David vs. GoliathWhat is the essence of the underdog?  Are they truly disadvantaged?  Or occasionally, are they disruptors that provides them with a brilliant new perspective on things?  Therein lies the question central to Malcolm Gladwell’s latest New York Times Bestseller. This is the key concept behind the latest book by Malcolm Gladwell‘s book, David and Goliath [Amazon link], and the topic of this month’s ALiEM bookclub discussion.

Book Synopsis: David and Goliath

Through a series of well planned vignettes, Gladwell makes a number of convincing arguments that explore the nature of those who are normally thought of as ‘underdogs’. In many ways, his book popularizes the concept of disruptive innovation, which was originally described by Clayton Christensen in his book, the Innovator’s Dilemma.

Take his title story: A shepherd challenges a seasoned warrior (who is double his size) in a battle to the death.  You’d place bets on the warrior no doubt. (In modern times, you’d probably see Vegas odds of 5:1 against the shepherd.)

Now let me change some details: What if I told you that the warrior may have had a diagnosis of gigantism: a pediatric growth hormone disease that while giving him his record stature, also condemned him to a life with poor vision and dependency on others? And what if I told you that shepherd was an expert slingshot artist with the ability to hit a quarter inch target from 25 metres away?

The shepherd just brought a gun to a fist fight. Who would you bet on now?

In a masterful tour de force of stories and arguments, Gladwell quickly makes you rethink the definitions of power and agency. By the end of his book, you are indeed convinced that strength, like beauty, is purely in the eye of the beholder. Flipping the paradigm, changing the question: these are the tricks of the trade for those with less power. From the members of a guerrilla militia to the leaders of the civil rights movement, challenging the status quo and questioning norms is how agile and mobile upstarts undermine establishments. Meanwhile, slow-moving monoliths may seem powerful, but are highly vulnerable to drastic changes.

Cunning upstart or disadvantaged underdog? 

Powerful giant or unresponsive monolith?

Each of these are two sides of the same coin. In the end, the victor truly does get to tell the story. Which story will be yours?

Relevance to Medical Education

The story of Free Open Access Meducation (FOAM) within medical education can actually be viewed in this very light. Just as paper disrupted the way the ancient Greeks shared their stores, just as Gutenberg disrupted the way that religious texts could be distributed, the advent of easily publishable digital platforms has become a disruptive force in medical education.

Disruptive innovations (as described by Clayton Christensen) are an example of how simpler-to-use technologies can turn industries on its head. Similarly, while FOAM resources may not have initially presented itself as an obvious contender medical education use, it has evolved into a major disruptive innovation in medical education. FOAM has emerged through scholarly blogs and podcasts, with a robust community of practice espousing its values and new culture. It has spread into apps, search engines, conferences, and most recently a journal!

Bookclub discussion questions

  1. Why does FOAM represent a disruptive innovation? What industry or established ‘giant’ is it toppling?
  2. By viewing FOAM as a ‘David’, what vulnerabilities does it reveal?
  3. What are other disruptive and ‘David’-like innovations that we see taking hold in our clinical environments?


How to join in the discussion:

There are two main way to join our ALiEM Book club discussion this month:

  • You can join us for a week-long, global bookclub during from July 11-17, 2014. Hashtag: #ALiEMBook. Tweet us directly at @ALiEMBook. Don’t forget to tag your questions/responses Q1, Q2, and Q3 depending on your answer!
  • You can write us a few words in the comment section below!



  1. Gladwell, M. (2013). David and Goliath: Underdogs, Misfits, and the Art of Battling Giants.  Little, Brown and Company.
  2. Christensen, C. (2013). The innovator’s dilemma: when new technologies cause great firms to fail. Harvard Business Review Press.
  3. Photo Credit: Photo used via Creative Commons license. Photo by Darrel Birkett

Teresa Chan, MD, MHPE
ALiEM Associate Editor
Emergency Physician, Hamilton
Associate Professor, McMaster University
Assistant Dean, Program for Faculty Development, McMaster University Ontario, Canada
Teresa Chan, MD, MHPE


ERDoc. #meded #FOAMed Own views expressed. Contributor to @ALiEMteam, @WeAreCanadiEM, ICE Blog, #FeminEM. @MedEdLIFE founder. Works @McMasterU & @HamHealthSci