Cut down in Medicine by Tall Poppy Syndrome

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President Bill Clinton had been in office two days when an unmarked vial arrived at the White House mailroom. The vial allegedly contained Clinton’s desensitization medicine for his allergies. White House Physician Doctor Burton Lee III, President George H. W. Bush’s appointee, prolific scientific author, and an influencer on HIV/AIDS legislation refused to inject the medicine until he had more medical information. Lee was discharged from duty the following workday. Although President Clinton had the prerogative of appointing his private physician, his immediate response reeked of payback. Dr. Lee’s crime? Practicing good medicine. Lee had become a victim of the Tall Poppy Syndrome (TPS).

The Tall Poppy Syndrome (TPS) is a relatively unknown entity in the United States but is well know in other Anglo-sphere nations especially Australia. It has worldwide recognition with various metaphors, words or phrases and may be traced back to antiquity. The metaphor involves an observer noticing a towering poppy in a field of poppies and the desire to “cut down” the tall poppy (TP) for uniformity. An Australian dictionary describes TPS as “the habit of denigrating or ‘cutting down’ those who are successful, high achievers, etc”. The TP is defined as “a person who is conspicuously successful; frequently one whose distinction, rank, or wealth attracts envious notice or hostility”.

Key words in the TP definition are “envious,” “conspicuous,” and “hostility”. In Australia, TPs are socially acceptable as long as they are not conspicuous; TP conspicuity qualifies cutting down without social repercussions to the cutter. Envy is our comparison emotion and is divided into two components: good or benign and bad or malicious. Good envy encourages emulation of the TP; bad envy deconstructs the TP. It would not be uncommon for cutters to possess low self esteem. Further psycho-social studies has identified worthiness, resentment as well as other inducing agents for cutting a TP down. Victims of TPS are found in many high profile industries: business, entertainment, sports, politics, and media.

TPS may be less prevalent in the United States than other countries because of the constitutional rights of the individual, our once celebrated “rugged individualism” and American capitalism which is based on meritocracy. Furthermore, in traditional medicine, the signs and symptoms of a syndrome are often confirmed with laboratory tests. In the 1950s, the psychologists appropriated the appellation of syndrome and changed the definition. Now syndrome is a complex of symptoms which exhibit the presence of a disease, a psychological disorder, or any kind of distinctive behavioral pattern. TPS fits this definition. Simplistically there is the envier with their motives, the envied with their behaviors and the cutting. Should the envied be cut down, the final act may result in schadenfreude. Schadenfreude is two German words, harm-joy, which means pleasure derived by someone from another person’s misfortune. Schadenfreude is also closely linked with envy. Many people shared schadenfreude when some of the above were cut down.

In medicine, the archetypical example of TPS occurs when a new doctor, who often possesses new skills or knowledge moves into town. Established doctors had previously informed the squatter there were not enough patients to initiate a new practice. Undeterred, the new physician stays and a whisper campaign, often driven by envy, begins by divulging that the freshly minted doctor is not practicing standard care medicine or worse. Occasionally, the new doctor moves on. Rivalries and nearly every new skill or discovery are breeding grounds for TPS especially in academics.

As medicine moves to a business model of doctor employment, the hierarchy and promotion may become a source of TPS. Older physicians’ practices have often been based on meritocracy but advancement may no longer be based solely on merit. Specific needs, “pull,” and social-justice identity politics may thwart the high achiever’s currency causing the doctor to be a cutter or to be cut.

The White House Medical Unit takes care of all things medical at the White House. The White House physician oversees a staff of five military physicians. Active-duty military officers are common because civilian physicians require office closure with the uncertainty of when they will open. In the early 2010s, a rivalry existed between Dr. Lonny Johnson and his boss, Dr. Jeffry Kuhlman, for control of the White House office. The U.S. Defense Department inspector general was summoned to settle the dispute in 2012 with Dr. Kuhlman retiring the following year. Dr Johnson would become President Trump’s doctor and be nominated for the Directorship of the Veterans Affair Administration. A new rivalry as well as accusations flared between Dr. Johnson and Vice President Pence’s doctor, Dr. Jennifer Pena. She has since resigned. Dr. Johnson withdrew his name from the V.A. nomination but remains on the White House unit. The inspector general has opened a new investigation.

Awareness of TPS supports its diagnosis. Recognition of TPS may make people mindful of their behavior. Behavior modification may abet the cutter, cuttee or both.

Dr. Garland is an orthopedic surgeon retired from private practice but remains academically active and divides his time between the central coast of California and southwestern Montana. He has no conflicts of interest in this paper.

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