By Payal Kohli, MD

Within the Indian caste system—the traditional organization of South Asian (particularly Hindu) society into a hierarchy of hereditary groups called castes or jatis—is a system of social stratification. Marriage occurs only within caste, caste is fixed by birth, and each caste is associated with a traditional occupation. Within this system, though, one is able to slowly ascend from one caste to another.

Bear with me as I draw some parallels between this and the medical culture and lay out the medical "caste" system:

• Just as one is born into a caste, we enter into ours automatically without choosing (medical student, intern, resident, fellow, attending).
• Just as there are traditional occupations within each caste, there are traditional roles assigned to us at each level of our caste system (pre-rounding, doing rectal exams, etc.).
• Just as one marries within one's caste, we automatically tend to socialize within our own caste. Seeing a medical student and a fellow having dinner together, for example, is quite uncommon.

Due to its inherent flaws and social injustice, even a culture as old as the Indian culture has done away with the "caste" system, which existed in the country for so many years. So why do we as a profession continue to dogmatically hold on to it? Does its presence make us afraid to speak up in the workplace when social injustices do occur?

As far back as I can remember, I have dutifully followed through on the expectations of my caste, no matter how unreasonable, as laid out to me by those in a caste above mine.

Let's start with my third year of medical school. One of my responsibilities was to tear myself away from whatever educational activity I was doing on-call to run to the basement of Massachusetts General Hospital at 9 pm with an empty cart. I would wait in line for 10–30 minutes—depending on how fast I could beat the crowd—only to collect 15 dinners (the infamous "9 o'clock meal") to bring back to my residents, who couldn't be bothered to interrupt their work to get dinner themselves. If I got the wrong kind of soft drink or forgot some utensils, I was promptly sent back, much like a butler. I don't suppose this activity was advertised as an educational experience in the Harvard Medical School course catalog, was it? I guess I shouldn't complain, the lowest caste in India is called the "untouchables" and is responsible for janitorial duties. I suppose this was a tad better than that.

As I moved on to the next higher caste (intern year), there were fewer unreasonable requests, and more of the typical "scut" expected from me. For example, no matter how many women I had already seen with abdominal pain in the ED during a shift, I was always "assigned" the young woman who needed a pelvic exam by one of the senior residents there. I kept my head down. I was in a lower caste and I expected it—partly because I felt as if these "rites of passage" would eventually end, with me having proven my worth to the higher castes.

Now, having entered the next higher caste as a fellow, I find myself at the bottom of the food chain once again, feeling as if I have to start my climb through the medical hierarchy once more. I continue to bear the brunt of my position within the hierarchy, having to assume the responsibilities of my attendings (such as fielding calls from their outpatients and filling prescriptions for them on nights and weekends). But the caste system becomes especially palpable when attendings lash out at fellows, being abusive and unprofessional, without consequence because of their privileged position.

I found myself in this situation recently, when an attending shouted multiple expletives at me in the middle of the night because his patient's medical condition had unexpectedly worsened (due to no fault of mine). I sat quietly and listened, paralyzed to do anything except cry and apologize for something that was out of my control. Even now, I cannot bring myself to complain about him because my position within the medical caste system doesn't provide me immunity or guarantee that I will be supported. I hardly want to compromise my reputation and my career.

My inability to address this type of unprofessional and disrespectful behavior within the workplace gives me pause. Why is medicine so hierarchical? Granted, some degree of hierarchy is necessary for protecting patients and training people safely, but is it too much? Are other fields like this? And, as we graduate from one level to the next, are we getting closer to being free of the hierarchy and "hazing" that occurs at each step of the way?

Even in a college fraternity—the pinnacle of hierarchy—the hazing ends after a few years. Yet, the fraternity of medicine remains much different. Every time we jump though one hoop, there appear to be infinite more ahead of us. This July, as the beginning of a new year dawns, I wonder, is it time we stopped jumping?

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Payal Kohli, MD, graduated from MIT and received her MD from Harvard Medical School. She completed her internal medicine residency at Brigham and Women's Hospital in Boston and was a research fellow at the TIMI Study Group. Dr. Kohli is now a clinical fellow at the University of California, San Francisco.

Keywords: Outpatients, Abdominal Pain, Culture, India, Occupations, Students, Medical, Workplace, Hospitals, General

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