Not All Medical Specialities Are Equal: The Unspoken Caste System in Medicine

Classism in society is often discussed along with how it should be abolished. But little attention is given to classism that exists within medicine. Two doctors who completed MBBS, cleared the same NEET-PG exam, and spent a similar number of years in post graduate training are often not treated equally either by society or even by their peers. This discrimination exists on multiple levels.

Why Are Some Medical Specialities Considered More Prestigious Than Others?

The most obvious form of discrimination relates to the speciality chosen and whether government or private quota was taken for postgraduate training. Government seats in medical and surgical branches are generally considered as the highest tier, followed by private clinical branches. Then comes government diagnostic branches and finally private diagnostic seats. The top tier has a layer of discrimination too. Among the clinical, patient facing branches, ENT, ophthalmology, and psychiatry are considered less prestigious than the others. Whereas, even though radiology is primarily a diagnostic branch, it is frequently considered in the top tier due to the opportunities in interventional radiology and the high income associated with the branch. Prestige in this context does not necessarily link to the skill set or knowledge required for the branch, but is more often determined by factors such as patient interaction, income, and public visibility.

This pattern is not unique to India. Cross-country research also finds a similar ranking. A Swedish study using Bourdieu's framework of social capital found surgery ranked as the most prestigious speciality, whereas psychiatry and geriatrics ranked lowest.¹ Another survey research in the United States reveals a similar conclusion, finding that income and perceived social status contributed to the perceived prestige more than the complexity of the speciality.²

NEET-PG Scores and the Perceived Hierarchy of Medical Specialties

An interesting point here is that, although it is often perceived that a clinical seat requires higher NEET-PG scores compared to diagnostic branches, in reality, someone who takes the diagnostic branch in government college may have a higher NEET-PG score than a candidate who secures the clinical branch in private colleges.

Government vs Private Medical College: Does the Bias Continue After Graduation?

A graduate from a government college and another from a private college working in the same government hospital are often not treated as equals either. Doctors who graduate from a government college are perceived to be superior and more credible than those who do not. This discrimination can be seen in rounds, referrals, and how seriously their opinion is taken by their peers.

How Speciality Hierarchies Influence Career Choices and Healthcare

The consequences of this classism, or what some may even consider as a caste system within medicine, are evidently seen as a shortage of doctors, especially in those specialities that are perceived as inferior across India. Family pressure, peer opinion, and fear of being judged or discriminated against by fellow medical professionals are a few of the reasons why young MBBS graduates hesitate to choose these specialities.

A 2024 review of 88 studies on India's health workforce found a persistent, inequitable shortage of health personnel. It was found that rural areas and some specialities were the most affected, and job dissatisfaction, poor recognition, and regulatory failures were cited as the probable causes.³

If this trend continues, there is a high possibility that these branches might face a serious dearth of specialists due to lack of opportunities and respect. In this era of evidence-based personalised medicine, this could result in low-quality reporting of test results, leading to poor patient care and outcomes.

No Medical Speciality Can Exist in Isolation

Ultimately, no speciality exists in isolation. Any clinical specialist depends on radiologists, pathologists, biochemists, and microbiologists to confirm the patient's diagnosis and provide quality care.  When one branch is viewed as inferior, the entire healthcare system suffers. Dismantling these hierarchies, therefore, is a necessity and of utmost importance for ensuring a sustainable and high-quality healthcare system for the future.

References

1. Olsson, Caroline, S. Kalén, and S. Ponzer. "Sociological Analysis of the Medical Field: Using Bourdieu to Understand the Processes Preceding Medical Doctors' Speciality Choice and the Influence of Perceived Status and Other Forms of Symbolic Capital on Their Choices." Advances in Health Sciences Education 24 (2019): 443–457. https://doi.org/10.1007/s10459-018-09872-3 .

2. Rosoff, Stephen M., and Matthew C. Leone. "The Public Prestige of Medical Specialties: Overviews and Undercurrents." Social Science & Medicine 32, no. 3 (1991): 321–326. https://doi.org/10.1016/0277-9536(91)90110-X.

3. Mehta Vini, Puneeta Ajmera, Sheetal Kalra, Mohammad Miraj, Ruchika Gallani, Riyaz Ahamed Shaik, Hashem Abu Serhan, and Ranjit Sah. "Human Resource Shortage in India's Health Sector: A Scoping Review of the Current Landscape." BMC Public Health 24 (2024): 1368. https://doi.org/10.1186/s12889-024-18850-x.