David and Goliath lessons for doctors and our health system

Davis Liu, MD | Physician | October 24, 2013

October 1st was a special day. The Affordable Care Act (ACA) also commonly known as Obamacare became official. The federal government shut down because Republicans and Democrats disagreed around Obamacare funding. Most importantly, October 1st was when I could finally read Malcolm Gladwell’s new book David and Goliath.

Gladwell ponders why do underdogs succeed when we least expect them to? Is it possible that advantages a Goliath has can be a disadvantage? When might a disadvantage for an underdog appear to be an advantage? As I put his observations together, I wondered are there any learnings for doctors and the health care system?


A David typically does not have the resources or power to make a difference as viewed by conventional terms. Gladwell uses stories like the US civil rights movement, successful individuals with a dyslexia, and his excellent New Yorker piece.

Despite having little in resources, underdogs are so desperate to succeed that they think very differently than a Goliath. This inherent disadvantage for a David ends up being a very different type of advantage. A different mindset as a David sees the world and options very differently. Given their disadvantage, they have no choice but to play by different rules. As a result, their solution is so novel and so different, it never would have occurred to anyone else. These solutions are the ones that propel us forward.  It is during times of desperation that true innovation occurs.

If we need any radical thinking, then it is around fixing our health care system. It is a mess by any measure with sky high expenditures and access and quality that isn’t even average compared to other industrialized nations.

So is it possible that a David might point us towards a better way of providing care?

Gladwell profiles Dr. Jay Freireich and his experience on the children’s leukemia ward while at the National Cancer Institute (NCI)  in 1955:

“The kids bled from everywhere — through their stool, urine — that’s the worst part. They paint the ceiling. They bleed from out of their ears, from their skin. There was blood on everything. The nurses would come to work in the morning in their white uniforms and go home covered in blood … When they came to the hospital, ninety percent of the kids would be dead in six weeks … They would bleed to death. If you’re bleeding in your mouth and nose, then you can’t eat. You stop eating. You try to drink. You gag. You vomit. You get diarrhea from the blood in the stools. So you starve to death. Or you get an infection and then you get pneumonia, then you get fever, and then you get convulsions, and then …” He let his voice trail off.

Yet Freireich and his colleague Tom Frei became convinced that the issue was because the platelet count was too low causing the bleeding even though the world expert at NCI didn’t it think so. After developing a novel more precise way of counting platelets, they temporarily stopped the bleeding by transfusing patients with platelets, over the objections of their supervisors.

Now that children didn’t bleed to death, Freireich and Frei moved on to thinking about treatment. Instead of offering one chemotherapy drug (monotherapy), why not do combination chemotherapy with four medications? Monotherapy alone never seemed to cure the cancer. This kind of thinking was completely unheard of. Give four toxic medications when one didn’t do the job? As the first textbook on hematology noted, chemotherapy medications, “cause more harm than good because they just prolong the agony…The patients all die anyway. The drugs make them worse, so you shouldn’t use them.” One drug alone didn’t work. But, four? Would doing a combination be better? Would it be too much for the patients?

Max Wintrobe [the world expert in hematology] thought the humane approach was not to use any drugs at all. Freireich and Frei wanted to use four, all at once. Frei went before the NCI advisory board to ask for approval. He got nowhere … When the experimental regimen was approved, some of the clinical associates — the junior doctors assisting on the ward— refused to take part. They thought Freireich was insane.

Nevertheless, Freireich pushed on as children continued to die. He tweaked protocols and continued to learn and make adjustments.  Progress did occur. As Gladwell notes:

In 1965, Freireich and Frei published “Progress and Perspectives in the Chemotherapy of Acute Leukemia” in Advances in Chemotherapy, announcing that they had developed a successful treatment for childhood leukemia. Today, the cure rate for this form of cancer is more than 90 percent. The number of children whose lives have been saved by the efforts of Freireich and Frei and the researchers who followed in their footsteps is in the many, many thousands.

As we now know nearly 50 years later, combination chemotherapy is now the cornerstone to any chemotherapy regimen. Their contribution set the standard for all cancer care.

Imagine what would have happened if Freireich was not “insane” enough to push through. What might our cancer care look like today?

I’ll offer a more recent example of a David. It is cardiothoracic surgeon Dr. Devi Shetty, who the Wall Street Journal dubbed “The Henry Ford of Heart Surgery.” A cardiothoracic surgeon in India, Dr. Shetty has the following challenges as noted in a Bloomberg piece:

  • One in four people there die of a heart attack and per-capita health spending is less than $60 a year.
  • Two-thirds of the population lives on less than $2 a day and 86 percent of health care is paid out of pocket by individuals.
  • The mortality rate from coronary artery disease among South Asians is two to three times higher than that of Caucasians, according to a study published in 2008 in the journal Vascular Health and Risk Management.
  • The average age for a first heart attack in India, Pakistan and other South Asian nations was 53 years, compared with 58.8 years in countries outside the region, according to a study published in 2007 in the Journal of the American Medical Association.


