John Henning Schumann
For years I've had a patient who is a gym teacher. As you might expect, he's pretty fit. Well into his 60s, he can do an impressive number of pushups, as he demonstrated one morning in our exam room.
He surprised me in a different way at an appointment several months ago. He pulled out results from medical tests that he'd had done at his church. He and many of his fellow congregants had each paid about $150 for screening tests that they were told could see if they were at risk for strokes, clogged leg arteries and other problems.
He'd had an electrocardiogram, which measures the heart's electrical activity. He'd also had ultrasound tests performed on the big arteries in his body — the ones on both sides of his neck that feed the brain (the carotids) and the aorta, the largest blood vessel in the human body.
The man was in good health. He didn't smoke, wasn't overweight and exercised regularly. I wouldn't have ordered these tests for him. They come with a risk of false alarms. And in my patient's case, there were no medically compelling reasons for them.
He was disappointed when the tests showed "mild carotid artery disease" on one side of his neck. As someone who prided himself on his health and fitness, he was disturbed to learn that his results indicated that he was at risk for a stroke.
Though his report described the risk as mild, all that mattered to him were the words "disease" and "stroke." By the time he came to see me, I had to work pretty hard to calm him down.
My experience with this patient and others like him led to me look at the website for Life Line Screening, the company that performed his tests. There I found testimonials from customers who felt screening had saved their lives, or at least uncovered problems before they became life-threatening.
A disclaimer acknowledges "there is debate about the importance ... of screening for vascular disease in general." The statement concludes with an admonition to "always consult with your doctor," as we are the ones who "know you best."
My opinion was that my patient could have done without the tests. The U.S. Preventive Services Task Force, which is the most unbiased source of recommendations on preventive care, recommends against carotid screening in healthy people, too.
So what is the evidence for Life Line's approach?
Dr. Stephen Brunton, a family doctor who's an advisor to the company, says Life Line's research distinguishes it from competitors and provides a counterargument to critics. "Our standards are wider, based on the data we've collected," he told Shots. Life Line has screened more than 8 million people over two decades, and willingly shares their data with independent researchers who have performed multiple analyses. The company's conclusion: vascular disease is more prevalent than conventional medical opinion suggests.
But there's another issue.
Life Line also has relationships with some 150 hospital partners, who stand to benefit from referrals of anxious customers like my patient the gym teacher for further testing and treatment.
The company says there's no conflict. "No money changes hands in these relationships," said Joelle Reizes, the company's communications director. "We partner with hospitals to answer the criticism that we leave patients 'hanging' after we provide them results." If a screening customer doesn't have a primary care physician, then a hospital partner can help link to one through their network.
Still, relationships between hospitals and screening companies have come under scrutiny, as Public Citizen, a consumer advocacy group, has criticized hospitals partnering with HealthFair (a competitor of Life Line Screening). Public Citizen recently sent letters to 20 hospitals in eight states asking them to sever ties with HealthFair, citing the "widespread consensus among medical experts ... that community-wide cardiovascular health screening programs are unethical and are much more likely to do harm than good."
In my practice, I strive to achieve the best results for patients using the best available medical science. I also try to minimize harm. As we often say, each patient is different. Some of us want every morsel of information about ourselves, while others prefer to know only what's necessary, or likely to inspire action. In the case of my gym teacher-patient, less would clearly have been more.
About 2,000 years ago, the Roman Empire stretched from the Middle East all the way across Western Europe. A wall marked the empire's northernmost boundary, at one point less than a mile from today's border between England and Scotland.
Many scholars think the Roman emperor Hadrian built the 73-mile wall at this point to keep the unruly Scottish out. When the Scottish vote in an independence referendum on Sept. 18, they will be deciding whether they want to separate from the rest of Britain.
And Hadrian's wall, which still stands, has some modern-day issues of its own. The organization that maintains the wall has lost its funding.
For most people, a hike along the wall demands only the most basic equipment: a water bottle, a sturdy pair of shoes, and (this being England) rain gear.
Alisha Martin, 9, is working a more authentic look. The girl is ready for battle, with a plastic helmet, shield and sword.
