The study deserves its rightful place at the bottom of the waste basket. All one needs to know is that the comparitor/control for accuracy was twice daily blood pressure taken at home. After 40 years of practice, the nurses in the hospital and even in my office do Not know how to take an accurate blood pressure. Those taking their own blood pressure I’m sure sit for two minutes, have the right size cuff if using an arm cuff at the level of the heart, and take their blood pressure under identical circumstances every day. What a farce. Virtually, each and every time a patient asked for an urgent visit because “my blood pressure is too high“ and upon arrival to the office don’t have a clue about how to take there blood pressure. It’s amazing how much high blood pressure I’ve cured by having a patient come in and demonstrating the right technique as well as simultaneous blood pressures comparing my calibrated cuffs against theirs.
Apple has joined Pharma in producing studies for purely marketing reasons. Garbage in, garbage out
A missing dimension is patient behavior over time. Repeated low-confidence alerts may normalize anxiety, reduce trust, or trigger alert fatigue, undermining real hypertension care. I agree the issue isn’t test accuracy alone. In my view, without clear pathways, education, and triage ownership, wearable alerts risk shifting cognitive load to patients and primary care without improving outcomes.
Re: my comment just made, and a future of tech physical surveillance and slavery under antichrist in the end times:
“Mary K. Baxter: Surveillance & mind-control by the beast: “A Divine Revelation of Hell” 1983
Chapter 18:
Open Visions from Hell, -A Divine Revelation of Hell, —Mary K. Baxter 1983
The Lord said, "This vision is for the future, and it will come to pass. But I shall return to redeem My bride, My church, and they shall not see it. Awaken, o My people I Sound the alarm to the comers of the earth, for I shall return as My Word has spoken."
I beheld the fiery serpent that was in the right arm of Hell. Jesus said, "Come, see what the Spirit is saying to the world."
I saw the horns of the fiery serpent as they entered the bodies of people on earth. Many were completely possessed by the serpent. As I watched, I saw a huge beast arise in a large place and turn into a man. The inhabitants of the earth ran from him, some into the wilderness, some into caves, and some into subway stations and bomb shelters. They sought any shelter to hide from the eyes of the beast. No one was praising God or talking about Jesus.
A voice said to me, "Where are My people?" I looked closer and saw people like dead men walking. There was a desperate sadness in the air, and no one turned to the right or left. I saw that the people were being led about by some unseen force. Now and then a voice spoke to them out of the air, and they obeyed the voice. They did not talk to one another. I saw too that the number "666" was written on each one's forehead and on his hands. I saw soldiers on horses herding the people about as though they were cattle.
The American flag, tattered and torn, lay forlornly on the ground. There was no joy, no laughter, no happiness. I saw death and evil everywhere.
The people walked one behind another into a large department store. They kept in step like discouraged soldiers and were dressed identically in a type of prison garb. A fence surrounded the store, and guards were stationed here and there. Everywhere I looked, I saw soldiers in battle-dress uniforms.
I saw these zombie-like people herded into the store, where they were able to buy only the barest necessities. As each completed his purchases, he was placed aboard a large green army truck. The truck, well-guarded, was then driven to another area.
Here, in a type of clinic, these people were examined for communicable diseases or crippling handicaps. A small number of them were shuffled to the side as rejects.
Soon, those who failed the examination were taken to another room. In that room, an impressive array of switches, buttons and gages lined an entire wall. A door opened, and several technicians came in. One of them began to call the names of the people in the room. Without a struggle, they arose when their names were called and marched into a large box. When they were inside, another technician closed the door and pulled a switch in a panel on the wall.
A few minutes later he opened the door, took down a broom and dust pan, and swept what remained of them off the floor. Nothing but a bit of dust was left of what had once been a roomful of people!
I saw those people who passed the medical exam being put back into the same truck and driven to a train. No one spoke or even turned to look at anyone else. At another building each person was assigned a job. They all went to work without a single dispute. I watched as they worked very hard at their assigned tasks, and then at the end of the day, they were taken to an apartment building with a high fence around it. Each undressed and went to bed. Tomorrow they would work hard again.
I heard a loud voice fill the night air. I saw a huge beast, and he sat on a large, I throne. All the people obeyed the beast. I saw spiritual horns growing from his head. They reached, into and out of every place on earth. The beast took upon himself many positions of authority and many j offices, and he became great in power.
