Minority Tax on Medical Students: A Review of the Literature and Mitigation Recommendations

Despite calls to increase the representation of historically excluded groups into the field of medicine, the proportions of students who are Black or African American, American Indian or Alaska Native, and Hispanic or Latino remain well below those of these groups in the US population. ^1-3 Both the Association of American Medical Colleges and the American Association of Osteopathic Colleges of Medicine have accreditation standards for medical education that require these institutions to recruit and support a diverse body of students and faculty and to include curricula on diversity, equity, and inclusion (DEI). ^{4, 5} When such diversity programming requires the time, energy, and effort of the underrepresented in medicine (URiM) members of the medical student community, the environment represents a potential nidus of the minority tax.

The concept of the minority tax (or cultural tax) has been characterized to include extra responsibilities placed on minority faculty to achieve diversity, experiences of racism and isolation, as well as inequities in key academic areas such as mentorship, clinical duties, and promotion. ⁶ While the concept was specifically developed in consideration of the experiences of faculty who are racially or ethnically underrepresented, the themes of the minority tax also can be applied to other underrepresented groups in medicine, including sexual and gender minorities, people with disabilities, and women. ^{7, 8} Moreover, a person with more than one underrepresented identity may experience a summative burden of additional responsibilities and isolation. ^{7, 9} For example, minority women have a minority woman tax ⁹ within their institutions. The minority tax is a structural cause of chronic underrepresentation in academic medicine because of its effects on URiM individuals’ entry, retention, and advancement in predominantly White institutions. ^10-12 The concept of the minority tax has been explored in terms of its relevance to the URiM pipeline at the faculty level. To date, few publications have discussed the effect of the minority tax at the level of the medical student or resident trainee. However, URiM students’ experiences of bias in evaluations ^{13, 14} and selection for academic awards, ¹⁵ as well as experiences of racism and discrimination ^{16, 17, 18} during medical school have been well-documented. In addition to these challenges, URiM students experience stereotype threat in which fear of failure because of their underrepresented identity leads to underperformance, ^{13, 19} and they experience isolation. ¹⁸

This narrative review summarizes the current literature on the minority tax in medical students, names the harms of the minority tax on URiM students, and proposes actions that medical educators and medical school leaders can take to eliminate the minority tax among medical students.

Because of the dearth of information on minority tax and students, we decided that a narrative review was the appropriate method for our study. The term minority tax is relatively new to the literature, with the earliest instance appearing in health sciences as a defined and named concept indexed in PubMed in 2015. ⁶

To accomplish this narrative review, we searched PubMed, Web of Science, and Scopus using the search term minority tax, which resulted in 37 unique, indexed publications that discussed the minority tax experienced by individuals in biomedical research or the field of medicine. Using Google Scholar, the key word minority tax yielded 1,130 results, excluding those previously identified in databases and excluding patents and citations. Of the 1,167 total articles, title review (done by D.B.) eliminated 1,040, leaving 127 results. Articles were eliminated on title review if they were not available in English; if they were unavailable for review; if the title indicated a nonmedical topic such as finances or law; or if the title indicated a focus on nonacademic aspects of medicine such as clinical care, quality improvement, or nonphysician staffing concerns. In an effort to find materials that may not be indexed within databases, we queried Google with “minority tax,” “minority tax medical students,” “minority tax health sciences students,” and “minority tax medical education.” This search added three articles to our final results: a professional society online news article reporting on a student focus group convened by the organization, ²⁰ a professional society forum post, ²¹ and a news article about an online peer-reviewed publication for medical students. ²² We discussed the nonindexed results and chose to include them because of their relevance to this topic and the relatively few articles identified. Two articles ^{23, 24} discussed medical students’ experiences of the minority tax outside of the United States, and we decided to include these for the same reasons. We conducted searches between August 2022 and March 2023. At the conclusion of our search, we had 130 articles for consideration. These 130 articles underwent abstract review (done by D.B.), and 52 articles underwent full article review (done by RMB). Table 1 shows the reasons that articles were eliminated at this stage.

To assess the quality of the papers, we used a modification of Ebell’s strength of recommendation taxonomy (SORT). ²⁵ The SORT criteria originally were created to critically assess the medical literature, principally in the clinical space. Rodríguez et al ²⁶ used a modification to this taxonomy to better assess the literature on underrepresented minority faculty working in the academic medical space. We used the same modifications to assess the level of evidence of those manuscripts included in this review (done by R.M.B. and verified by K.M.C. and J.E.R.). We summarized the main findings of each media source (done by R.M.B. and verified by K.M.C. and J.E.R.); in addition, we identified the harms to the individual underrepresented student documented in the literature that met criteria for this review, and we also delineated solutions to mitigate or eliminate those harms described in the literature (done by RMB and verified by K.D., K.M.C., and J.E.R.). During this process, we had no disagreements on the application of the SORT criteria or on the findings that we identified.

