Recent sociopolitical and institutional shifts have eroded support for individuals, teams, and institutions working to achieve health equity—the opportunity for all individuals attain their full potential for health and well-being 1. This backsliding has increased the burdens and risks faced by individual healthcare leaders working to advance health justice. The additional uncompensated work demanded of minoritized individuals to advance diversity, equity, and inclusion (DEI), is commonly referred to as the “minority tax”; the exploration of this tax and its impacts forms the basis of Ordonez et al.'s paper, “A Double-Edged Sword: A Qualitative Study of the Minority Tax in Academic Emergency Medicine Faculty” 2. The sword they describe will feel familiar to those who have led equity efforts in recent years—on one edge, a deep sense of personal fulfillment from values-aligned work, and on the other a substantial emotional and professional cost. This exploration of the challenges of leading equity efforts in academic emergency medicine (EM) reveals systemic failings which, if redressed, hold promise for improving the resilience, professional fulfillment, and career longevity of EM physicians. In this commentary, we highlight some of the authors' most insightful findings, while building upon their recommendations based on our own experience leading programmatic, institutional, and national efforts to advance health justice. Ordonez et al.'s qualitative study explores the lived experience of 21 academic EM faculty leaders engaged in DEI work 2. Their research reveals three primary themes: the mechanisms of the minority tax, for example, uncompensated expectations and symbolic inclusion; the dual impacts on faculty, which include both significant emotional strain and a deep sense of personal purpose; and potential mitigation strategies, including systemic and institutional support as well as equitable distribution of the work. The stories shared by study participants mirror our own lived experiences: feelings of gratitude for the opportunity to lead this work; a deep sense of moral obligation to do so; and often an overlaid feeling that “If I don't do it, no one will, and the initiative will die before it's vetted or heard” 2. This dynamic highlights a critical flaw in our system: even when DEI work is (or was) identified as a hospital or departmental priority and supported with funding and other resources, the burden of operationalizing equity efforts disproportionately falls on those most affected by existing harmful systems—namely, our racially minoritized colleagues. As others have demonstrated, this disproportionate burden to lead health justice work is also common among students and trainees who hold minoritized or marginalized identities; either implicitly or explicitly. Residents are often tasked with serving as “race/ethnicity ambassadors” for their programs 3, and medical students feel pressure to work extra hours to advance their school's diversity initiatives 4, which can in turn affect academic success 5. The experiences reported by faculty in Ordonez et al.'s study 2 highlight the later stages of a career-long path curtailed by systemic inequity. Though not all DEI leadership roles are uncompensated, and not all DEI leaders identify with experiencing a minority tax, Ordonez et al.'s study reveals an important distinction among equity leaders which is again mirrored in our own experiences. While 16 of the 21 participants reported direct experiences with the minority tax, “the five participants who felt they had not experienced the minority tax identified as white and/or LGBTQ+” 2. This should serve as a critical reminder of intersectionality: while all DEI work is demanding, the “minority tax” in its truest form—a burdensome, uncompensated, and often tokenizing expectation—is levied disproportionately on racially and ethnically minoritized people. In identifying health equity leaders, building program teams, and creating structural supports to sustain the people and the work, it is critical that we account for the added pressures of structural and interpersonal racism that impact our racially and ethnically minoritized colleagues 6. Acknowledging that this burden is not uniformly experienced is critical to avoid gaslighting and invalidating the lived experience of our colleagues; failing to do so perpetuates the very inequities we seek to dismantle. Structural change and institutional culture are interdependent and mutually reinforcing; both are needed to mitigate the harms of the minority tax and create more just and welcoming healthcare spaces. The people who lead healthcare institutions, contribute to revising policies, and enforce institutional practices have hearts and minds that can be shaped, learn, and grow. As influential leaders in health equity have reminded us, much of the work of health equity essentially comes down to “convincing people to care about the humanity of others” 7, 8. Leaders—faculty, nurse managers, administrators, and senior residents alike—must lead by example and actively uphold spaces where it is normal to address the isolating and harmful