Impact of ‘Minority Tax,’ Need for Diversity in Academia Discussed at APA’s Fourth Town Hall

Structural racism has led to a lack of diversity in the psychiatric academic workforce and needs to be addressed, said panelists in the fourth online town hall meeting hosted by APA’s Presidential Task Force to Address Structural Racism Throughout Psychiatry last month. The panelists also described the impact of the “minority tax,” defined as extra, financially uncompensated duties and responsibilities that minorities are asked to perform to increase diversity at their institutions, such as serving on a search committee that would otherwise be all White.

“[The minority tax] is a major source of inequity in academic medicine. … It is one of the major factors in delaying promotion for us in academia,” said Sheritta Strong, M.D., director of inclusion and an assistant professor of psychiatry at the University of Nebraska Medical Center. She added that when there is a lack of mentorship by minority psychiatrists, psychiatrists and residents who are members of ethnic and racial minorities may fall prey to accepting roles that may be “tokenized” and incorporate activities that are not recognized for promotion.

“Often residents will describe feeling pressured to be involved in things and to do more within their communities. It can be hard to say no,” said Nicole Pacheco, M.D., an APA/APAF SAMHSA Minority Fellow, chair of the Minority Fellowship Program, and a psychiatry resident at Columbia-New York State Psychiatric Institute.

Pacheco described the following four domains where leadership is necessary to increase diversity:

Nhi-Ha Trinh, M.D., M.P.H., director of the Psychiatry Center for Diversity in the Department of Psychiatry at Massachusetts General Hospital, emphasized the necessity of tailoring mentorship.

“[It] is very important [to] focus on the individual trainee and junior faculty member regarding their academic pursuits, the time they can devote to those pursuits, and also what their individual career path might be, which may be different from what the mentor or sponsor might envision,” Trinh said.

“Creating a nurturing environment through representation; being very clear about the values and policies, both written and unwritten, in our programs; and having a zero tolerance policy regarding bias and discrimination toward our trainees, staff, and our patients [is essential],” Trinh added.

Crystal Clark, M.D., M.Sc., an associate professor of psychiatry and behavioral sciences and obstetrics and gynecology at the Northwestern University Feinberg School of Medicine, said that the pipeline for bringing more trainees from minority and underrepresented populations into psychiatry as a career does not begin in medical school.

“We have to get down to primary education, really. To achieve that [comes down to] finding a way to be more present in the community, finding a way to reach out to young students in high school and even elementary school … so that [mental illness] is not seen as a horror that can happen to you but is seen as just one of the many health conditions that someone might suffer from.”

Clark described how structural racism works against minority and underrepresented groups from childhood and narrows the medical school pipeline. She said that it begins with redlining, the discriminatory practice of denying financial and other services to residents of certain areas based on their race or ethnicity.

“The aftermath of that means there are underresourced neighborhoods where a disproportionate number of African Americans, Hispanics, and other underrepresented groups live … that led to disadvantages and disparities in education,” Clark said. She explained that schools in these neighborhoods often lack the resources to provide adequate education so that children may test into desirable secondary and high schools that will prime them for college and graduate or medical school.

“If there’s [only] a few of us getting into medical school, that leaves a small pool of us to consider a career in psychiatry,” said Anthony Kulukulualani, M.D., an APA/APAF Jeanne Spurlock Congressional Fellow and a psychiatry resident at the Brody School of Medicine at East Carolina University. He added that medical school curricula may diminish psychiatry and offer less exposure to it compared with other specialties. “There’s a stigma that we wouldn’t be viewed as real doctors within our profession as well as within our communities.”

Michael Mensah, M.D., M.P.H., APA’s resident-fellow member trustee and co-chief resident in the University of California, Los Angeles Department of Psychiatry, expanded on the dearth of underrepresented minorities in psychiatry, notably in academic psychiatry departments. He said there hasn’t been much change since 2007.

“Part of the issue is that we don’t have an abundance of ways for departments to recruit residents internally to become faculty,” Mensah said. “We don’t necessarily have programs to help residents to do the research necessary to qualify them for faculty [positions].”

“No one is talking about the issues that Black and Brown residents encounter within clinical practice, and as a result there is a huge disconnect between faculty and residents such that residents don’t feel like they want to be a part of faculty. They feel this is not a place for them,” Mensah added.

“It doesn’t take just singular commitment at the level of each individual person, but institutions themselves have a responsibility,” said Gabriel Felix, M.D., an APA/APAF Public Psychiatry Fellow and adult psychiatry resident at Cambridge Health Alliance/Harvard Medical School.

Mensah emphasized the need for residents and faculty in minority and underrepresented populations to ensure their own well-being as a counterbalance to the minority tax.

“You’re a valuable member of your community. You need to preserve yourself and make sure you are feeling healthy enough to take care of your patients and yourself,” Mensah said. “Don’t overwhelm yourself with this responsibility. If you burn out as a result of anti-racist work, that is a loss to your community that really can’t be replaced.”

A question-and-answer session after the panel discussion was moderated by task force member and APA Trustee-at-Large Michele Reid, M.D., a clinical assistant professor in the Department of Psychiatry and Behavioral Neurosciences at Wayne State University in Detroit and the chief medical officer of CNS Healthcare.

The next town hall will take place on May 1 from 4 p.m. to 5:30 p.m. as part of APA’s online 2021 Annual Meeting (see Psychiatric News). ■

Archived recordings of the town halls held to date are posted here.