The beast pushed himself into many places and deceived many people. The rich and the famous were deceived as well as the poor and disfranchised. Small and great paid homage to the beast.
A large machine was brought into an office. The beast put his mark on it, and his voice came out of it. There was also a "big brother" machine that could see into homes and businesses. Only a single machine of this type existed, and it belonged to the beast. The part of the machine that was located in the homes of the people was invisible to the naked eye, but it could and did report to the beast every move the people made. I watched as the beast turned his throne around and faced toward me. On his forehead was the number 666.
As I watched, I saw another man in another office become very angry at the beast. He demanded to talk with him. He was yelling at the top of his voice. The beast appeared and seemed very courteous as he said, "Come, I can help you take care of all your problems."
The beast took the angry man into a large room and motioned for him to lie down on a table. The room and the table reminded me of a hospital emergency room. The man was given an anesthesia and wheeled beneath a vast machine. The beast attached wires to the man's head and turned on the machine. On the top of the machine were the words, "This mind eraser belongs to the beast, 666."
When the man was removed from the table, his eyes had a vacant stare, and his movements reminded one of a zombie in a movie. I saw a large blank spot on the top of his head, and I knew his mind had been surgically altered so he could be controlled by the beast. The beast said, "Now, sir, don't you feel better? Didn't I say I could take care of all your problems? I have given you a new mind. You will have no worries or troubles now."
The man did not speak.
"You will obey my every command," said the beast as he picked up a small object and attached it to the man's shirt. He spoke again to the man, and he answered without moving his lips. He moved like a living dead man. "You will work and not get angry or frustrated, nor will you cry or be sad. You will work for me until you die. I have many like you that I control. Some lie, some kill, some steal, some make war, some have children, some run machinery, and some do other things. Yes, I control everything." An evil laugh came from him.
The man was handed papers to sign. He gladly gave all his belongings to the beast.
In my vision I saw the man leave the office of the beast, get in a car and drive home. When
he approached his wife, she tried to kiss him, but he made no attempt to respond. He had no feeling for his wife or anyone else. The beast had made him incapable of feeling any emotion.
The wife became very angry and screamed at her husband, but to no avail. At last she said, "OK, I'll call the beast. He will know what to do." After a quick phone call, she left the house and drove to the same building her husband had just left.
The beast welcomed her in and said, "Tell me all your troubles. I am sure I can help you."
A very handsome man took her by the arm and led her to the same table her husband had been on earlier. After the same operation, she also became a depersonalized slave of the beast.
I heard the beast ask her, "How do you feel?" She did not answer until after he had attached a small object to her blouse. Then she acknowledged that he was master and lord and began to worship him.
"You will be a breeder," he said. "You will have perfect babies, and they will worship and serve me." The woman replied in a robotic voice, "Yes, master, I will obey."
I saw the woman again. This time she was in another building. There were many pregnant women there. The women lay lifelessly on their beds and in chanted monotones praised the beast. All had 666 on their foreheads.
When their babies were born, they were taken to another building where mind-altered nurses had the task of raising them. The nurses also had 666 on their foreheads.
The beast grew in power until his empire stretched across the earth. The babies also grew, and at a certain time, they also went beneath the mind-destroying machine. They worshiped the beast and his image. But the machine had no power over the children of God.
I heard the voice of the Lord say, "Those that worship the beast and his image shall perish. Many shall be deceived and will fall, but I will save my children from the beast. These things will take place in the end times. Do not take the mark of the beast. Repent now before it is too late.
"The beast will call himself a man of peace. And he will bring peace to many nations out of a very chaotic time. He will be able to supply the world with many inexpensive goods, and he will assure that everyone's pay is sufficient. He will make an alliance with many nations, and the great men of the world will follow him into a false sense of security.
"Before these times I will raise up an army of believers that will stand for truth and righteousness. The mighty army that Joel spoke about will hear My voice from the rising to the going down of the sun.
"In the night hours also they will hear My voice, and they will answer Me. They will work for Me, and they will run like mighty men of war. They shall do great works for Me, for I will be with them." All these things were revealed to me by the Lord Jesus Christ in an open vision. They are the words of His mouth, and they concern the times of the end.”