manifestations of structural racism, heteronormativity, and other systems of oppression for providers and patients alike. Recognizing and defending the inherent worth and dignity of each of our patients and each of our colleagues creates spaces in which we can each feel supported and valued. This in turn fosters the delivery of more human-centered healthcare and supports the creation of more equitable systems and structures in which that care is provided. However, no single leader or leadership team—no matter how dynamic, visionary and resilient—can create durable impact in isolation. Organizational cultural shifts that create and sustain more inclusive spaces are necessary but insufficient to creating systems in which each patient and clinician thrives. Structural reforms to shift the conceptual frameworks that constrain institutional practices and incentives, including those that shape who is hired, how decisions are made, what work is rewarded, and with whom accountability lies, are equally necessary. In addition to the recommendations named by Ordonez and colleagues 2, a myriad of examples and guides to equitable structural reform have emerged in recent years 9, 10. It is clear from this body of work that collective efforts are needed to normalize equity work and demonstrate its value—to create systems that ensure each of our patients and colleagues experiences their optimal health. Instead, shifting laws and changes in the enforcement of protective policies at the national and state levels are having clear and measurable impacts on cultural norms in medicine and beyond 11. As Ordonez and colleagues underscore, the “current sociopolitical backlash of DEI in higher education” 2 has reduced human and capital resources for equity work, and led to DEI leaders now facing “even greater scrutiny” for their efforts 2. Particularly as health equity leaders are singled out and targeted, the work to create a just healthcare system must shift from relying on a vulnerable, centralized office or figurehead leader to a “shared responsibility” 2 collectively held by each of us. The familiar phrase of “living in unprecedented times” elicits visceral reactions from many of us, because we recognize the historical parallels—we have been here before—and failing to do so risks allowing history to repeat itself. Over centuries, racism and other interrelated systems of oppression have acted like a multi-headed hydra, ever-evolving and acting through different methods, yet nevertheless reproducing the same stratified outcomes in each generation and each system 12. Like the innumerable people who worked for justice in the centuries before us, when faced with resistance it is natural to feel threatened and fearful. While the instinct to step back for professional and, unfortunately, personal safety is understandable, doing so often comes with a painful sense of betraying both our own values and the people we work alongside. Throughout these challenging shifts in public discourse and increased structural violence 13 in the United States, we see the hurt, we feel the fear, and we walk alongside each of you actively working to dismantle and improve this imperfect system. While fear is certainly contagious, we must remember that so too is courage. Despite recent legislative attacks, many leaders in emergency medicine at national, regional, and institutional levels continue to affirm their commitment to the pursuit of health equity and a diverse physician workforce 14. Throughout these very much precedented times, many have continue to reaffirm their “unwavering commitment to ensuring a diverse and representative emergency physician workforce” 15 and have stated a “unique duty to advance health equity and dismantle systemic barriers to equality” 16. While laws can shutter offices, they cannot erase the moral and professional ethics that compel us in this work toward a more just healthcare system. While we may not achieve health equity in our lifetimes, we must nonetheless continue our work toward this undeniable goal. Ordonez et al.'s work serves as a critical reminder and call to action. It captures the “double-edged sword” of DEI work: deeply meaningful to those who lead it, while simultaneously “emotionally and professionally costly.” In an era where courageous leaders in medicine and broader society face hostile political attacks 11, relying on the moral obligations of those most affected to solve these intractable challenges is not just unsustainable—it is exploitative. The systemic failures reflected in the minority tax demand systemic and shared solutions, not personal resilience. This work of dismantling systemic inequity cannot be the uncompensated, risky labor carried out by a few. It must be a “shared responsibility” 2 championed, resourced, and protected by our institutions. We call on every leader in medicine to act as a courageous steward of medical ethics both publicly and privately, supporting our work toward health justice and ensuring each member of our communities has the opportunity to thrive. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Aviña‐Cadena et al. (Sun,) studied this question.