The Alamo redux or how Davids defeat the Goliaths of healthcare

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Every American knows 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."

There's another David vs. Goliath story worth describing that has implications for the healthcare 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.

The Yazidis knew that if ISIS were to control the temple, all their sacred statues and artwork would be destroyed. Eighteen Yazidi men defended the temple for four months. These brave defenders said that they would rather die than see this temple fall. Finally, Kurdish reinforcements arrived; 200 men at first, and ISIS was defeated. The best testament to what happened is the existence of the temple itself. While ISIS destroyed many other sacred buildings across Iraq and Syria, Sharfadin temple still stands without any damage. *

Nearly every culture has a David vs. Goliath story, an Alamo or Sharfadin story of a small number of men who stand their ground against a large opposition force. Even today, we see this scenario in Ukraine, where a relatively small number of committed Ukranians can hold their ground against a large number of Russian soldiers.

So, what does this have to do with modern healthcare? These stories are metaphors for the underdog defeating the giant or the "big guy." This blog discusses how that concept applies to healthcare and how small practices can still thrive in the backyard of large practices or large medical corporations 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 to their institutions.

According to Malcolm Gladwell in his book David and Goliath**, those material advantages limit their options.

Let's remember 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 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 the implementation process within days. These small 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 first page of Google and even 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 healthcare Goliaths

In the late 1980s, a urologist, Dr. Abraham Morgentaler, researched the relationship between testosterone and prostate cancer. Since the early 1950s, testosterone was described as "adding gasoline to a fire." The party line was that testosterone would either cause prostate cancer or, if the man already had prostate cancer, the additional testosterone would result in increased growth of the prostate cancer.

Dr. 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 enough testosterone, any additional testosterone is treated as excess and does not accumulate in the prostate. 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. 1,2

Dr. Morgentaler presented his findings at the American Urologic Association in 1995. One of the influential chairmen of a major urology department stood up and publicly referred to his work as "garbage." Even in his own hospital, an endocrinologist at Beth Israel Deaconess Medical Center referred to his research giving testosterone to patients with precancerous prostate biopsies as "dangerous." However, he prevailed and continued to do 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 in men without fear of causing prostate cancer or fear of escalating prostate cancer in men diagnosed and treated for prostate cancer. This was in large part due to not accepting the status quo and being relentless in his pursuit to change the prevailing dictum regarding testosterone and prostate cancer.

It is possible in healthcare 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. Malcolm Gladwell pointed out that if you total up all the wars fought in the last two hundred years between small and large countries, and if one country has ten times the population of another country, the smaller, weaker country wins 30% of the time. Look at Israel, with a population of 8 million, which is surrounded by 22 hostile Arab/Islamic countries; Israel wins nearly every military engagement against its Arab neighbors. (I hope this situation holds true in 2023)

Remember that Apple was created in a garage and competed against IBM and software behemoth Microsoft--and ultimately came out on top.

Once upon a time, California farmers 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. Just remember, there are many examples of healthcare Davids slaying Goliaths.

Bottom Line: What is our message for the healthcare profession? We are surrounded by Goliaths, e.g., large group practices, multi-specialty group practices, hospitals, insurance behemoths, AMA, CMS, and other government oversight organizations, to name a few. However, with a carefully thought-out plan of action, perseverance, and identifying their weakness, even single doctors and small groups can be Davids who take on the Goliaths.

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, Marketing Your Medical Practice-Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.

1. Agarwal PK, Oefelein MG. Testosterone replacemen testosterone therapy after primary treatment for prostate cancer. J Urol. 2005 Feb;173(2):533-6.

2. Kaufman JM, Graydon RJ. Androgen replacement after curative radical prostatectomy for prostate cancer in hypogonadal men. J Urol. 2004 Sep;172(3):920-2.

*For more information on the defense of the Sharfadin temple see Ari Shapiro’s NPR article, Outmanned And Outgunned, Fighters Defend Yazidi Shrine Against ISIS. February 2015

** Malcolm Gladwell, David and Goliath, Underdogs, Misfits, and the Art of Battling Giants, Little Brown and Company, 2015.