This may be a LITTLE “off-topic”, but since the Bible says in the last days, “your young men will see visions and old men dream dreams,” I’m inclined to believe a dream I had and wrote down over a year ago:
In this dream, I’m in public transport; something modern looking, perhaps even a monorail or BART-type conveyance. Near me is a young lady with a white cell phone: and I begin to speak to her, and even in the dream I’m wondering where my words are COMING from; as I’ve got no specific knowledge of what I’m telling her, which is this: “the biometric data about you your phone collects will at length be used to allow you to be “worked” to the point you will have no time for contemplation or meditation.” Upon waking, or still within the dream, I begin to think of the implications of what I’ve said, which are these: In the past, slaveholders could not push their slaves (which were valuable property: Judas, for instance, offered 30 pieces of silver to betray Jesus, was receiving the price of one slave at that period.) You didn’t want your slave to drop dead, so you must have given them some margin; for rest, (and who knows, singing those spirituals as they picked cotton?)
But with this new tech, a modern “slave” can be safely pushed to the physical and mental limit, leaving no time to contemplate God or their situation… And this idea seems foreshadowed by chapter 18, of a 1980s book, “A Divine Revelation of Hell,” about a grim American (& likely worldwide) workforce under 24/7 monitoring; monitoring which even alerts authorities if someone is ANGRY: working hard all day, and falling into bed at night, exhausted.
For anyone interested, this book by a shy, unassuming author, Mary Baxter, is still available. If a comment this long is allowed, I’ll place it here: but the takeaway is that mankind doesn’t have the morals to handle the power we now possess; and it will turn upon us:
Mary K. Baxter: Surveillance & mind-control by the beast: “A Divine Revelation of Hell” 1983
"Primary care needs to get out of the preventive care business." It is nice to see a common sense solution to the shortage of primary care physicians. The task of primary care medicine is to differentiate health from disease for people that have symptoms or questions concerning their physical health. If disease is found, they can recommend options for treatment and/or refer the patient to a specialist. If no disease is found, they can give reassurance. Doctors don't know the cause of most diseases and don't know how to prevent hardly any of them. The recommendations of those that think they do usually revolve around management of "lifestyle" factors that are impossible to verify or falsify with any scientific validity. We have grandmothers that have traditionally filled that role.
What’s striking here is the sharp distinction drawn between reassurance and prevention. I partly agree that primary care is overburdened by speculative lifestyle counseling with weak falsifiability. However, I think abandoning prevention entirely risks widening inequities, since not everyone has a “grandmother” buffer. The challenge is redefining prevention as targeted, evidence-driven triage rather than moralized lifestyle policing.
If it’s as good at detecting blood pressure as it is at falls it’s NBG. Mine would routinely allow me when I was sitting in a chair, listening to the patient’s story. I had to turn the thing off and I love my watch. I do more EKGs on it than on the 12 lead.
This highlights the human–machine mismatch more than algorithm failure. Context blindness, sitting still versus falling, creates noise that clinicians quickly learn to ignore. I agree the tech is impressive yet intrusive. In my view, wearables currently function best as clinician-facing adjuncts (like quick ECGs), not autonomous screening tools imposed on everyday life.
“Primary care needs to get out of the preventive care business.”
Huh? This statement casts the entire essay into serious doubt.
Primary prevention using well supported methods is the best way to reduce morbidity and mortality in the future, and should be the goal of primary care family docs, pediatricians and internists.
The solution to overloading primary care doctors with new patients is not to stop providing preventative care. It is to continue to increase the number of primary care physicians.
What this critique surfaces is a definitional clash, not a factual one. I agree prevention matters, but primary care cannot absorb unlimited population screening triggered by consumer tech. In my opinion, the real fix is tiered prevention: broad public health measures upstream, while clinicians focus on evidence-based prevention for clearly stratified, high-risk patients, not every alerted wrist.
Thanks. I know how that sentence sounds, but my take is from someone in clinic having to prioritize interventions for a complicated underserved panel. Our current model both in medical training and public health approach has been undifferentiated and medicalizes everything. My point is this version of an unfocused primary care model takes away or distracts from other interventions that might be higher value. (Education, food chain, public transportation, employment etc). Not to mention that model leads to administrative burden and "burnout" at mass scale of providers.