"A Roman costume," she says, "because it's Hadrian's Wall. Hadrian built it to keep out the barbarians."
"Hadrian was a emperor, I think?" She glances at her mother, who nods encouragingly. "Yeah, emperor."
Tourist David Fletcher explains it this way: "The Romans, who were occupying England at the time, were a bit cheesed off at the Scottish people, who kept stealing their sheep."
"Marauding tribes!" adds his wife, Kath.
"Marauding. And Hadrian said, 'Enough is enough!' " Fletcher says.
The wall took six years to build. It originally stood 15 feet high. The Romans put a major fort every five miles along its length.
"There's quite strong evidence that the wall was painted white in Roman times," says Linda Tuttiett, chief executive of the Hadrian's Wall Trust. "So as you can imagine, that would have been visible from miles and miles and miles away."
It made a grand statement about the empire's size and strength. And it also said something about the people who withstood the massive Roman Empire.
"It's a testimony to the strength of feeling and character of the Scots as they were at the time," she says.
And perhaps as they are today as well, given Scotland's upcoming vote.
"Indeed," says Tuttiett. "Who knows how that strength of character has developed?"
Two thousand years later, this wall is a lot less imposing. It's no longer white. The forts are gone. It looks like a garden wall, running along cliffs and hills surrounded by heather and scrubby trees. Hadrian's Wall — now standing only a few feet tall — stretches from one horizon to the other.
"Many, many of the farms and barns and churches across Hadrian's Wall are built out of the very stone of the wall," Tuttiett says. The Romans were great stonemasons. So after the empire fell, people took those nicely-cut stones for their own buildings.
Today the wall is a UNESCO heritage site, and Tuttiett's organization has led the preservation effort — planting new grass, coordinating archaeological programs, and making sure nobody takes a stone for themselves. At least, that's what her organization used to do. Government funding dried up, and now the trust has been forced to close.
"You really hate to see it disappear, because it is a great link to the past," says American tourist Steve Taylor, who's visiting from Houston. "And at the same time, you kind of wonder how long do you keep it around? Forever? I don't know the answer to that."
Nobody expects the wall to vanish, but it won't be kept up like before. Responsibility will lie with 300 or so different entities along the wall's route, rather than one single organization.
"Wall maintenance has been a bit of an issue for almost 100 years, so these aren't new issues that are cropping up," says Dr. Andrew Birley. He's the archaeologist who runs excavations at a nearby Roman fort called Vindolanda, and the third generation of his family to excavate this site.
Birley says studying ancient history gives him a long view of borders and empires.
"Frontiers are not permanent things. Hadrian's Wall is a great example of that. It took a mighty Roman army here for almost 300 years to maintain this barrier between peoples," he says.
As an Englishman, Birley won't be voting on Scottish independence. But he says his personal view is, why shove up more walls? He thinks, better to bring barriers down than put new ones up.
Each weekend, we look back on the tech week that was, which includes original content from NPR and the stories worth noting from across the Internet. Here we go...
Amazon Buys Twitch: In a nearly $1 billion purchase, Amazon bought the exceedingly popular Twitch, which allows viewers to watch live streams of gamers gaming. Amazon edged out Google, which had been expected to pay a similar amount for the service.
Sad Desk Microwave: For our weekly innovation pick, we went with the Brainwave, a UK-based designer's concept for a small desktop microwave, powered by your computer. The only downside is it's only a prototype, for now ...
The Big Conversation
Big Banks Breached: The nation's largest bank, JP Morgan Chase, and four other US banks were attacked by sophisticated hackers. Federal investigators are looking into whether Russians were behind this breach, possibly in retaliation for U.S.-led sanctions.
Smartwatches Galore: So much smart watch news, so little time. LG and Samsung have unveiled new devices, and mark down Sept. 9 for Apple's next announcement. The invite says only, "Wish we could say more," but tech watchers are wondering whether the much-rumored iWatch will finally make its first appearance.
The Verge: This is Uber's Playbook for Sabotaging Lyft
Uber's been aggressively trying to crowd out its competition in various cities, and The Verge says it got the playbook.
