well as illustrating ways in which senior leadership can help mitigate the effect of the minority tax on URMM faculty and thereby increase equity in academic medicine. This Invited Commentary is designed to help individual URMM faculty overcome the “taxes” they face by providing our personal experiences with and perspectives on each. Together, we have a total of 31 years of work in diversity and inclusion in the field of academic medicine (see below) that inform these perspectives.
K.M.C.: I am a family physician and have served or am currently serving as a minority affairs dean, diversity and inclusion dean, and senior associate dean for academic affairs. I cofounded and codirect the Center for Underrepresented Minorities in Academic Medicine with my coauthor, J.E.R. In addition, I have over 40 publications, most dealing with underserved populations or URMM faculty and students, and am a member of the National Academy of Medicine Roundtable on the Promotion of Health Equity. I also serve as the Southern Region Representative to the Association of American Medical Colleges Group on Diversity and Inclusion. The work of my office and the admissions office led to the 2018 incoming medical school class at East Carolina University being the most diverse class in the school’s 42-year history.3
J.E.R.: In addition to serving as cofounder and codirector of the Center for Under represented Minorities in Academic Medicine, I am also a family physician with over 100 publications. I have served on 3 diversity and inclusion committees and was the cochair on one of these committees. I am the newly appointed interim associate vice president for health equity and inclusion for the health sciences campus at the University of Utah. Our office oversees and supports the diversity efforts of our 6 health sciences campus institutions: the Colleges of Nursing, Health, and Pharmacy; the Eccles Health Sciences Library; and the Schools of Medicine and Dentistry.
Mitigate the Effects of the Isolation and Gratitude Taxes—Align Your Career Direction With the Institutional Mission and Seek Opportunities Elsewhere in Academia if Necessary
URMM faculty report a disconnect between stated institutional goals and actual activities of the institution.4,5 This disconnect can facilitate isolation and a feeling of poor fit known as the isolation tax. In most cases, URMM faculty are not in leadership positions6–9 and have little influence on the mission, vision, and goals of an academic institution. When career direction is aligned with the institutional mission and there is a critical mass of URMM faculty, isolation can be diminished.10 Mitigating the effects of the gratitude tax involves URMM faculty realizing that being grateful for a current job or position does not mean letting opportunities for advancement that may be in a different state or at another institution pass by without investigating them. Not only that, addressing the gratitude tax means that URMM faculty should actively and frequently look at career advancement opportunities outside of their current institution because growth and advancement may not always come from within one’s home academic environment. Transitioning to a new position or the next job does not mean that you are ungrateful for the position, opportunities, or people left behind.
J.E.R.’s personal perspective
I worked for many years in an institution where the stated mission was the same as mine—a mission centered around care for underserved minority patients—in an environment where URMM faculty were welcomed and sought after. This happened at 2 different institutions in my career. However, as time went on, our missions diverged because of both personal growth and my role in the application of the institutional mission. I sought out new opportunities that were in better alignment with my newly gained perspective on my personal mission. Throughout my career, each academic appointment has offered a unique opportunity to be more effective in leading a cultural change. And in each instance, a major motivation for seeking an academic appointment external to my current institution was the opportunity for career advancement and the opportunity to have a greater impact in diversity and inclusion.
Sometimes, I felt like I was paying a gratitude tax, which kept me from seeking new positions. I had traveled so far, economically and professionally, that I was overwhelmed with gratitude at having obtained more economic security than anyone in the previous generations of my family. Early in my career, I lost precious time for career progress because there was no structure in place to assign value to service to URMM patients. This was not unique to the institution where I was working. I wanted to give back because I had been “given” so much. It never occurred to me that I had earned my position. I gave back primarily by staying in a position in which I knew I could no longer grow and not seeking external opportunities. I believed that considering other institutions was a betrayal of those generous enough to give me my first academic positions. This idea may have been subtly reinforced by leaders in an effort to discourage me from leaving. Gratitude, however, does not mean sacrificing your career; it means positioning yourself where you can do the most good. For me, that has meant moving, with each move providing greater alignment with what my personal mission was at the time. I am fortunate because every academic move I have made has been the best move of my career.