Instead of giving healthy people the flu vaccine or colonoscopy referrals we need to prioritize those with comorbidities who are acutely ill.
I completely agree that it is not a doctor’s job to somehow prevent a society-wide problem of terrible lifestyles. Does anyone think that it is doctors or hospitals that caused an obesity rate in France that is less than 25% of what we have in the US? Exactly how could that happen? Diabetes, hip and knee replacements, heart disease, and related illnesses are overwhelmingly the result of a problem in our society.
Sorry, JD. Opportunistic screening causes more harm than good. It’s evidence based is essentially non existent. Try colonoscopy. NORDICC study says no good. Ditto modern Canadian mammogram study. How about PSA screening? Do you prefer impotence or incontinence? And you won’t live a minute longer.
We doctors can’t prevent much. That’s your job to do. Eat healthy. Stay this. Exercise. Listen to your body and report any change to your doctor.
I agree opportunistic screening often disappoints and can harm, yet dismissing prevention entirely overshoots. In my view, medicine should pivot from blanket screening to informed choice: transparent tradeoffs, symptom vigilance, and selective prevention where benefit is demonstrable, not hope-driven testing.
I agree that most screening is pretty useless (except cervical cancer- despite the lack of trials). However, BP and Hba1C are essentially diagnostic in their own right. With a few caveats there are very few false positives or false negatives, so they shouldn't be seen as opportunistic screening. They are more like opportunistic diagnosis. I'm not aware of the evidence for opportunistic diagnosis but it makes a lot of sense.
According to ChatGPT 48% of Americans have hypertension/high blood pressure. I'm one of them. I take Losartan. Everytime I go to any Dr for anything, they take my BP. I think having it on the watch is a not needed feature. Having to check it and see it would make my BP rise!
I've had the thought recently: If you could have a full body monitor/scanner/tester that was constantly evaluating the state of your entire body, would you want such a device? Would such a device be "healthy" for you? I think certainly not. Constantly fretting over every little variation or deviation from mean would not make a happy, full, well-lived life.
This raises a crucial psychological dimension often overlooked in tech-driven health. I agree, hyper-surveillance can amplify anxiety and reduce quality of life, even if medically informative. In my view, health tech should balance insight with peace of mind: intermittent, context-aware monitoring may empower without obsession, preserving both mental wellness and genuine preventive benefit.
It reminds me of the "move fast and break things" mentality of silicon valley. It sounds like those testers I see at drug stores would be more reliable as a prescreening* and then the pharmacy could send someone home with a proper tester and some instructions for a small fee or just as a public good.
I work in a factory big enough place to have nurses on site that in the past have done BP testing. Not everyone is so lucky but it's such a simple test that there should be more options that don't tie up doctor time while reaching more people.
Love my Garmin watch, 24/7 wearer but from what I understand about BP monitoring I don't expect a watch will replace the cuff tester in my time. Sometimes I am wrong though.
*Assuming if you have BP below target while out shopping you are probably ok.
I think it's reasonable for everyone to have their BP check formally once in their 20s, once in their 30s and every 5 years after that. It's a simple and cheap test. You don't need a doctor or a nurse
I agree the problem is getting them to a test. I had mine measured in my late teens before a surgery and then didn’t give it much thought until my 40’s. My dentist has measured it but that’s not a great environment to get a normal reading. Optometrists might play a bigger role in screening. I find that a more relaxed environment.
Just thinking now it’s good to know when a paramedic asks if it’s normally low in the ambulance. Many people wouldn’t know one way or another.
Regarding your interesting comment on the usefulness of the Apple Watch for the detection of hypertension, in our department we have taught that there are at least five aspects to consider when deciding whether to use a diagnostic test. Four of them go well beyond its operational performance (sensitivity, specificity, overall accuracy, Youden index, post-test diagnostic probabilities, even the number needed to test for a true positive or a false negative, and the diagnostic help-to-harm ratio).
It is worth noting that the detection of hypertension using the Apple Watch shows a very modest overall diagnostic odds ratio (DOR) of 10.6; in other words, it is a diagnostically weak test.
The first of these additional aspects is the user’s pre-test probability of hypertension. Assuming some hypothetical validity of hypertension detection by Apple Watch PPG, and given its relatively higher specificity, such a tool would be indicated not as a screening test, but rather as a confirmatory test—used in the clinic or in a primary care setting, not in the community.
