A recent study by Simons et al showed that from 2007 to 2020 the proportion of underrepresented minority (URM) residency applicants increased slightly, but the proportion of URM urology residents remained unchanged.¹ Furthermore, the representation of these diverse groups was low at the faculty level. The study indicated that there was a “leaky pipeline,” and this was further evidenced by a stepwise decrease in the proportion of URM members represented at each stage of the educational pipeline from college to faculty (p <0.0001).¹ Using American Urological Association Census data, we previously analyzed rates of academic promotion among women and URMs in urology. Although fewer women achieved associate professor or professor ranks compared to men, sadly, there were too few URM faculty to analyze.²

The findings of these studies illustrate that current efforts to cultivate interest in medicine, urology and academic urology have largely been unsuccessful. In recent years, many urology programs have created Diversity, Equity and Inclusion (DEI) committees. These committees are designed to accomplish several goals. These goals include opportunities for students to pursue away rotations in urology, research programs, the promotion of diversity within the faculty themselves and mentorship programs.

Many of these DEI committees rely on their URM faculty members to help energize these efforts. The term “minority tax” has been introduced in recent academic literature to refer to disparities in diversity efforts, clinical assignments and mentorship for URM faculty.³ The American Psychiatric Association’s Presidential Task Force describes minority tax 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.” Here, we further illustrate the burden of the “minority tax” described by Pololi et al⁴ and how it relates to urology.

Many URM faculty members feel an internal obligation to their communities. They often volunteer and/or are asked to serve on DEI committees that aim to increase representation of URMs in their program.⁵ Faculty who participate in these efforts feel conflicted, as these pursuits do not hold equal recognition to other academic efforts when evaluated by others. Additionally, their extra work may go uncompensated when compared to time spent on clinical volume or grant submissions.⁴ This disparity points toward a need to not only promote a faculty’s work on these efforts but also include this in their promotional file and in some instances provide financial compensation. These financial models have been successful in departmental leadership roles for quality improvement, residency program director and fellowship program director positions.⁶

Similarly, many URM faculty feel a responsibility to caring for underserved populations. It is common for patients from underserved communities to have no insurance or insurance with a low level of reimbursement.⁷ Depending on an institution’s compensation model, this may unfairly be a detriment to a URM faculty’s clinical revenue when compared to their peers.⁸ This may further disadvantage URM faculty as they may need to see a greater volume of patients to generate an equal salary. Some academic institutions have moved toward a work relative value unit to successfully mitigate this disparity.⁹

Mentorship is an essential component of success in academics.⁵ Mentorship has an important role in career development, grant applications, research and general advice. Mentorship also helps guide URM faculty toward promotion in their careers. Few institutions have URM faculty in senior mentorship roles, and thus nonURM senior mentors have taken on this responsibility. It is important that those mentors be consciously aware of the unique challenges and struggles URM faculty feel to avoid a pattern of isolation.

Ultimately each institution will have its own unique structural problems that they must address, and this requires thoughtful and strategic planning. Structural change includes acknowledging that URM faculty are vulnerable. Institutions must be prepared to promote emotional, intellectual, financial and environmental wellness. Change starts by engaging them, listening to their needs and investing in them, which will in turn empower them to be successful.