Our study provides a narrative review of the literature exploring the experiences of URiM medical student trainees as those experiences relate to the minority tax. Only six articles included in this review were categorized as original research and provided metrics for review. However, even articles that ranked at a lower tier of evidence, based on the modified framework of Ebell’s taxonomy ²⁵ suggested by Rodríguez et al, ²⁶ brought forth findings that were consistent across articles and largely consistent with the experiences of minority faculty in academic medicine.

We found the diversity efforts disparity ²⁷ that has been defined for URiM faculty to also be present for URiM trainees in clinical and educational settings. Students felt as though their diversity identities were manipulated for institutional gain. They were commonly asked to address institutional inequity and systemic racism in the medical education experience, when they did not cause those inequities and were the ones who were adversely affected by them. Students expressed a sense of duty to right institutional wrongs while at the same time worried that such efforts would negatively impact their academic performance and could ultimately hinder matching into a residency program of their choice. Trainees reported fighting to belong, dealing with assignment bias and lower grades because of their diversity identity, and facing increasing complexity and a compounding of exclusion and bias with intersecting identities. If no diversity office was present at the institution, trainees felt an even stronger diversity efforts disparity and more pressure to do DEI work. Those increased pressures were complicated by having to educate peers and sometimes even faculty. In addition to diversity and inclusion advocacy, trainees felt the need to address racial justice and underscored challenges with discrimination and bias experienced particularly in the clinical environments of medical schools, including clerkships. Details of the major findings of the articles are outlined in Table 2, sorted by strength of evidence, with the strongest level of evidence first, followed by year of publication. In Table 3, we synthesize the harms of the minority tax on URiM students enumerated in the literature, and we propose specific actions medical school administrators, deans, and course directors can take to address these harms. In addition to the published literature, the recommendations come from collective years of author experience.

The findings of this literature review offer compelling evidence that URiM medical students are experiencing the minority tax. In particular, the survey by Kamceva et al ²⁸ quantified the average hours spent on activities that constituted a minority tax and demonstrated that students spend fewer hours on other medical school activities. This finding suggests that students’ contributions to DEI work take away time from other crucial medical school activities. The 62 more hours per year that the URiM students spend on DEI initiatives and the 36 more hours spent on advocacy ²⁸ also may be labeled a majority subsidy, ³⁵ highlighting the time saved by non-URiM medical students who nonetheless benefit from the efforts of their URiM peers.

Particularly concerning is that the few published accounts of URiM students’ experiences of the minority tax depict numerous situations in which URiM students’ time, energy, and resources support activities that fall under the purview of the responsibilities of the hospital systems or medical schools themselves. To this end, URiM students cited many examples of this kind of work, including contributing to medical school DEI curricula through serving on panels to educate other students about their identity, ^{20, 28} giving lectures, ³⁴ or developing curricula; ^{21, 22, 34} mentoring other URiM students; ^{20, 22, 28, 32} administrating premedical URiM pipeline programs, ²² other community service, ²², ³² and social activism; ³⁴ working on URiM recruitment ^{22, 32} and being featured in website and other marketing materials; ²⁰ and spending extra time with Black and Brown patients to try to mitigate the negative effects of racism on those individuals’ care. ²¹ When hospitals and medical schools invite, ask, or obligate URiM students to carry out these essential accreditation-required functions of equitable education and care without compensation, reward, or recognition, they impose the minority tax on URiM students; and such experiences, alongside other negative experiences associated with being URiM, impede academic success and detract from URiM career choice in academic medicine. ³⁶

Many medical schools and hospitals may engage in DEI inititatives in a genuine effort to strive for educational and health equity. The actions in Table 3 serve to align intentions of inclusivity with the impact on URiM students. Medical school administrators and course directors in states where legislation impacts DEI activities will need to review curricular and extracurricular offerings with university legal counsel to ensure compliance.

The personal accounts of URiM medical students’ experiences of the minority tax^32-34 depict URiM students’ resilience and personal investment in DEI activities. Some of the first-person learner accounts express a sense of pride and mission, ^{22, 33, 34} and one characterized the mentorship as rewarding. ²⁸ Taken all together, the proposed actions in Table 3 function to showcase the advanced skill sets of URiM students contributing to DEI activities as markers of success within academic medicine.

The minority tax has been characterized as a significant cause of the attrition of URiM faculty in the field of academic medicine. ^{6, 7, 10, 37, 38} This is the first review and summary of the peer-reviewed and other select literature of the minority tax among medical students. Identifying the minority tax among URiM medical students offers opportunities to intervene and mitigate the minority tax earlier in the URiM pipeline to academic medicine. A careful read of the few articles on the minority tax among medical students reveals a multitude of harms imposed on URiM students by the institutions levying such taxes. Enumerating these harms may enable medical educators and medical school leaders to evaluate the experiences of URiM students within their institutions and to take actions to eliminate or mitigate the minority tax on URiM students.