The second aspect concerns ease of use, immediacy, intrinsic safety, comfort, innocuous, costless. From this perspective, the Apple Watch would be close to an ideal test for detecting hypertension. We should not forget that there is a growing group of patients with sympathetic hypertonia associated with metabolic syndrome (highly prevalent in the USA) who develop induced “hypertension” (false positives) simply due to the pressure exerted by the sphygmomanometer cuff during measurement—a phenomenon that years ago we referred to as “white-coat hypertension.” Because the Apple Watch sensor is imperceptible, this particular source of error would likely be eliminated.
However, the third—and perhaps most important—element to consider is whether the use of the Apple Watch hypertension sensor would alter the natural history of the risks inherent in so-called “chronic and pathological esencial” arterial hypertension. This question may ultimately be impossible to answer, because medicine continues to suffer from a profound ignorance and conceptual distortion regarding hypertension itself: is it a sign, a symptom, a risk factor, a prognostic marker, an abnormality, a disease, an illness?
In practice, hypertension is instead defined as a pair of numbers—120/80—applied normatively and universally (why could 123/77 or 125/81 not be normal for a given individual?), which have been arbitrarily established using risk-based criteria (because those risks do indeed decrease modestly when such numbers are controlled). Consequently, clinical management becomes centered almost exclusively on prescribing one or more “antihypertensive” drugs, titrated according to those numerical targets.
But what if essential hypertension is, in fact, a homeostatic sympathetic response to mitochondrial distress caused by hypoperfusion secondary to an underlying endotheliometabolic disease that continues to progress unchecked within the organism? In that case, what would truly be the value of having “controlled hypertension”?
I really wish people would stop using sensitivity and specificity to define tests. They are among the most outdated and over-rated statistics in testing. Also, when you quote a PPV or NPV you MUST quote the prevalence - in this example 20%- otherwise it makes no sense whatsoever. Much better to use likelihood ratios with pre and post test probabilities. Bottom line, this is a crummy test that has been improperly studies but will probably make Apple another fortune.
Sensitivity and specificity can be more easily described to laypersons than likelihood ratios. E.g., "if you're like the people in this study who had hypertension, your watch will fail to detect high blood pressure about 59% of the time" (or something like that).
I completely disagree. What people want to know is the probability of having hypertension if the watch gives an alert. In this case, 71%, and if the test is negative it is 23%. This is patient informative. You can't get those numbers if all you know is the sensitivity and specificity.
All the caveats aside, I really like the thinking and the approach. I also agree with the conclusion that a watch reminder is not a solution to hypertension.
One question I have is as follows:
Given the age distribution of the digitally misdiagnosed population, what would be the potential spillover benefit of a primary care visit to diagnose other possible undetected cardiometabolic (or even neoplastic) conditions? Could there be a spillover benefit here and would this benefit justify the primare care system overload?
The study deserves its rightful place at the bottom of the waste basket. All one needs to know is that the comparitor/control for accuracy was twice daily blood pressure taken at home. After 40 years of practice, the nurses in the hospital and even in my office do Not know how to take an accurate blood pressure. Those taking their own blood pressure I’m sure sit for two minutes, have the right size cuff if using an arm cuff at the level of the heart, and take their blood pressure under identical circumstances every day. What a farce. Virtually, each and every time a patient asked for an urgent visit because “my blood pressure is too high“ and upon arrival to the office don’t have a clue about how to take there blood pressure. It’s amazing how much high blood pressure I’ve cured by having a patient come in and demonstrating the right technique as well as simultaneous blood pressures comparing my calibrated cuffs against theirs.
Apple has joined Pharma in producing studies for purely marketing reasons. Garbage in, garbage out
Ben Hourani MD,MBA
A missing dimension is patient behavior over time. Repeated low-confidence alerts may normalize anxiety, reduce trust, or trigger alert fatigue, undermining real hypertension care. I agree the issue isn’t test accuracy alone. In my view, without clear pathways, education, and triage ownership, wearable alerts risk shifting cognitive load to patients and primary care without improving outcomes.
I think this article gets the sensitivity and specificity numbers the wrong way around (after defining them correctly).
