John Goldie is a retired GP and medical educator.
Imagine two patients attending a busy morning surgery.
The first arrives with a typed list of symptoms, dates, and questions. He speaks calmly, waits his turn, and answers in neat, linear sentences. The GP finds herself offering extra explanation, even a bit of reassurance she doesn’t strictly have time for.
The second comes in talking fast and breathily, jumping between her chest pain, her neighbour, her panic, and the reduction in her benefits. The story tangles as soon as it begins. The GP feels the pressure of the clock. She redirects, summarises, cuts in. When the patient leaves, she reflects on how she agrees with her GP colleagues that this patient is a ‘heartsink’.
“What is being sorted here is not illness severity, but mental style — and with it, moral worth.”
Both patients had the same symptoms and required the same care. However, one mind made the work smooth; the other made it onerous. Without malice or awareness, the GP sorted them into different moral categories: the organised mind that deserves time, and the chaotic mind that drains it. This hierarchy is invisible but foundational. It reveals how quickly clinical difficulty transforms into moral judgement.
The epistemic injustice literature — following Miranda Fricker1 — already documents a systematic hierarchy of credibility in health care.2 What emerges is a stratified order in which some minds are treated as credible, rational, and deserving, while others are treated as unreliable, irrational, and morally diminished. ‘Caste system’ here is a metaphor: not a claim about social caste itself, but a way of naming a stable, inherited hierarchy of mental worth that feels natural to those who operate within it. What is being sorted here is not illness severity, but mental style — and with it, moral worth.
English literature recognised this before medicine did. Charlotte Brontë’s Jane Eyre gives us Bertha Mason, whose inner life is erased the moment she is labelled ‘mad’. Virginia Woolf’s Mrs Dalloway shows Septimus Warren Smith, a traumatised veteran whose articulate interiority is invisible to the doctors who dismiss him as hysterical and lacking insight. More recently, Margaret Atwood’s The Handmaid’s Tale highlights societal bias against women. Literature repeatedly exposes the same pattern: minds that are orderly, articulate, rational, and socially respectable are treated as fully human, while minds that are chaotic, traumatised, poor, female, belong to people of ethnic minority, or are cognitively different are treated as lesser. These stories reveal the cultural scaffolding beneath modern clinical practice — a hierarchy of minds that medicine still enacts, even if it refuses to name it.
Contemporary healthcare research confirms this structure. Certain patients receive systematic credibility deficits that clinical factors alone can’t explain.3 Work on epistemic injustice in medicine shows that some groups are routinely granted less authority over their own accounts of illness, creating a stable hierarchy of whose minds are believed. Studies in psychiatry demonstrate this most starkly: once a person carries a psychiatric diagnosis, their testimony is more readily dismissed, their physical symptoms more likely to be misattributed, and their decision making more easily overridden.4 Similar credibility penalties exist for people with learning disabilities, for women describing pain,3 and people of ethnic minority whose reports of symptoms are doubted or minimised.
“… chaotic, non-linear, or emotionally charged narratives attract shorter consultations and less explanation, while orderly, articulate minds are rewarded with time and trust.”
Research on ‘heartsink’ patients, the term itself a symptom of the caste system, shows that chaotic, non-linear, or emotionally charged narratives attract shorter consultations and less explanation, while orderly, articulate minds are rewarded with time and trust.5,6 Taken together, these findings describe not isolated biases but a stratified order of mental worth within clinical practice — a system in which some minds are treated as inherently more rational, reliable, and deserving.
Because this hierarchy is invisible, it feels natural. Because it feels natural, it feels justified. And because it feels justified, it goes unchallenged. Yet every day in primary care, this quiet sorting of minds determines who gets time, who gets empathy, who gets believed, and who gets labelled. It shapes diagnostic delay, missed safeguarding, avoidable harm, and the ethical climate of the consulting room. The stakes are not only epistemic but ethical: whose suffering counts, and whose does not.
If we want more equitable, patient-centred care, we need to make the invisible visible. Practices can support this by using structured consultation tools that slow premature closure, for example, Roger Neighbour’s five checkpoints,7 encouraging reflexive discussion of challenging cases, and actively seeking patient feedback. Simple micro-practices help too: offering the ‘chaotic narrator’ one uninterrupted minute before redirecting; checking whether a credibility judgement is based on evidence or on narrative style; and noticing when emotional intensity is being mistaken for unreliability. These steps, partial remedies for a deeper structural issue, can help ensure that all patients — not just the orderly, articulate ones — are listened to, respected, and given equal consideration.
References
1. Fricker M. Epistemic Injustice: Power and the Ethics of Knowing. Oxford: Oxford University Press, 2007.
2. Nielsen KM, Nordgaard J, Henriksen MG. Fundamental issues in epistemic injustice in healthcare. Med Health Care Philos 2025; 28(2): 291–301.
3. Côté CI. “They are not almighty god, they are doctors, they are human”: a qualitative study of mechanisms underlying epistemic injustices in chronic pain patients’ testimonies. Soc Theory Health 2025; DOI: 10.1057/s41285-025-00218-9.
4. Crichton P, Carel H, Kidd IJ. Epistemic injustice in psychiatry. BJPsych Bull 2017. 41(2): 65–70.
5. Moscrop A. ‘Heartsink’ patients in general practice: a defining paper, its impact, and psychodynamic potential. Br J Gen Pract 2011; DOI: https://doi.org/10.3399/bjgp11X572490.
6. Heritage J, Robinson JD. The structure of patients’ presenting concerns: physicians’ opening questions. Health Communication 2006; 19(2): 89–102.
7. Neighbour R. The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style. 2nd edn. Boca Raton, FL: CRC Press, 2005.