The iPad education revolution stalls.
The Atlantic: Inside Google's Secret Drone Delivery Program
It's not just Amazon toying with drones. Can Google rule the skies?
Well, this was kinda demoralizing.
A federal judge in Austin struck down part of a Texas law that would have required all abortion clinics in the state to meet the same standards as outpatient surgical centers. The regulation, which was set to go into effect Monday, would have shuttered about a dozen abortion clinics, leaving only eight places in Texas to get a legal abortion — all in major cities.
Judge Lee Yeakel ruled late Friday afternoon that the state's regulation was unconstitutional and would have placed an undue burden on women, particularly on poor and rural women living in west Texas and the Rio Grande Valley.
Texas Attorney General Greg Abbott, a Republican running for governor, immediately filed an appeal with the 5th U.S. Circuit Court of Appeals.
"We applaud today's ruling from Judge Yeakel," says Rochelle Tafolla, a spokeswoman for Planned Parenthood Gulf Coast in Houston. "But we also understand that the fight to protect women's access to medical care, including safe and legal abortion, is not over."
Supporters of the law argued that the surgical center requirement would make abortion safer, but the judge found no health benefit. He ruled that the effect might actually be the opposite, writing: "Higher health risks associated with increased delays in seeking early abortion care, risks associated with longer distance automotive travel on traffic-laden highways, and the act's possible connection to observed increases in self-induced abortions almost certainly cancel out any potential health benefit associated with the requirement."
Yeakel also noted that the intent of the Texas rule was to close existing abortion clinics, given that the state left no provision for "grandfathering" existing clinics that could not afford millions of dollars in upgrades to comply with the regulations that govern surgery centers.
A local Houston obstetrician-gynecologist who performs abortions calls Yeakel's ruling "beautiful." (The physician asked not to be identified because he fears retribution from abortion protesters.)
The doctor says that if the Texas law had been upheld, he would have had to stop performing abortions in his two office locations because they do not meet the surgery center requirements, which include particular hallway dimensions and certain equipment. He says he cannot afford to construct or purchase an outpatient surgery center, and leasing space in an existing center is difficult because other tenants don't want protesters around.
"This was a good case," he says "There is no medical anything, anywhere, to show that having this done in a hospital or ambulatory surgical center is safer. It's nonsense; it's not. Complications are the same, risks are the same."
With the day the law was supposed to go into effect fast approaching, the doctor says he told some patients who called this week seeking abortions to make appointments, but to keep in contact with his office.
" 'You call me, listen to the news, keep your fingers crossed and pray for the women of Texas to have their constitutional rights restored.' That's what I told patients today," he says.
Texas Right to Life, a Houston-based group, said in a statement that "Pro-Life Texans are disappointed in the dangerous ruling and disconcerted by the prospect that the financial interests of big business abortionists are placed in higher regard than the safety and health of women. The women of Texas have been subjected to shoddy, sub-par and potentially dangerous abortion facilities for too long."
In the decision, Yeakel, who was appointed to the court in 2003 by President George W. Bush, focused on poor, rural and disadvantaged women. He says the burden did not just involve the hundreds of miles some women would have had to travel. He says that distance had to be assessed along with other factors, such as the need for child care, the unreliability of transportation, the inability to take time off work, and even immigration status and the inability to pass immigration checkpoints.
He writes in the decision, "When viewed in the context of the other state-imposed obstacles a woman faces when seeking an abortion in Texas — including a sonogram requirement, a waiting period, and the reduced number of abortion performing physicians resulting from the admitting-privilege requirement — the court is firmly convinced that the State has placed unreasonable obstacles in the path of a woman's ability to obtain a pre-viability abortion."
The Houston doctor who says he's relieved by Yeakel's decision,also says he realizes he may have to cancel abortion appointments next week — depending on how the Fifth Circuit responds. He says his patients have to become more proactive.
"I'm there to support them in their right to choose," he says. "But you know, I'm not going to take the whole thing on my head. If they want it, they should be out there, actually protesting and voting too."
This story is part of NPR's reporting partnership Houston Public Media and Kaiser Health News.