All Together Now: Building a More Inclusive Osler Residency Program

Published in Aequanimitas - Aequanimitas Summer 2020

Meron Hirpa, an Osler internal medicine resident and chair of the House Staff Diversity Council, has made outreach to underrepresented in medicine (URM) students a part of her life.

“I’m of Ethiopian descent and the first physician in my family,” she says. “Mentors were key to helping me navigate my medical career and to providing me with the assurance that I belong in medicine. I am committed to helping those who come from similar backgrounds to show them that it is possible to train at a leading institution like Johns Hopkins.”

She tutored and mentored throughout high school, college and medical school. Though she didn’t do it for the recognition, she believes the work boosted her school admission prospects. Her efforts continued when she became a resident at Johns Hopkins. In addition to chairing the Diversity Council, which she helped create in 2018, Hirpa describes herself as “sort of the go-to person for recruiting.”

Yet, as she winds down her residency, she worries that those efforts have taken time away from the research and clinical work that would have helped her career.

In essence, she’s been paying a “minority tax,” a term that describes the additional and usually uncompensated work of promoting diversity and inclusion. Minority tax assignments include educating the majority, mentoring and recruiting members of a minority group, and serving on diversity boards and task forces. These efforts fall disproportionately to underrepresented minorities — under the assumption that they are uniquely qualified or motivated to do them.

In an October 2019 opinion piece in Annals of Internal Medicine, Johns Hopkins nephrologist Deidra Crews (Osler, 2006), associate vice chair for diversity and inclusion in the Department of Medicine, and cardiologist Roy Ziegelstein (Osler, 1989), vice dean for education, take the minority tax concept a step further.

They describe a “majority subsidy” that occurs “when diversity and inclusion are ‘owned’ primarily by a small number of persons,” yet benefit the entire institution. The result is a system that penalizes the very people it is supposed to help, they write, while giving an unearned advantage to people who don’t expend similar effort.

Crews knows about this subsidy firsthand. “I get asked to do a lot of things that my colleagues who are more representative of the majority do not, by any stretch of the imagination, get asked to do,” she says.

“I’ve spoken at churches and schools. I’ve advised countless URM trainees and junior faculty, both at Hopkins and across the U.S. I delight in doing it, but it does take time away from the things that provide academic credit. The case we’re trying to make is ‘OK, if we’re going to do that, we need to get credit.’”

Crews and Ziegelstein propose several solutions. They recommend incentives for faculty who undergo mentoring and unconscious bias training, and write that all faculty members should be required to serve as mentors for URM trainees and junior faculty members. Performance metrics, particularly for leaders, “must be more explicitly tied to diversity efforts and outcomes,” they write.

Nationwide, underrepresented minorities make up 37% of the population but less than 10% of faculty positions, according to the Association of American Medical Colleges (AAMC).

Sanjay Desai (Osler, 2003), director of the Osler Medical Residency, says URM trainees comprise 12.5% of the program's population, a number that has changed little over the past five years. “We have a strong mission for diversity, but achieving it is challenging,” he says.

The department’s diversity council, led by Crews, plays a large role in recruitment, and is not comprised solely of URM members, he says. “They reach out to every URM applicant before they arrive. I interview every single applicant, and I’m not a URM.”

Yet Desai acknowledges that the work of attracting a diverse Osler population often falls to URM trainees and faculty. “We had a goal this year of having every URM applicant interviewed by a URM faculty member,” he says. “That’s clearly a minority tax. It’s what both applicants and the diversity council say they wanted, but we only had the numbers to do it about half the time. Meanwhile, just 5% of non-URM applicants were interviewed by URM faculty.”

Going forward, Desai plans more outreach to local universities, including Howard University and the University of Maryland, Baltimore County, to introduce URM students to opportunities at Johns Hopkins.

“I see that as a leadership responsibility,” he says. “I would not limit it to URM faculty. We’re really trying to send the message that diversity is beneficial to all of us, and that we all have a role and contribution in the mission.”