In healthcare, the concepts of equality and teamwork are essential for the functioning of medical services. However, an underlying issue that disrupts this dynamic is ‘gradism’ – a form of discrimination or bias based on professional grade or rank. This often-unspoken phenomenon, although not recognised legally, affects various medical professionals, especially those in SAS (specialist, associate specialist, and specialty) doctor and dentist roles.

SAS doctors are a crucial part of the NHS workforce in the UK, contributing years of experience and expertise to patient care. Despite this, they often face challenges related to their career progression, professional development, and recognition.

While gradism can manifest in any profession, it is particularly prevalent in hierarchical structures like medicine, where the consultant-grade doctors hold more power and influence. On a day-to-day basis, gradism can manifest as subtle attitudes and systemic barriers that undervalue the contributions of doctors who are not consultants and not in training, like SAS doctors. 

The role of SAS doctors

SAS doctors occupy a unique position in the medical hierarchy. They are experienced physicians who often have the same clinical skills and responsibilities as consultants but without the same formal title or career pathway. SAS roles are highly varied, including:

• specialists and associate specialists who are senior doctors working with a high level of autonomy
• specialty doctors, who have chosen not to pursue consultant-level training for various reasons, such as work-life balance, a desire to specialise in particular areas without pursuing a full consultant role, or having had barriers that prevented them from completing traditional training programmes.

Despite their essential contributions, SAS doctors frequently find themselves marginalised due to gradism. 

How gradism affects SAS doctors

The consequences of gradism for SAS doctors are profound, affecting both their professional and personal lives.

1. Limited career progression opportunities, such as leadership roles: Of the 149 trusts that responded to a freedom of information request from the BMA, over 33% confirmed that not a single SAS doctor held a leadership or extended role within their trust.
   
   Many SAS doctors feel they are in a ‘career cul-de-sac’. The pathway to becoming a consultant is often the most prestigious and recognised, while SAS roles are seen as static. This glass ceiling can be disheartening for doctors who possess vast expertise and years of experience. This hierarchy, not based on skills or ability, can lead to fewer opportunities for leadership roles, research involvement, or professional development courses, reinforcing a sense of being ‘stuck’ in their careers.
   
   Additionally, some SAS doctors who wish to progress to consultant roles face administrative barriers or are not given the same level of support and mentoring as trainees on the traditional consultant track.
   
   
2. Lower pay and benefits: Despite performing similar work to consultants, SAS doctors often receive lower pay and fewer benefits. They are not entitled to the same perks as those on the consultant pay scale, leading to financial inequality that is hard to justify considering the demands of their job. The pay gap is enhanced further as many SAS doctors do little or no work in the private sector.
   
   Despite performing similar duties to consultants in many cases, SAS doctors frequently face significant pay gaps. The financial disparity between SAS doctors and consultants is not only a matter of salary but fewer opportunities for bonuses, awards, or formal recognition of their work. The devaluation of SAS doctors’ contributions can lead to dissatisfaction and resentment, particularly when they see their consultant colleagues being rewarded for tasks they also perform. In addition, they may not be able to provide the same work that they do in NHS hospitals outside the NHS.
   
   
3. Undervaluation of clinical expertise: Gradism often leads to an undervaluation of the clinical expertise of SAS doctors. They may have years, sometimes decades, of experience in their field, but this is not always recognised or respected by their consultant counterparts. This can lead to an environment where SAS doctors feel their opinions are not valued in decision-making processes, even in cases where their experience could be highly beneficial. SAS doctors may be excluded from critical team meetings, discussions or decision-making, despite their expertise. 
   
   
4. Workplace dynamics and culture: In many hospitals, gradism creates a subtle yet palpable divide between consultants and SAS doctors. This can manifest in unequal distribution of tasks, with SAS doctors often being allocated less desirable or more routine work, despite being capable of handling more complex cases. The work output of SAS doctors is frequently not coded in their names, making them feel invisible.
   
   The hierarchical culture can also foster an environment where SAS doctors feel hesitant to speak up or advocate for themselves, fearing further marginalisation. In a 2022 BMA survey, 43% of SAS doctors reported they had been bullied at least once in the previous 12 months and 75% of them felt this was because of their grade.
   
   
5. Barriers to professional development: SAS doctors often face more obstacles when it comes to accessing professional advancement either by blocked study leave requests or undermining their methods to develop by de-skilling them.
   
   The GMC’s ‘Fair to refer’ report says SAS doctors may experience professional isolation because they are often excluded from decision-making processes and are less involved in key discussions about patient care. This exclusion can lead to a sense of detachment from the team and a feeling that their contributions are not valued. 
   
   
6. Lower wellbeing: One of the most detrimental effects of gradism is the toll it takes on the mental health of SAS doctors. Being constantly devalued or overlooked can lead to feelings of frustration, isolation, and burnout. Many SAS doctors report feeling stuck in their roles, with little opportunity for career advancement or personal growth. The lack of acknowledgment and respect can also cause anxiety and depression, further exacerbating the already high stress levels common in the medical profession.
   
   
7. Patient care: Lastly, gradism doesn’t only affect doctors – it has ripple effects on patient care. When SAS doctors are not involved in critical decisions or their expertise is overlooked, patient outcomes can suffer. The exclusion of SAS doctors from leadership roles or meetings can result in a lack of diverse perspectives, which is crucial for comprehensive patient care.
   
   Moreover, the demoralisation of SAS doctors can lead to disengagement, further reducing the quality of care they provide. It can lead to inefficiencies, as SAS doctors may be underutilised or not given roles that match their skills, leading to wasted talent.

Read more: Addressing gradism: a call for change 

Amit Kochhar is a member of the BMA SAS doctors committee and an associate specialist in ENT