Are all medical specialities EQUAL?

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I finished studying my medical specialties last year under my MBChB program, and like many people at that stage, I was asked the same question over and over again: So, what are you going to specialize in? It is meant to be a polite conversation starter asked casually, almost playfully, as though the answer is simply a matter of preference, like choosing a favourite colour. But the longer I sat with that question, the more uneasy it made me. Because beneath it sits a far more uncomfortable one: are all medical specialties actually equal?

The uncomfortable truth? They’re not. Not in pay, not in prestige, and certainly not in how society regards them. And yet, what unsettles me most is not that a hierarchy exists, it’s that the hierarchy so often runs directly against what our communities need to survive.

In low- and middle-income countries, the most celebrated specialties tend to be the ones that serve the smallest patient populations. Neurosurgery. Cardiothoracic surgery. Interventional cardiology. These fields are impressive, technically demanding, and publicly admired. Meanwhile, primary care, emergency medicine, anesthesia, obstetrics; the spaces where preventable deaths happen every day are overstretched, understaffed, and quietly devalued. The contradiction is glaring: the specialties that save the most lives carry the least prestige.

Once you notice this, it becomes hard to accept the popular story that doctors simply “choose” where they end up because it forces a harder question: if prestige doesn’t match population need, then who—and what—is shaping those values? We talk about specialization as though it’s driven by passion alone, but choice in medicine is rarely free, it’s never a pure expression of personal passion: you “find your calling,” you “choose your path.” Anyone who’s walked through medical training knows that this freedom is mostly an illusion.

This myth of choice is shaped—sometimes aggressively—by money, policy, and history. In countries without loan forgiveness or livable public-sector wages, debt becomes a silent negotiator. A graduate may genuinely want to work in a rural district hospital, but the arithmetic doesn’t care about ideals. When survival depends on income, lucrative urban subspecialties stop being optional and start feeling inevitable.

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Even when money isn’t the primary barrier, training itself often is. Essential fields like anesthesia or pathology may have painfully limited residency slots, while already saturated specialties continue to expand. Add to that a medical education system inherited from colonial models, designed around tertiary hospitals rather than population health and you begin to see how prestige is taught, not discovered. From early on, students learn which fields are “serious,” which are “fallbacks,” and which are quietly framed as wastes of potential.

The market finishes what history and policy started. Private hospitals create posts where profits are highest. Public hospitals, where need is greatest, are left scrambling for generalists. What we call individual choice is often just people responding rationally to a distorted system. And that distortion is not accidental.

The way specialists are distributed is not a personal failure of young doctors, it is a political one. When governments underfund family medicine, fail to build career pathways in emergency care, or offer doctors in the public hospitals salaries that barely cover living costs, they are making decisions about which lives matter. When brain drain is treated as inevitable rather than preventable, when retention incentives are absent or symbolic, the message is clear: some specialties will be allowed to thrive, others will be left to wither.

Layered onto this are the realities of class. For students from lower-income backgrounds, the barriers are even steeper. Competitive specialties often require unpaid work & research years, international conferences, and insider mentorship, all luxuries not everyone can afford. Talent alone does not level that playing field.

So when we ask whether all medical specialties are equal, we need to be precise about what we mean. They are not equally valued. But more importantly, they are not equally valuable in every context. A rural district does not need another plastic surgeon nearly as much as it needs a general surgeon and an anesthesiologist. A community with high maternal mortality does not benefit from prestige, it benefits from presence, skill, and continuity of care. True equality would mean aligning respect and compensation with population impact, not procedural glamour.

Which brings us to the real provocation. Whose interests does the current system actually serve? When graduates crowd into urban subspecialties while entire regions lack basic surgical access, this is not freedom playing out organically. It is a system performing exactly as it was designed to rewarding profit, prestige, and inherited power over health equity.

Making medical specialties “equal” does not mean flattening differences or pretending every role is the same. It means democratizing who gets to decide what is valued in medicine. It means shifting power away from markets and colonial legacies and toward communities and public health needs.

Until that happens, the hierarchy will remain and it will continue to cost lives and call it progress.