Re: my comment just made, and a future of tech physical surveillance and slavery under antichrist in the end times:
“Mary K. Baxter: Surveillance & mind-control by the beast: “A Divine Revelation of Hell” 1983
Chapter 18:
Open Visions from Hell, -A Divine Revelation of Hell, —Mary K. Baxter 1983
The Lord said, "This vision is for the future, and it will come to pass. But I shall return to redeem My bride, My church, and they shall not see it. Awaken, o My people I Sound the alarm to the comers of the earth, for I shall return as My Word has spoken."
I beheld the fiery serpent that was in the right arm of Hell. Jesus said, "Come, see what the Spirit is saying to the world."
I saw the horns of the fiery serpent as they entered the bodies of people on earth. Many were completely possessed by the serpent. As I watched, I saw a huge beast arise in a large place and turn into a man. The inhabitants of the earth ran from him, some into the wilderness, some into caves, and some into subway stations and bomb shelters. They sought any shelter to hide from the eyes of the beast. No one was praising God or talking about Jesus.
A voice said to me, "Where are My people?" I looked closer and saw people like dead men walking. There was a desperate sadness in the air, and no one turned to the right or left. I saw that the people were being led about by some unseen force. Now and then a voice spoke to them out of the air, and they obeyed the voice. They did not talk to one another. I saw too that the number "666" was written on each one's forehead and on his hands. I saw soldiers on horses herding the people about as though they were cattle.
The American flag, tattered and torn, lay forlornly on the ground. There was no joy, no laughter, no happiness. I saw death and evil everywhere.
The people walked one behind another into a large department store. They kept in step like discouraged soldiers and were dressed identically in a type of prison garb. A fence surrounded the store, and guards were stationed here and there. Everywhere I looked, I saw soldiers in battle-dress uniforms.
I saw these zombie-like people herded into the store, where they were able to buy only the barest necessities. As each completed his purchases, he was placed aboard a large green army truck. The truck, well-guarded, was then driven to another area.
Here, in a type of clinic, these people were examined for communicable diseases or crippling handicaps. A small number of them were shuffled to the side as rejects.
Soon, those who failed the examination were taken to another room. In that room, an impressive array of switches, buttons and gages lined an entire wall. A door opened, and several technicians came in. One of them began to call the names of the people in the room. Without a struggle, they arose when their names were called and marched into a large box. When they were inside, another technician closed the door and pulled a switch in a panel on the wall.
A few minutes later he opened the door, took down a broom and dust pan, and swept what remained of them off the floor. Nothing but a bit of dust was left of what had once been a roomful of people!
I saw those people who passed the medical exam being put back into the same truck and driven to a train. No one spoke or even turned to look at anyone else. At another building each person was assigned a job. They all went to work without a single dispute. I watched as they worked very hard at their assigned tasks, and then at the end of the day, they were taken to an apartment building with a high fence around it. Each undressed and went to bed. Tomorrow they would work hard again.
I heard a loud voice fill the night air. I saw a huge beast, and he sat on a large, I throne. All the people obeyed the beast. I saw spiritual horns growing from his head. They reached, into and out of every place on earth. The beast took upon himself many positions of authority and many j offices, and he became great in power.
The beast pushed himself into many places and deceived many people. The rich and the famous were deceived as well as the poor and disfranchised. Small and great paid homage to the beast.
A large machine was brought into an office. The beast put his mark on it, and his voice came out of it. There was also a "big brother" machine that could see into homes and businesses. Only a single machine of this type existed, and it belonged to the beast. The part of the machine that was located in the homes of the people was invisible to the naked eye, but it could and did report to the beast every move the people made. I watched as the beast turned his throne around and faced toward me. On his forehead was the number 666.
As I watched, I saw another man in another office become very angry at the beast. He demanded to talk with him. He was yelling at the top of his voice. The beast appeared and seemed very courteous as he said, "Come, I can help you take care of all your problems."
The beast took the angry man into a large room and motioned for him to lie down on a table. The room and the table reminded me of a hospital emergency room. The man was given an anesthesia and wheeled beneath a vast machine. The beast attached wires to the man's head and turned on the machine. On the top of the machine were the words, "This mind eraser belongs to the beast, 666."
