As I began interviewing for my first post-fellowship position as a neuro-oncologist, I immediately realized that I could work in private practice and earn a great salary or make a lot less by opting to work in a teaching hospital where I could do research and help train new doctors. In the end, I took a job in a teaching hospital that gave me the time, resources, and support to pursue a career in health equity.
But as a first-generation Guyanese physician, the decision wasn’t easy — especially about the salary.
I’m not alone. Every year thousands of physicians must make this same decision when they consider pursuing a career in academic medicine. But it weighs heavier on Black, Indigenous, and people of color (BIPOC) physicians, who are less likely to have generational wealth and are often saddled with significant student debt. That’s reflected in the makeup of today’s physician pool: Black, Latinx, and Native American physicians make up 11.1% of the total physician population and 9.3% of medical school faculty, though they account for 31.7% of the U.S. population.
While compensation is not the only barrier to diversity in academic medicine, it is one of the biggest.
It’s a privilege to be a physician. It’s also a privilege to be financially and professionally secure enough to undertake the path to becoming a physician, which includes four years of medical school and a minimum of three years of residency, and lasts even longer for those pursuing Ph.D.s or fellowships for certain specialties. And this doesn’t take into account what premedical students often pursue to become competitive applicants, which can include years of volunteer or service-based work.
All that preparation costs money. It’s not just the direct cost of medical education, but also the added fees for test prep, applications, and examinations, not to mention the costs of traveling for medical school and residency interviews.
Then there’s the opportunity cost: years of income lost while paying out exorbitant tuition. Investing $300,000, the cost of attending many medical schools, in an index fund mirroring the S&P and making a 10.5% annual return would yield more than $800,000 in 10 years.
For many, becoming a physician is still a worthwhile investment. Once you’re in the club, you can make a better living than most Americans, though for many young physicians like me, that goal is long delayed. I maxed out my credit cards to pay for traveling to medical school interviews. The interest accumulated until I could use the student loans I obtained to pay off my credit cards, trading one debt for another. Later, I used my salary as a resident and a fellow to settle costs, begin paying off school loans, pay for professional fees, and help my family. Student loans — which I’ll be paying off for another decade — are the largest accounts on my credit report and the biggest hindrance to purchasing my first house.
So it was a tough decision to join the ranks of academic medicine and take a lower salary. It was a decision I could make because I’m part of a dual-income household. But many in my position can’t choose that option.
Over the past few years, there has been a renewed focus on the importance of diversity within medicine, with many academic medical centers expressing sentiments supporting inclusion, diversity, equity, antiracism, and social justice (IDEAS) efforts.
BIPOC will continue to be underrepresented in this field for the next few years, given that the pipeline of future physicians reflects the country’s current imperfect institutions, with many students filtered out from consideration of a medical career before the end of high school.
But I believe there are ways to begin closing the representation gap in academic medicine and medical school faculty now.
One solution is to increase the compensation of academic physicians. While they generate less revenue for hospital systems and medical organizations than physicians who mainly see patients, conducting medical research and teaching new physicians is important work that deserves to be compensated fairly. An overall increase in compensation would help make this career choice attainable for those without significant resources.
Another option is targeted funds and grants to attract first-generation or BIPOC physicians. This could be done based on need. New faculty recruits could fill out financial forms to determine eligibility for this kind of funding, or it could be done through a proxy indicator, such as qualification for federal Pell Grants. Other programs could include robust loan repayment programs that work in addition to federal options, mortgage-assistance programs, housing subsidies, and sign-on bonuses.
Transparency about compensation is also important. I’m not referring just to the overall compensation, but what goes into it. BIPOC physicians bear the “minority tax,” and are often asked to undertake many unpaid obligations, such as serving on diversity committees and antiracism task forces. While important work, it takes away from time that could be spent on academic productivity or clinical work. Time and effort served on these committees and tasks forces should be compensated.
Transparent salaries would also help address the gender wage gap. The Association of American Medical Colleges offers access to its faculty salary report for $1,150 for non-members; providing this service for free to prospective and junior members would help mitigate the asymmetry in salaries.
Where will this money come from? This is where the nation’s leading institutions in academic medicine need to set an example. Mass General Brigham, Mayo Clinic, Cleveland Clinic, and Cedars-Sinai all reported hundreds of millions of dollars in operating income (profits) last year. More than 40 universities with endowments of more than $1 billion each are associated with medical schools. The combined endowments of Harvard, Yale, Stanford, and the University of Pennsylvania clock in at more than $120 billion. Institutions like these have the money to invest in programs and initiatives that recruit and retain BIPOC faculty members.
National agencies also need to set an example, particularly to help academic medical centers that may not have the financial flexibility to invest in supportive programs. The National Institutes of Health, which provides a significant portion of research funding in the U.S., has a diversity program consortium. Increased funding for this program could be used to support researchers of diverse backgrounds at institutions lacking financial resources. For teaching hospitals, the graduate medical education program under Medicare provides salaries for resident physicians. An increase in this program’s funding could be used to support diverse teaching faculty. Both of these suggestions draw upon the continued commitment of the federal government to improving diversity and advancing equity.
While statements of solidarity emphasizing IDEAS are helpful, talk is cheap. It’s time to pay up.
Joshua A. Budhu is a neuro-oncology fellow at the Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Massachusetts General Hospital, and a Commonwealth Fund Fellow in Minority Health Policy at Harvard University.