The Tall Poppy Syndrome in Medicine - Juniper Publishers

Arthritis & Bone Research - Juniper Publishers

Mini Review

An unmarked vial arrived at the White House two days into President Bill Clinton’s first term. It was alleged to be his desensitization medicine for his allergies. White House (WH) Physician Dr. Burton Lee III, President George H.W. Bush’s appointee, prolific scientific author and Presidential-Congressional influencer on HIV/AIDS legislation, refused to inject the medicine until content confirmation. Phone conversations to Clinton’s Arkansas medical doctors (on call) over the week-end were unrevealing. Dr. Lee had become conspicuous and was discharged (cut down) from duty the following Monday. President Clinton possessed the prerogative of appointing a new WH physician, but his timing reeked of payback. Lee’s crime was practicing good medicine. Was Dr. Lee tall popped; had he become a victim of the Tall Poppy Syndrome (TPS)? The Tall Poppy Syndrome is a metaphor wherein a poppy tower over the others; some want the tall poppy to cut down so that all are uniform. The Australian National Dictionary describes TPS as “a person who is conspicuously successful; freq. one whose distinction, rank, or wealth attracts notice or hostility”. The syndrome has been documented since antiquity and described in most countries.

Australia’s recognition of TPS is dominant amongst the Anglo-sphere nations while it remains relatively unknown (and undiagnosed) in the United States. High profile, conspicuous people are often victims such as athletes, people in the media/entertainment industry, business and, especially politics. The syndrome is uncommon in science, arts and medicine. Envy (on the part of the cutter) and worthiness (the tall poppy got what he/she deserved because of egregious behavior) are often causes for cutting [1]. In contradistinction to the Australian experience, I have observed TPS in medicine personally and in the world and American medical literature. American medicine is very competitive: college, medical school, internship, residency, fellowship, job seeking, practice building and “publishing or perish”. Medical and personal advancements may become contentious especially when new ideas or procedures are introduced; this leads to individual and institutional rivalries and sometimes a victor. The road to victory often entails envy as well as other emotions such as resentment, anger and even hate and includes a specific victim but may also ensnare many peoples, hospitals and even countries. One of the greatest medical rivalries existed between Robert Koch (Germany) and Louis Pasteur (France) who worked in medical microbiology and the germ theory of disease. Their rivalry was set in the backdrop of the Franco-Prussian War (1870-1871) which included Germany’s seizure of Alsace-Lorraine, where Pasteur worked, and its increasing dominance of scientific information over Europe. This compelled countrymen to defend their scientists, research and country.

Anthrax was prevalent and European farmers had a vested interest in Koch’s original anthrax work but their rivalry was exacerbated when Pasteur began anthrax research. European countries were colonizing Asia and Africa and were seeking to understand tropical diseases. Our own nascent medical leaders and schools were looking for direction in public health and infectious disease (Koch won). Their feuding reached a pinnacle after a medical meeting in London in 1881 when Koch and his students published several articles attacking Pasteur’s work. Further attacks against each other occurred at a meeting in Geneva in 1883 with their respective follow up responses. The rivalry tainted their work for years to come [2].

Our early history of anesthesia was undermined by different claimants’ invention of ether [3]. William T. G. Morton, a dentist, was given credit for ether’s discovery although Charles Jackson, a chemist, and Horace Wells, a dentist, refuted the claim for years. Sir Humphrey Davey, a Cornish chemist, previously noted nitrous oxide’s anesthetic and pain reducing effects in 1940 and Wells used it for dentistry in 1844. Dr. H. J. Bigelow, a surgeon at the Massachusetts General Hospital, published a report on the use of ether in 1847. The School of Medicine at the University of Pennsylvania was the foremost medical school and condemned its usage because of its side effects and would not use ether until 1853. Ether’s potential spread immediately to London and Paris where new rivalries erupted. Because of the confusion caused by the Boston (pro) - Philadelphia (con) rivalry, many American doctors went to Europe to learn anesthesia - ether techniques. One of America’s most famous rivalries - feuds involved heart surgeons, Doctors Michael E De Bakey and Denton Cooley [4]. Both had appointments at Baylor College of Medicine and worked at The Methodist Hospital in Houston, Texas. Less than friendly competition resulted in Dr. Cooley relocating a short distance to St. Luke’s Hospital where he founded the Texas Heart Institute.

