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Taxes, Subsidies, and Road Hogs: Minority Groups Are Still Underrepresented in Orthopaedics


Taxes, Subsidies, and Road Hogs: Minority Groups Are Still Underrepresented in Orthopaedics

by Melissa Erickson, MD, FAAOS and Andrea Goodwin, MA, MS, AAOSNow, October 2020

Medicine would benefit from an increase in diversity. Although lack of diversity is multifactorial, literature has shown that within academia, women and faculty of color experience similar inequities, as do those of different sexual orientation and less advantaged socio-economic backgrounds. Patients, trainees, and physicians continue to experience health care differently based on race, ethnicity, gender, sexual orientation, socioeconomic background, religion, and disability. Although we recognize the unique experiences associated with membership in a marginalized group based on any of the previously listed demographic categories or the intersectionality of multiple categories, for the purposes of this article, members of those groups are collectively referred to as “minorities.”

Minorities experience disproportionately more micro- and macroaggressions, as well as implicit and explicit biases, compared to their majority counterparts. This can result in poor patient care, decline in clinical performance, burnout, and attrition. Several diversity initiatives at the national level have tried to address the various disparities. Multiple orthopaedic societies have assembled diversity committees and task forces for their practicing members. Also, an increasing number of orthopaedic residency programs have diversity and inclusion committees to enhance efforts directed at trainees at the residency and medical school levels. Despite these efforts, the number of minorities in orthopaedic surgery is far from reflective of the patient populations served.

The history

In an attempt to increase diversity, institutions frequently position minority representatives on the “front lines” of diversity committees and recruitment efforts. At first glance, this trend seems positive, as it often demonstrates visible progress that is appreciated by potential candidates. This also serves as a means to garner input from minorities to identify issues of which majority members lack firsthand experience or awareness. Often, minorities are passionate about participating in such groups because it offers a way to share perspectives and solutions that can help those who follow. However, there are potential issues with this strategy.

Frequently, minorities are asked to serve on multiple committees. For example, when filling academic tenure-track positions, many search committees are specifically required or highly encouraged to include a member who represents or specifically addresses diversity. This comes with associated time commitments. When studying the “invisible work of academia,” the University of Oregon found additional inequality with regard to faculty of color, queer faculty, and faculty from working-class backgrounds.

“Cultural taxation” was initially coined to describe this burden minorities carry to address diversity-related issues. The increased responsibilities placed on minorities in the name of efforts to improve diversity result in a minority tax. Although the concept of taxation theoretically applies to all, the minority tax disproportionately falls on minorities in multiple ways. Rodriguez et al., discussed racial inequities seen in diversity efforts, racism, isolation, mentorship, clinical duties, and promotion. These and other studies have shown that although the responsibilities associated with the minority tax were developed in response to fixing disparities, the time and energy consumed by those activities detract from time that can be spent on research and other scholarly endeavors necessary for career advancement. Those activities are often not necessarily valued as contributory factors in evaluation for promotion or tenure.

Denker et al., explored this concept as it applies to gender by citing the “masculine” activities of research and administration compared to the “feminine” activities such as teaching and service. The burden of those devalued activities can create the counterpart of the minority tax, known as the “majority subsidy,” which allows majority members to have more time and opportunity to advance their careers through the traditional means of research and publication, while minorities are left to “fix diversity.” This creates a vicious cycle and perpetuates the disparities seen in medical education, academic promotion, and leadership.

Current situation within orthopaedics

Orthopaedic surgery has historically struggled with diversity. AAOS, multiple subspecialty groups, and residency programs have invested in diversity initiatives, yet progress is slow. The “leaky pipeline” is evident, marked by a gradual dropout of women and individuals of color at each stage in clinical care and academia. In 2019, 50.5 percent of enrolled medical students were women, and there were incremental increases in the number of underrepresented minorities (6.3 percent Hispanic/Latino/Spanish origin, 3.2 percent Black/African American, 5.5 percent American Indian/Alaska Native). Comparatively, the 2018 Orthopaedic Census Survey reported that 7.6 percent of practicing orthopaedists were women and 15.3 percent were nonwhite (including 6.7 percent Asian). There are currently three female chairs among 190 orthopaedic surgery residencies in the United States.

The data have spawned multiple conversations. In a relatively homogenous specialty, and in light of current events, these conversations can be uncomfortable for most. The temptation is to take the path of least resistance and mind one’s own business, even when witnessing discrimination. It is easier to remain silent, especially if the offender is a colleague, friend, or person with more seniority. One can rationalize, “I am not a person of color, female, LGBTQ (lesbian, gay, bisexual, transgender, and queer [or questioning]), disabled, in a disadvantaged socio-economic class” or “The discrimination was not directed at me.” This is known as the proverbial “staying in one’s lane.” These and other justifications are evident in the explanation, “I personally have never had that problem.”

Addressing lack of diversity is challenging, and it can always be passed on as someone else’s problem. However, it is critically important for the health and well-being of our colleagues, trainees, and patients. This is not about us as individual orthopaedists. This is about us as a community of orthopaedic surgeons with the opportunity to pursue progress and excellence in caring for our patients and colleagues. Engage in the conversations, learn about your biases, intervene when you see discrimination, value minorities who take on the additional “taxation” with promotion/compensation, advocate for minorities, and encourage those you mentor to do the same. Do not stay in your own lane: Hog the road—this is everyone’s lane.

Melissa Erickson, MD, FAAOS, is an orthopaedic spine surgeon at Duke University and an MBA candidate in the Fuqua School of Business. Her general research interests include healthcare disparities in patients and providers.

Andrea Goodwin, MA, MS, is a sociology PhD student at the University of North Carolina at Chapel Hill and a predoctoral trainee in the Carolina Population Center’s biosocial training program. She is a scholar of medical sociology and the sociology of health and well-being, and her general research interests include social stratification’s association with health disparities in the U.S. context.


  1. University of Oregon Social Sciences Feminist Network Research Interest Group: The burden of invisible work in academia: social inequalities and time use in five university departments. Humboldt J Soc Relat 2017;39:228-45. 
  2. Padilla AM: Research news and comment: ethnic minority scholars; research, and mentoring: current and future issues. Educational Researcher 1994;23:24-7. 
  3. Rodriguez JE, Campbell KM, Pololi LH: Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ 2015;15:6.  
  4. Denker KJ: Doing gender in the academy: The challenges for women in the academic organization. Women and Language 2009;32:103-12. 
  5. Ziegelstein RC, Crews DC: The majority subsidy. Ann Intern Med 2019;171:845-6.