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How Davids can defeat the Goliaths of health care


With planning and perseverance, small practices can still succeed against large practices and health care organizations

Most Americans know the story of the Alamo, where a handful of Texans fought off a much larger Mexican army until reinforcements arrived. This led to the battle cry of "Remember the Alamo."

Another, more contemporary David vs. Goliath story also has implications for the health care profession. In 2015 the Yazidi, an ethnic and religious minority in Iraq, were at war with ISIS. The Yazidis were defending their sacred temple, Sharfadin. To Yazidis, this 800-year-old shrine is one of the holiest places on earth.

Eighteen Yazidi men defended the temple for four months, saying they would rather die than see this temple fall. Finally, Kurdish reinforcements arrived; and ISIS was defeated. While ISIS destroyed many other sacred buildings across Iraq and Syria, Sharfadin temple still stands undamaged.

Nearly every culture has a David vs. Goliath story of a small number of men who successfully resist a large opposition force. Even today we see this scenario in Ukraine, where a relatively small number of committed Ukrainians are holding their ground against a large number of invading Russian soldiers.

These stories are examples of the underdog defeating the "big guy." This same concept applies to health care and how small practices can thrive in the shadow of large practices or medical institutions that employ hundreds and even thousands of doctors.

The small practice or the solo doctor is always thinking about how large groups have more resources and staff to attract more patients. But according to Malcolm Gladwell’s book David and Goliath, those material advantages also limit their options.


woman doctor with other doctors in background ©


emember that large groups operate by committee. To accomplish anything, they must submit proposals that must be approved, then modified and resubmitted. Funding needs to be allocated, then the proposal often must be scaled down and resubmitted. This process can take months or even years to accomplish.

However, a small group practice can decide on an idea or proposal by a staff member or one of the physicians and begin implementing it within days. These practices have the advantage of speed, which allows them to compete with the giants.

I was in a two-member urology practice. The community contains several medical schools and a large multi-specialty hospital that spends hundreds of thousands of dollars on marketing and practice promotion. However, with social media and search engine optimization, our small practice appears on the top of Google's first page. This is an example of how the Internet has leveled the playing field and allowed small practices to compete against the giants.

David against health care Goliaths

In the late 1980s, urologist Abraham Morgentaler, M.D., researched the relationship between testosterone and prostate cancer. Since the early 1950s, the party line had been that testosterone would either cause prostate cancer or, if the patient already had it, the additional testosterone would result in increased growth of the prostate cancer.

Morgentaler showed in an elegant fashion that raising testosterone levels in the blood did not raise testosterone levels within the prostate gland. He suggested that once the prostate has been exposed to a certain level of testosterone, any additional testosterone does not accumulate. In other words, the prostate has been "saturated" with regard to testosterone. It is this saturation that resolved the paradox of the harmful effects of testosterone and prostate cancer.

Morgentaler presented his findings to the American Urologic Association in 1995. One of the influential chairmen of a major urology department publicly referred to his work as "garbage." Even in his own hospital, an endocrinologist referred to his research giving testosterone to patients with precancerous prostate biopsies as "dangerous." However, he prevailed and continued to work on the safety of using testosterone in men with diagnosed prostate cancer who have been treated with radiation or radical prostatectomy.

Today, most urologists throughout the world are comfortable using testosterone without fear of causing or escalating prostate cancer in men. This was due in large part to not accepting the status quo and being relentless in his pursuit of changing the prevailing wisdom regarding testosterone and prostate cancer.

It is possible in health care for Davids to take on Goliaths. There are so many times that we believe that we cannot compete or overtake the giants in our profession. Gladwell pointed out that if you total up all the wars fought in the last 200 years between small and large countries, and if the larger country has ten times the population of the smaller, the smaller country wins 30% of the time.

Remember that Apple was created in a garage and competed against IBM and software behemoth Microsoft--and ultimately came out on top. Or that once upon a time, California vinters dared to think they could make wine as good as the French winemakers who had dominated the global wine trade for centuries.

Then there's Southwest Airlines' Herb Kelleher, Virgin's Richard Branson, Fedex's Fred Smith, and thousands of entrepreneurial Davids who took on Goliaths and won, not on the battlefield but in the marketplace. It happens every day.

What is the message for doctors in small practices? We are surrounded by Goliaths, e.g., large group practices, multi-specialty group practices, hospitals, insurance behemoths, CMS, and other government oversight organizations, to name a few. However, with a carefully thought-out plan of action, perseverance, and identifying opponents’ weaknesses, even single doctors and small groups can be Davids who successfully take on the Goliaths.

Neil Baum, MD, is a professor of clinical urology at Tulane University in New Orleans, LA.

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