Johns Hopkins oncology surgeon Fabian Johnston is often the only black person in the room.
“I interviewed with 23 residency programs, and in all those institutions, I can recall meeting only one other person of African descent,” says Johnston, whose family migrated from Jamaica when he was 4. “I think my medical school class had 10.”
Because he doesn’t look like his peers, Johnston at times wonders if he belongs, particularly when colleagues seem to underestimate him. “Those things hurt,” he says. “You need people who believe in you, who lift you up.”
In 2013, he became assistant professor of surgery at an academic medical center in the Midwest. There was just one other black surgeon on staff, but Johnston hoped to change that by continuing to mentor and support trainees of color.
He was, however, given some advice by that one African American partner: Be cautious about being asked to represent diversity and inclusion at this institution as a token, Johnston was told. Instead, focus on advancing your own career.
In essence, the older surgeon was warning Johnston not to pay the “minority tax,” a term coined as “cultural taxation” in 1994 to describe the additional and usually unrewarded 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. Yet diversity and inclusion benefit the entire institution.
In an October opinion piece in Annals of Internal Medicine, Johns Hopkins nephrologist Deidra Crews, associate vice chair for diversity and inclusion in the Department of Medicine, and cardiologist Roy Ziegelstein, vice dean for education and former vice chair for diversity and inclusion, have taken the concept of the minority tax a step further. Ziegelstein coined the phrase “majority subsidy,” which the two describe in the article — and denounce.
“This majority subsidy is created when diversity and inclusion are ‘owned’ primarily by a small number of persons from underrepresented in medicine (URM) groups and diversity efforts are marginalized,” they write.
“When this occurs, diversity and inclusion are no longer treated as a critical aspect of an institution’s mission. Would we ever allow clinical excellence, professionalism, and scientific discovery to be championed by only a few?”
The issue is vitally important because the current system penalizes the very people it is supposed to help, they say, while giving an unearned advantage to people who don’t expend similar effort.
“All aspects of excellence have to be owned by everyone in the organization,” says Ziegelstein. “When we farm out diversity in recruitment to a small group, we not only tax them, we also give a subsidy to the people who are not in those groups who should be owning this.”
And what’s more, it’s not a. Despite decades of work to improve diversity in academic medicine, the numbers remain low.
Nationwide, underrepresented minorities make up 37 percent of the population but less than 10 percent of faculty positions, according to the Association of American Medical Colleges (AAMC). Much of that representation is concentrated in lower-ranking faculty jobs, while diversity in leadership positions remains even more elusive.
“Even though medical school faculty diversity has been increasing overall, it has not kept pace with the diversity of medical school students or the general society at large,” notes a 2016 AAMC analysis.
That’s not acceptable, says Ziegelstein. “There are all sorts of reasons to advocate for diversity,” he says. “The most important is that it’s a central component of excellence. The more diverse the group, the better.”
In the face of those shortfalls, Johnston didn’t heed that surgeon’s suggestion. He has repeatedly advocated for URM residents in need of a supportive voice as a sponsor or champion. “We want to make sure folks work past any doubts or roadblocks to find their way to the other side,” he says.
And at Johns Hopkins, where Johnston is now associate professor of surgery and oncology, he spends hours each week mentoring junior faculty members, residents and students. He also supports students and trainees across the country through his roles in the Association for Academic Surgery and the Society of Black Academic Surgeons. Often, he meets or telephones mentees late in the evenings, after his children have gone to sleep.
“It’s part of who I am,” Johnston says. “When I was in college and medical school, I never imagined I would be at Johns Hopkins. Along the way, there were people who supported me, but also people who doubted me. My contribution is to help people push through that. I think a lot of people need both support and tough love.”
Johnston knows that the hours he spends helping others are hours he’s taking away from his own career. “Those are times I could be focused on research or writing papers or a billion other things,” says Johnston, who develops innovative approaches to palliative care for African American patients with advanced gastrointestinal cancer.
The solution, say Crews and Ziegelstein, is to spread responsibility across the institution and reward it appropriately.
“Deidra and I are offering a new perspective that recognizes diversity in terms of promotions and compensation,” Ziegelstein says. “We are proposing specific changes not just at Hopkins, but everywhere.”
In the opinion piece, they write: “Every member of every committee with the authority to select, hire, or promote must recognize the value and importance of diversity as a means to achieve excellence. Participation in efforts that support the recruitment and promotion of URM trainees and faculty should be recognized and rewarded in the promotion and tenure process, regardless of whether those who engage in them are from URM groups.”
They also recommend incentives for faculty members 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.
“We don’t lack good intentions, but we have to wake up and say good intentions are not getting the results we want,” says Ziegelstein. “I am optimistic that systems are being put into place at Johns Hopkins that will effect positive change.”
Some of that work is already taking place in the Department of Medicine, where faculty members are participating in a bias reduction study. And Crews says she’s one of the lucky ones — she gets salary support as a diversity leader, a sign that it is a priority within the Department of Medicine. “Some departments have diversity leaders who are not being compensated for it,” she says.
Crews knows that her work as a diversity advocate can take the focus off her research into health disparities and kidney disease care. The work is so groundbreaking that in 2018, she won the $250,000 Johns Hopkins University President’s Frontier Award, granted each year to a single faculty scholar considered to be on the cusp of transforming their field.
“I am very much a researcher, but until recently, I was more known at Hopkins as a person who does work around diversity than around my science,” says Crews. “In some ways, that troubled me.”
And she still pays that minority tax. “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.’”
Sherita Golden, vice president and chief diversity officer of Johns Hopkins Medicine, strongly agrees, noting that such efforts need to “count” when it comes to assessing institutional service and promotion. “For example,” Golden says, “if a minority faculty member chairs a departmental or institutional diversity council or oversees a minority student summer pipeline program, he or she should not also have to teach in the clinical skills course.” She adds, “Also, as diversity and inclusion work becomes more scholarly and data-driven, it should begin to count toward academic promotion. This will make it more appealing for both minority and majority faculty to engage in these important efforts.”
Meron Hirpa, an Osler internal medicine resident and chair of the House Staff Diversity Council, has made outreach to URM students a part of her life.
“I’ve always been interested in diversity efforts,” she says. “I come from a URM background. I’m of Ethiopian descent and the first physician in my family. As a first-generation immigrant and physician, 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 URM students 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.”
“At Hopkins, I noticed there were not as many URM [house staff] as I would like. I wanted to be involved with recruitment efforts. It didn’t feel like a burden — I’ve always felt a great responsibility to give back to my community. But at earlier points in my career, these things were valued,” she says.
“Now I’m in my last year of residency and applying for jobs. Unfortunately, I’m noticing those efforts are not valued as much as research or clinical work. If I go into academic medicine, publishing more would have helped my career going forward.”
She likes the solutions outlined in the Crews and Ziegelstein article.
“Everyone should be a champion of diversity efforts,” she says. “If an institution truly believes that diversity, equity and inclusion are important and lead to excellence, it needs to be reflected in its promotion and tenure process.”