… on returning to India in 1989, Dr. Shetty performed the first neonatal heart surgery in the country on a 9-day-old baby. He also confronted the reality that almost none of the patients who came to him could pay the $2,400 cost of open-heart surgery.

“When I told patients the cost, they would disappear. They literally didn’t even ask about lowering the price,” he says.

Sounds desperate. Not much in resources. Innovation needed. Shetty has no choice but to solve this problem. Sure he could walk away like many others, and like others did at NCI in the 1950s. Despite the stark reality, Shetty’s zeal and passion to solve the problem resulted in a remarkable solution. Do what other industries have done to drive costs down, use economies of scale. Increase the volume of cases performed to drive the costs of the procedure down. Be fanatical about costs. As a result, the cost of heart surgery is now less than $1600 compared to the US at over $106,000. Understandably some of the cost is due to differences in costs of living, but look at the following innovations created out of desperation and a sense of urgency (from the Wall Street Journal and Bloomberg):

  • At his flagship, 1,000-bed Narayana Hrudayalaya Hospital, surgeons operate at a capacity virtually unheard of in the U.S., where the average hospital has 160 beds, according to the American Hospital Association.
  • Narayana’s 42 cardiac surgeons performed 3,174 cardiac bypass surgeries in 2008, more than double the 1,367 the Cleveland Clinic, a U.S. leader, did in the same year. His surgeons operated on 2,777 pediatric patients, more than double the 1,026 surgeries performed at Children’s Hospital Boston.
  • The large number of patients allows individual doctors to focus on one or two specific types of cardiac surgeries … surgeon Colin John, for example, has performed nearly 4,000 complex pediatric procedures known as Tetralogy of Fallot in his 30-year career. The procedure repairs four different heart abnormalities at once. Many surgeons in other countries would never reach that number of any type of cardiac surgery in their lifetimes.
  • Between Narayana Hrudayalaya and another hospital he runs in Calcutta, Dr. Shetty’s group performs 12% of India’s cardiac surgeries, his surgeons perform two or three procedures a day, six days a week. They typically work 60 to 70 hours a week, they say. Residents work the same number of hours. In comparison, surgeons in the U.S. typically perform one or two surgeries a day, five days a week, operating fewer than 60 hours.
  • When Shetty couldn’t convince a European manufacturer to bring down the price of its disposable surgical gowns and drapes to a level affordable for his hospitals, he convinced a group of young entrepreneurs in Bangalore to make them so he could buy them 60 percent cheaper. A 300-bed, pre-fabricated, single-story hospital in the city of Mysore cost $6 million and took six months for construction company Larsen & Toubro Ltd. to build, Shetty said. Only the hospital’s operating theaters and intensive-care units are air-conditioned, to reduce energy costs.

In other words, patients with a particular problem flow through his hospital system as quickly and efficiently as possible with each surgeon uniquely skilled in their particular illness. Heart surgeons like Colin John easily have exceeded the 10,000 hours of delibrate practice to be true “Outliers” in their field. Arguably, the hospital’s expertise and wisdom has exceeded that as well.

If health care is to make a significant leap forward, it will be only possible if we have the mindset of a David. As Gladwell noted in a talk in Dubai about the keys to a high performing culture, two common ingredients are a sense of urgency and a lack of resources. Clearly this was the case in both Freireich and Shetty. Children bleeding to death with a fatality rate of 90 percent within six weeks? Patients in India desperate for heart surgery but have no money or access to medical care? In these two situations we see the desperation. We feel the urgency. We sense the lack of resources.

Yet these stories propelled health care forward. As Gladwell demonstrates in his book, the status quo can become disrupted when those who appear to be at a disadvantage actually have a set of different advantages. Sometimes these underdogs fundamentally change the world we live in. Who are the underdogs in today’s health care system?

Is it patients? Is it unthinkable that patients in the United States needing open heart surgery would fly to the Cayman Islands? Aren’t patients who are equally desperate as noted in a New York Times piece, willing to move beyond the status quo?

Is it technology entrepreneurs? They too are patients sometimes and see a broken health care system which has opportunities to improve. Is it possible that their solutions might pave the way for a true innovation?

Is it doctors? What does Gladwell’s insight mean for us?

It is very possible that like other occupations which were outsourced overseas like autoworkers, computer programmers, and others, that this too will occur. Without legislating reimbursement cuts, the government, insurers, and large employer groups can simply find others who can provide care cheaper, not because the labor is cheap, but because they fundamentally changed how care was provided. Perhaps an example like Shetty.

They had to change how care was provided. They were desperate. They had no choice. They may even exist today, but we don’t know it yet.

And it’s very possible as a result of their disadvantage that they indeed change the world simply because they were David.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.