K.M.C.’s personal perspective
After I finished my residency training, I focused on teaching and clinical care and was just thankful for the opportunity to have a job. I never saw academic medicine as a place where I could contribute to the body of medical knowledge with an article or project. My thankfulness became a manifestation of the gratitude tax in that I was so appreciative to have a job that I dared not look for opportunities for advancement outside of the state, even when I felt like my career direction and the direction of the institution were diverging. I never thought I had permission to look elsewhere. The gratitude tax not only limited my outlook but also hindered my growth as an academic physician because I never worked with institutional leadership to cultivate my own career direction and development. For a time, I settled for merely having a job, doing whatever was asked of me, always sacrificing personal and professional growth to benefit the institution and assuming that the direction of others’ career paths would eventually advance my career. Of course, that was not always the case, whether intentional or not. In fact, my experience of helping fulfill the dreams of others resulted in me paying the minority tax.
Most medical schools where I have worked have missions that involve service to underserved populations or providing minority students access to a medical education. Discovering that my mission aligned with that of the institution came from time spent in studying the institution’s leadership and the opportunities it provided to develop my leadership skills at the national level. My faith and a family of mentors, both URMMs and non-URMMs, encouraged me to look beyond state and institutional boundaries to possibilities across the country. That wider scope led me to pursue my current job in the state of North Carolina.
Overcome the Mentorship Tax—Use Strategic Guidance to Help Advance Your Academic Medicine Career
The shortage of effective and committed mentors, along with the difficulties in figuring out institutional culture, promotion and tenure guidelines, how to navigate institutional politics, and where to find institutional resources, is known as the mentorship tax. This tax disproportionately impacts URMM faculty and can lead to low job satisfaction and a departure from academic medicine. The literature has demonstrated that URMM faculty need mentors, and programs that provide mentoring for this group have demonstrated successes.11–13 However, a single mentor is unlikely to meet all of the professional development needs of an individual faculty member.14,15 Actively seeking mentors includes reviewing research interests, scholarship, and the careers of others to ensure that a potential mentor has similar interests and goals as well as a track record of mentorship. Minority faculty should look for overlap in career goals and trajectory and remember that becoming a mentor is as important as getting one. Mentors can vary from coaches to peer mentors to sponsors.16 While URMM faculty can benefit from URMM mentors, it is equally important to have non-URMM mentors for balance and different perspectives.13 Non-URMM allies can be some of the most life-changing mentors in the career of an URMM academic.17
J.E.R.’s personal perspective
In mentoring relationships, I have learned from both those senior and junior to me. I learned early on that to have a good mentor–protégé relationship, I needed to follow the mentor’s advice. When I did not, the results were personally and professionally unpleasant, and it ruined my credibility with that mentor. In one case, I felt I could no longer seek my mentor’s wisdom because of my mishandling of her advice.
One of my mentors, who is a non-URMM woman and family medicine department chair, has given me great advice on what worked for her career and what did not. From her, I learned what behaviors, as a man and URMM faculty leader, are acceptable and which ones are not. She was especially instructive on behaviors that I could adopt to support my women colleagues in their careers. The information this mentor shared would not have made nearly the same impact on me if it had come from a male mentor. At the same time, my URMM female mentors and some URMM peer mentors have taught me that my words, though they are not intended to be, can be seen as divisive, alienating readers and learners. Through their influence, guidance, and feedback, I have found ways to express my ideas and opinions using clear, inoffensive words. A simple substitution, using “non-URMM” as a term to describe the common backgrounds of most leaders in academic medicine, is one example of the many ways my language has changed.
I have also been “sponsored.” While on the surface this may look like mentorship, sponsorship is actually more—it is risking your reputation to advance another’s career. Metaphorically, the mentor can show you where the door is and tell you how to get to it. The sponsor, however, actually opens the door for you and helps you walk through it and reap the rewards on the other side. Most URMM faculty mentors are not in a position to be a sponsor, as evidenced by their relative scarcity in medical school and academic health center leadership. In sponsorship, the protégé has an obligation to the sponsor, whereas some mentorship relationships are simply the mentor giving and the protégé receiving. In my case, my sponsor was my current chair, also a URMM man, who put my name, my accomplishments, and my skills on the desk of the CEO of the health system at the University of Utah, thereby associating them with his own. This provided me a path from faculty member to senior administrator in the health system and university governance.
K.M.C.’s personal perspective
At the beginning of my career, I never viewed mentors as people who could help me discover and identify my passion. I viewed mentors as those who could help me along the traditional missions of any academic center—for me, clinical care and teaching. As I have grown in experience, I have learned that mentors can help beyond assisting with assigned job responsibilities. They can help me discover and birth a vision—a potential career direction that I did not even know would appeal to me. I needed mentors who told me what I needed to do to discover and develop my unique talents and abilities rather than people who would just point out the multitude of reasons why I could not pursue my interests if they were misaligned with the institution’s.
