INTRODUCTION Medicine has a complicated history with diversity. Only recently have U.S. medical schools seriously invested in diver- sity, equity, and inclusion (DEI) eforts, with outcome metrics that are slow to improve and evidence of impact that is modest at best [1]. Te U.S. physician workforce does not refect the diverse patient populations it serves, and it may take decades for medical schools to fully correct that disparity [2]. Not surpris- ingly, this gap is notable among medical school faculty members in particular. Of the approximately 176,000 full-time faculty members in U.S. medical schools, a dishearteningly low pro- portion are underrepresented in medicine (URM)—only 3.6% are Black or African American and 3.2% are Hispanic, Latino or of Spanish origin [3]. Te already low numbers of URM faculty members are further reduced in leadership roles and at higher professoriate ranks [3, 4]. One theory for the disproportionately low number of URM faculty in medical school leadership is ‘minority tax’ [5]. Minority tax is defned as the burden of time and resources placed on minority persons to represent and advocate for their communities [6]. It is characterized by the synergistic efects of cultural isolation, lack of mentorship, disparities in clinical assignments, and additional responsibilities that hinder career advancement for those who are URM [7]. Combined with the high number of requests to represent URM persons in various workplace initiatives and experiences of discrimination, these stressors reduce time for scholarship and other activities ofen required for promotion in the professoriate [8, 9]. Tough minority tax has been examined previously among faculty cohorts, related studies suggest that the experience and efects of the minority tax may begin as early as medical school [10, 11]. Previous studies have shown that while URM medical JOURNAL OF WELLNESS ORIGINAL RESEARCH 1 ©JWellness 2022 Vol 4, (1) *Correspondence To: Marija Kamceva Email: mkamceva@partners.org Copyright: © 2022 The author(s). This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. More Work, Less Reward: The Minority Tax on US Medical Students Marija Kamceva, MD 1 , Bafour Kyerematen, MD 2 , Sabina T. Spigner, MS, MPH 3 , Samuel Bunting, MD, MS 4 , Simiao Li-Sauerwine, MD, MSCR 5 , Jane Yee, MD 6 , Michael A. Gisondi, MD 1 https://doi.org/10.55504/2578- 9333.1116 Received Date: Dec 13, 2021 Revised Date: Apr 13, 2022 Accepted Date: May 05, 2022 Publication Date: Aug 29, 2022 Website: https://ir.library.louis- ville.edu/jwellness/ Recommended Citation: Kamceva, Marija; Kyerematen, Bafour; Spigner, Sabina; Bunting, Samuel; Li-Sauerwine, Simiao; Yee, Jane; and Gisondi, Michael. (2022) "More Work, Less Reward: Te Minority Tax on US Medical Students," Journal of Wellness: Vol. 4: Iss. 1, Article 5. Afliations: 1 Stanford University School of Medicine, 2 University of Oklahoma College of Medicine, 3 University of Pittsburgh School of Medicine, 4 Te University of Chi- cago, 5 Te Ohio State University, 6 University of Utah Introduction: Minority tax is defned as the burden of time and resources placed on minority persons to represent and advocate for their communities. We determined whether medical students underrepresented in medicine (URM) or from historically excluded (HE) populations experience a minority tax and charac- terized its efects. Methods: Tis cross-sectional survey of US medical students occurred November 2020 - June 2021. We used Mann-Whitney U tests to compare metrics between URM and HE participants and their peers. Te primary outcome was time invested in activism/diversity initiatives versus other work. Secondary outcomes included measures of microaggressions, discrimination, institutional culture, anxiety/depression, mentorship, and sleep. We performed thematic analysis of open-ended questions about participants’ experiences with minority tax. Results: A total 282 students included 39 (13.8%) URM and 150 (53.9%) HE participants. Compared to peers, URM and HE participants invested an additional 36.4 (p = 0.005) and 46.8 (p = 0.006) annual hours on advo- cacy and 62.4 (p < 0.001) and 41.6 (p = 0.001) annual hours on diversity initiatives, respectively. URM and HE participants reported more microaggressions / discrimination, less inclusive environments, and no dif- ferences in access to mentorship or sleep. Six themes were evident: (1) URM and HE students feel obligated to do diversity, equity, and inclusion (DEI) work, (2) students doing DEI work experience minority tax, (3) minority tax is negatively associated with wellness, (4) learning environment changes may mitigate minori- ty tax, (5) there is a demand for increased representation and improved DEI education, and (6) an increased DEI budget might reduce the minority tax for students. Conclusion: URM and HE medical students experience a minority tax that may afect their wellbeing. Tese fndings should serve as a call for action by medical school leaders. ABSTRACT JOURNAL OF WELLNESS ORIGINAL RESEARCH