Competition, Rivalries, and the Tall Poppy Syndrome in Medicine and Orthopedics

Social comparisons, although often subconscious, contribute to defining who we are. We constantly compare ourselves to new acquaintances, neighbors, friends (often through social media), professional colleagues, and people in the media. Comparison allows us to identify ourselves: our self image, intellectual and physical abilities, and financial and social standing.

The main comparison mechanism is the very complex emotion envy which may be defined as lacking another’s superior talents, skills, achievements, or possessions and desiring them or wishing the envied lacked them. Social comparison may be upward, downward or sideways. The medical professional frequently compares upward since we have seemly done it forever beginning in high school. This entire process often segues into friendly competition: jockeying for college, medical school, internship, residency, fellowship and employment. Comparison persists into medical practice contrasting skills or knowledge with partners and leaders but, especially, local peer-competitors. Downward or even sideways comparison boosts self image if a patient switches to the competition.

The psychological sciences have attempted to view the negative emotions such as envy as functional states and not necessarily bad, morally wrong or sins [1]. Benign or good envy stimulates the envier to improve to be like the envied (from schooling into practice); bad or malignant envy may not only involve wishing the envied lacked those traits but also lead to taking action to negate those traits. In this light, good envy may boost self esteem; bad envy may boost it as well but by an unsavory mechanism.

Awaiting acceptance to medical school perhaps produced emotions unknown to the student. If one’s intense competitor was not accepted to medical school, schadenfreude (schaden - harm, freude - pain) was experienced; pleasure derived from another person’s misfortune. Should the intense competitor receive an acceptance letter, gluckschmerz, a pseudo-German-word, would be felt; feeling unhappy about someone’s good fortune.

Unchecked competition leads to rivalries. One of the greatest medical rivalries occurred between Louis Pasteur (French) and Robert Koch (German) over germ theory [2]. The FrancoGerman War (1870-1871) exaggerated nationalist sentiment; countrymen felt compelled to defend their country, their scientists and research. Anthrax was prevalent and European farmers had a vested interest in Koch’s anthrax work. Other European countries were colonizing Asia and African necessitating understanding of tropical diseases. America’s nascent medical leaders and schools were looking for proper direction in public health and infectious disease. Jonas Salk and Albert Sabin would continue the infectious disease (poliovirus) - vaccination rivalry in the first half of the 20th century.

The early history of anesthesia was undermined by different claimants of ether’s invention [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 claims 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 demonstration 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 for surgery until 1853. Ether’s potential spread immediately to London and Paris where new rivalries began. Because of the confusion caused by the Boston (pro) - Philadelphia (con) rivalry, many American doctors went to Europe to learn anaesthesia - ether techniques.

One of America’s most famous medical rivalries-feuds involved heart surgeons, Doctors Michael E. DeBakey and Denton Cooley [4]. Both had appointments at Baylor College of Medicine and worked at The Methodist Hospital. Less than friendly competition soon resulted in Dr. Cooley relocating a short distance to St. Luke’s Episcopal Hospital where he founded The Texas Heart Institute. Dr. DeBakey and Dr. Domingo Liotta developed an artificial partial heart assist, the left ventricular bypass, but Dr. Liotta and Dr. Cooley redesigned it for an emergency bridge for heart transplantation. Dr. Colley was the first to implant the artificial heart while the patient awaited a heart donor. Dr. DeBakey 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 censured by the American College of Surgeons. The two protagonists never spoke for forty years before finally reconciling.

The above are also examples of the Tall Poppy Syndrome (TPS) which involves an action arising from envy of a person or a person’s lack of deservingness - a person does not deserve their status and needs to be cut down to size. The TPS is a metaphor depicting a poppy field wherein a tall poppy (envied) stands out among the others (enviers); sooner or later one or more of the small poppies cuts the conspicuous tall poppy down. Individuals, institutions and even countries may become involved. The succeeding paragraph is a more typical TPS encounter that orthopedists or other practitioners may experience.

Dr. L J began his solo orthopedic practice as a sports doctor when the specialty was dawning [5]. Arthroscopic equipment was basic and evolving which he assisted in developing. Some orthopedic surgeons were envious and threatened by his newer skills. Dr. L J’s admission to the state orthopedic society was delayed for 11 years. Admission to the American Orthopedic Society for Sports Medicine (AOAAM) was delayed as well. Articles for some publications were also blocked. Eventually, L J enjoyed an illustrious career.

More playful competition, although it may become edgy, occurs when the orthopedic surgeon is the butt of jokes regarding knowledge versus strength. Interchanges between the orthopedic surgeon and the anesthesiologist are common in the operating theater [6]. This rivalry was appreciable enough to stimulate a scientific study. The results demonstrated that not only were orthopedic surgeons stronger but also smarter than anesthesiologists.

Emotions are beneficial for self image including the so called dark ones when utilized appropriately. Emotional intelligence is the ability to recognize one’s own and others emotions and utilize this information to manage emotions [7]. Self-awareness includes knowing one’s emotions, strengths and weakness and the consequence on others. Self-regulation recognizes the disruptive emotion and allows adaptation. Empathy, traditionally a physician stronghold, considers others feelings especially in decision making. All permit sound competition and rivalries and prevent participants from being the source of TPS as well as becoming a victim (tall poppied).

1. Laham SM (2012) “The Science of Sin: The Psychology of the Seven Deadlies (And Why They Are so Good for You). New York: Three Rivers Press 130-157.
2. Ullmann A (2007) “Pasteur-Koch: Distinctive Ways of Thinking about Infectious Disease.” Microbe 2: 383. Link: https://goo.gl/GUx9Yq
3. Tirer S (1988) “History of Medicine Rivalries and controversies during early ether anaesthesia.” Can J Anaesth 35:605. Link: https://goo.gl/hUr69T
4. Ackerman T (2001) “Cooley writes about DeBakey feud, reconciliation.” Houston Chronicle.
5. Johnson L (2018) “What’s Important: Making a Difference May Include Being Different”. J Bone Jt Surgery 100:443. Link: https://goo.gl/o8xce1
6. Subramanian P, Dantharuban S, Subramanian V, Willis-Owen S A G, Willis-Owen A C (2011) “Orthopedic Surgeons: as strong as an ox and almost twice as clever? Multicenter prospective comparative study.” BMJ 343:7506. Link: https://goo.gl/NsGj9u
7. Coleman D (2000) “Working with Emotional Intelligence”. New York: Bantam Books 26-27.