I have had a few key mentors throughout my academic career. The most prominent, a URMM woman, family physician, and department chair, helped me define and think through my professional priorities and how they align with the institution’s. We would talk every 2 to 3 months, and I would organize my part of the discussion around the topics of teaching, research, clinical care, community, and administration. The conversation would always end with a task list that would be helpful in my development: a recommendation to read a paper, attend a conference, or contact a certain person. These sorts of connections can happen in any place. This particular mentor came into my life at the recommendation of a colleague. We were at an alumni gathering for our medical school during a national meeting when, after sharing my path in academic medicine with my fellow alumnus, my colleague suggested I contact the person that would become my future mentor. My fellow alumnus told me that I needed a mentor and recommended that I call. I took that advice; I called and received mentorship that has been career shaping.
I have enjoyed and benefited from a family of men and women, URMM and non-URMM mentors; this mosaic of mentoring works well for me. It enlarges my circle of mentors and allows me to focus needed assistance on the particular strengths of each individual mentor.
Overcome the Clinical Assignments and Diversity Efforts Taxes—Know the Literature Concerning URMM Faculty in Academic Medicine and Negotiate for Supported Time for Scholarship
URMM faculty and junior faculty generally have more clinical care duties and a greater community presence18 than non-URMM faculty; these are, respectively, the clinical assignments and diversity efforts taxes. These increased clinical care duties and greater community presence reduce time for scholarly pursuits, which can lead to a lack of promotion and advancement and can result in attrition.18 For example, URMM faculty with a high proportion of clinical time often care for sicker patients with more complex health issues,9 which reduces time for research or scholarly activities, compared with non-URMM faculty of the same rank. URMM faculty need to be aware of these aspects of the minority tax. A presence in and engaging with minority communities are duties that should be shared by academic leadership across the institution and country regardless of URMM status, and extra efforts should be made to help prepare URMM faculty for longevity in academic medicine.
K.M.C.’s personal perspective
My first job landed me on several committees and required lots of community engagement, leaving little time for scholarship. At the time, I was unaware of the importance of scholarship in career advancement. I learned that I had to balance clinical, committee, and community work as well as make time for scholarship around those activities. For me, that translated to finding myself on the sofa at night and on weekends writing and sometimes using my own resources, independent of those provided by the school, to advance my career.
Supported time is a must for advance ment. Once a scholarly product is produced, the institution will sometimes be willing to build in supported time for additional scholarship. Take what you can get, but do not be shy about asking for supported time. How much you ask for will be determined by the mentorship structure around you, your scholarship goals, and other competing obligations.
J.E.R.’s personal perspective
The underlying passion that drives me is my desire to provide outstanding care to underserved and minority patients by preparing students for a career in caring for the underserved and improving URMM representation within academic medicine. As I began to experience clinical successes early in my career, I began writing about those successes. The result of this writing was, among other things, the development of a national reputation, as well as career progression from assistant to full professor, which I earned 3 years ago. A focus on documenting scholarship through publication has been instrumental in that journey. Without it, I am confident that I would not have been able to progress academically. Once institutional leaders learned of my success in publication, I received more time for supported scholarship; the nights and weekends I spent writing early in my career paid off.
The following take-home tips provide some ways to overcome the different aspects of the minority tax. Align your career direction with the mission of the institution, and do not be afraid to seek opportunities at other academic institutions. Use strategic guidance from URMM and non-URMM mentors to aid career advancement, negotiate for supported time for scholarship, and know the literature concerning URMM faculty in academic medicine (see Table 1). Though these tips are a good starting point, more conversation and action aimed at improving institutional climate and defining pathways for the advancement of URMM faculty are needed.
1. Rodríguez JE, Campbell KM, Pololi LH. Addressing disparities in academic medicine: What of the minority tax? BMC Med Educ. 2015;15:6.
2. Association of American Medical Colleges. Underrepresented in medicine definition. https://www.aamc.org/initiatives/urm
. Published 2004. Accessed May 31, 2019.
3. WITN. White coat ceremony welcomes Brody School of Medicines most diverse class ever. https://www.witn.com/content/news/White-coat-ceremony-welcomes-Brody-School-of-Medicines-most-diverse-class-ever-490041741.html
. Published 2018. Accessed May 31, 2019.
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