The core issue of the minority tax—whether imposed on trainees or faculty—is the unequal usurpation of time, energy, and other resources from URiM individuals for tasks specifically related to URiM identity to serve the broader academic medical institution. Thus, many of the actions proposed here to end the minority tax among students involve investment of resources to accomplish the programming achieved through the disproportionate contributions of URiM learners. Other actions here convey the value of all DEI work contributing to the academic success of learners who engage in it. Importantly, medical schools seeking to eliminate minority taxation of URiM students will need to invest in professional support for DEI recruitment, mentorship, and curricula with sufficient faculty and staff to alleviate the burdens placed on medical students. A key challenge will be the limited number of URiM faculty available for these roles within medical education. As medical educators seek to eliminate minority taxation of students, investing in and supporting faculty and staff efforts will be crucial to avoid transferring the minority tax from students onto URiM faculty. Ultimately, hospitals and medical schools seeking to increase the representation of URiM students, residents, and faculty will need to invest in precollege pipeline programs, community college pathways to medicine, and new historically Black college and university medical schools, ³⁸ as well early science, technology, engineering, and mathematics education, because the URiM pipeline starts in early childhood. ¹⁰

One common theme across the spectrum of clinical care, research, and other academic activities is that URiM trainees and faculty more often engage in and are assigned activities, tasks, and responsibilities that do not result in high performance as measured in academic and clinical terms, respectively, across these fields. When the causal locus of lack of advancement for URiM trainees and faculty is located in the individual’s choice to engage in these activities, the message to URiM trainees and faculty is that they and their interests are a poor fit for academic medicine, and the solution is to leave, constituting a leak in the URiM pipeline. Institutions have an opportunity to name and value these DEI, mentoring, and clinical service activities, advancing and promoting the URiM and other faculty who contribute these services, thus shifting the academic environment to welcome and include URiM individuals.

Given that academic scholarship on the minority tax is a relatively new topic in academic medicine, a lack of standardized language is available to report, capture, and subsequently search in the medical literature. While this literature review included PubMed-indexed publications and nonindexed publications on medical society news forums, other types of publications and media—including social media posts and reports written by individual medical students or medical student groups such as the Student National Medical Association, Latino Medical Student Association, and White Coats for Black Lives—were not included in this narrative review. This omission may lead to the false conclusion that URiM students are not voicing concerns or objections to their experiences of the minority tax. Moreover, the limited sample sizes of the published articles included in this review may mean that we did not fully capture the themes of the medical student minority tax. Investigating additional experiences, particularly through interviews and focus groups, could add nuance and depth to the current characterization of the medical student minority tax. Another key opportunity to represent and include students’ voices in this work is analysis of the anecdotal experiences of URiM students shared on social media platforms.

This narrative review demonstrated that few publications directly address the minority tax among medical students. In addition, the strength of evidence among the articles gathered on this important topic demonstrates the need for more qualitative and quantitative research studies on the minority tax among medical students. This narrative review does not address the minority tax among graduate medical education (GME) trainees; however, one of the articles included in this review ³⁴ and others that were screened for this review ^39- 41 did include studies and firsthand accounts of minority tax experienced among GME trainees. Themes from the pieces discussing GME minority tax mirrored those of URiM students presented here: experiences of microaggressions and bias, as well as performance of additional services because of their race/ethnicity in areas of patient care, residency recruitment, curriculum, and diversity committees. Such experiences may detract URiM residents from pursuing careers in academic medicine and contribute to the leaky URiM faculty pipeline.

Understanding the impact of the minority tax on the URiM pipeline to academic medicine will require further research on the minority tax among medical students, residents, and fellows, as well as among faculty. At the same time, published studies of the impact, effectiveness, and resources required to implement interventions to eliminate the minority tax will spur the proliferation of more effective efforts toward this end across academic medical centers.

Finally, we did not include social media posts in this narrative review. However, reviewing social media platforms for firsthand account reports of minority taxation among students likely represents a wealth of information about students’ experiences of the minority tax and constitutes an area of future research.

Medical students who are underrepresented in medicine experience the minority tax in addition to microaggressions, bias, and racism. The services that URiM students provide to hospitals and medical schools because of their racial and ethnic identities constitute an unjust experience stemming from structural racism. Medical educators and medical school leaders can take specific actions to eliminate the minority tax on medical students and to foster an equitable learning environment. Further research on the minority tax among medical students, residents, and fellows is needed to understand how the minority tax in undergraduate and graduate medical learning environments contributes to underrepresentation of racial and ethnic minority faculty within the field of academic medicine.