Breaking stereotypes or making compromises? gender, income, and the unequal landscape of medical specialty choice

BACKGROUND: Medical specialty choice shapes both physician identity and healthcare systems. Specialty choices are influenced not only by academic interest and aptitude but also by gender norms and socioeconomic pressures. While these dynamics are well documented in high income settings, fewer studies examine how perceived gender roles and income expectations jointly influence specialty preferences in LMICs contexts. METHODS: This sequential mixed methods study combined a cross-sectional online survey with semi structured interviews. The quantitative phase included 155 medical students (response rate 79.5%) and examined associations between demographic characteristics and specialty preferences. The qualitative phase comprised 34 interviews purposively sampled across all five cohorts. Interview data were analyzed thematically using Braun and Clarke's six step framework, following an inductive and reflexive approach guided by Social Cognitive Career Theory to explore how students understood and negotiated gender norms, income potential, and workload intensity. RESULTS: Quantitative analysis showed no statistically significant associations between income-based specialty preference and gender, GPA, family income, hometown, or high school background (all p > 0.05). High income specialties were selected by 60 students (39%), low-income specialties by 26 (17%), and other fields by 69 (44%), with similar gender distribution across these groups (p = 0.81). In contrast, qualitative analysis revealed pronounced gendered patterns. Many female students chose specialties they perceived as low intensity, often citing anticipated caregiving responsibilities and work life balance concerns as reasons for avoiding surgery, emergency medicine, and other high intensity fields. Male students frequently reported social and familial pressure to pursue prestigious or high-income specialties, prioritizing financial stability and provider roles even when these conflicted with personal interests. Across both genders, themes highlighted the centrality of perceived income, prestige, mentorship inequities, and cultural narratives of sacrifice in shaping career compromises. CONCLUSION: Specialty choice among medical students in LMICs reflects not only personal interest but also structural inequities linked to gender norms and income expectations. Although quantitative analysis of demographic factors did not independently predict specialty preferences, qualitative findings revealed powerful social pressures that shape career compromises. Targeted, gender sensitive career counselling, equitable mentorship, and financial support are needed to enable students to choose specialties that align with their values and competencies.