Although Doctors De Bakey and Domingo Liotta developed an artificial heart assist, the left ventricular bypass, Doctors Cooley and Liotta redesigned it for an emergency bridge for heart transplantation. Dr. Cooley was the first to implant the artificial heart when a patient awaited a heart donor. Dr. De Bakey claimed Dr. Cooley stole his artificial heart and began a campaign to reprimand Dr. Cooley. Dr. Cooley resigned from Baylor after a dispute with its trustees and was eventually censured by the American College of Surgeons. The two protagonists never spoke to each other for forty years before finally reconciling. The preceding accounts were initially driven by envy as is the succeeding story which is the most likely TPS situation the practicing physician will encounter. The above reports may garner the most attention but the it is the close to home encounters with colleagues, close friends or other professionals that offer the opportunity for TPS occurrence. Dr. LJ entered private practice when arthroscopy and sports medicine were at their infancy. He was instrumental in a design of the motorized arthroscopic shaver as well as other arthroscopic instruments.

His surgical techniques were disparaged by his local colleagues - competitors. Memberships in state and national societies - organizations were denied or delayed many years. Original scientific papers were also opposed. Over time, Dr. L. J.’s achievements were accepted as were many” memberships and scientific papers and he eventually enjoyed a rewarding and illustrious career [5]. The risk of TPS for doctors moving from the cottage industry to the corporate world will not lessen the likelihood of TPS. They will be moving into the hierarchical world; hierarchy creates competition for advancement and envy. WH physician Navy Rear Adm. Ronny Jackson, who served as the personal physician for three presidents, was nominated for Secretary of the Department of Veteran Affairs. Adm. Jackson had a previously strained relationship with a WH Navy captain in 2013. A recent occurrence between Adm. Jackson and the doctor of Vice President Pense’s wife led to memos and accusations of drinking on the job, bullying, and improperly giving prescription medications. These allegations, not verified, were leaked to the press by Sen. Jon Tester (D. Mont.), the senior Democrat on the Senate Veterans Affairs Committee. Dr. Pense’s doctor has since resigned from the WH medical department. Adm. Jackson withdrew his name for the V.A. appointment.

Although the original cutting down began between colleagues, Senator Tester finished the task. Deservingness of the tall poppy’s status adds another dimension to TPS. In 2016, the Dean of the University of Southern California (USC) Medical School resigned his post because of drug usage and providing drugs to non-patients. He remained on the faculty treating patients while under supervision and undergoing treatment. A year later he resigned from the faculty and was stripped of his medical license in 2018. USC’s only full-time gynecologist for nearly 30 years was accused of serial misconduct. He was suspended in 2016; internal investigations were performed as well as an outside investigation which determined some of his medical behavior was outside the scope of current medical practice. He was allowed to resign quietly with severance pay in 2017. The lead physician at the student health center was fired as well as the clinical director; the physician has filed a lawsuit against the university for defamation. The female who finally initiated the investigation (cutter) resigned her post (she was cut down as well). In 2018, the USC president resigned. USC has set aside $215 million for compensation for victims.

The medical board is reviewing the gynecologist’s medical license. Our cannons for practicing medicine are constantly changing due, if for no other reason, to the complexities of our society spurred by growth and diversity. Hard work, intellectual ability and technical skills are no longer sufficient for success. Emotional intelligence, not just our time-honored empathy, is necessary to navigate the intricacies of the one on one (and group) encounter, which, by the way, no longer absolutely exists due to the iPhone and EMR. The other four elements of personal competence as described by Daniel Coleman are: self-awareness, self-regulation, motivation and social skills [6]. Practicing them will increase one’s chance of success and happiness and reduce the possibility of becoming the cutter or being cut down. Primum non nocere has guided patient care for centuries. Computers, iPhones and artificial intelligence may seem to undermine and marginalize our tasks but they,” along with movements such as #MeToo, only confirm the importance of the axiom and how far reaching a tiny task may spread [7]. The axiom should include our colleagues as well as ourselves.

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