When the man was removed from the table, his eyes had a vacant stare, and his movements reminded one of a zombie in a movie. I saw a large blank spot on the top of his head, and I knew his mind had been surgically altered so he could be controlled by the beast. The beast said, "Now, sir, don't you feel better? Didn't I say I could take care of all your problems? I have given you a new mind. You will have no worries or troubles now."
The man did not speak.
"You will obey my every command," said the beast as he picked up a small object and attached it to the man's shirt. He spoke again to the man, and he answered without moving his lips. He moved like a living dead man. "You will work and not get angry or frustrated, nor will you cry or be sad. You will work for me until you die. I have many like you that I control. Some lie, some kill, some steal, some make war, some have children, some run machinery, and some do other things. Yes, I control everything." An evil laugh came from him.
The man was handed papers to sign. He gladly gave all his belongings to the beast.
In my vision I saw the man leave the office of the beast, get in a car and drive home. When
he approached his wife, she tried to kiss him, but he made no attempt to respond. He had no feeling for his wife or anyone else. The beast had made him incapable of feeling any emotion.
The wife became very angry and screamed at her husband, but to no avail. At last she said, "OK, I'll call the beast. He will know what to do." After a quick phone call, she left the house and drove to the same building her husband had just left.
The beast welcomed her in and said, "Tell me all your troubles. I am sure I can help you."
A very handsome man took her by the arm and led her to the same table her husband had been on earlier. After the same operation, she also became a depersonalized slave of the beast.
I heard the beast ask her, "How do you feel?" She did not answer until after he had attached a small object to her blouse. Then she acknowledged that he was master and lord and began to worship him.
"You will be a breeder," he said. "You will have perfect babies, and they will worship and serve me." The woman replied in a robotic voice, "Yes, master, I will obey."
I saw the woman again. This time she was in another building. There were many pregnant women there. The women lay lifelessly on their beds and in chanted monotones praised the beast. All had 666 on their foreheads.
When their babies were born, they were taken to another building where mind-altered nurses had the task of raising them. The nurses also had 666 on their foreheads.
The beast grew in power until his empire stretched across the earth. The babies also grew, and at a certain time, they also went beneath the mind-destroying machine. They worshiped the beast and his image. But the machine had no power over the children of God.
I heard the voice of the Lord say, "Those that worship the beast and his image shall perish. Many shall be deceived and will fall, but I will save my children from the beast. These things will take place in the end times. Do not take the mark of the beast. Repent now before it is too late.
"The beast will call himself a man of peace. And he will bring peace to many nations out of a very chaotic time. He will be able to supply the world with many inexpensive goods, and he will assure that everyone's pay is sufficient. He will make an alliance with many nations, and the great men of the world will follow him into a false sense of security.
"Before these times I will raise up an army of believers that will stand for truth and righteousness. The mighty army that Joel spoke about will hear My voice from the rising to the going down of the sun.
"In the night hours also they will hear My voice, and they will answer Me. They will work for Me, and they will run like mighty men of war. They shall do great works for Me, for I will be with them." All these things were revealed to me by the Lord Jesus Christ in an open vision. They are the words of His mouth, and they concern the times of the end.”
This may be a LITTLE “off-topic”, but since the Bible says in the last days, “your young men will see visions and old men dream dreams,” I’m inclined to believe a dream I had and wrote down over a year ago:
In this dream, I’m in public transport; something modern looking, perhaps even a monorail or BART-type conveyance. Near me is a young lady with a white cell phone: and I begin to speak to her, and even in the dream I’m wondering where my words are COMING from; as I’ve got no specific knowledge of what I’m telling her, which is this: “the biometric data about you your phone collects will at length be used to allow you to be “worked” to the point you will have no time for contemplation or meditation.” Upon waking, or still within the dream, I begin to think of the implications of what I’ve said, which are these: In the past, slaveholders could not push their slaves (which were valuable property: Judas, for instance, offered 30 pieces of silver to betray Jesus, was receiving the price of one slave at that period.) You didn’t want your slave to drop dead, so you must have given them some margin; for rest, (and who knows, singing those spirituals as they picked cotton?)
But with this new tech, a modern “slave” can be safely pushed to the physical and mental limit, leaving no time to contemplate God or their situation… And this idea seems foreshadowed by chapter 18, of a 1980s book, “A Divine Revelation of Hell,” about a grim American (& likely worldwide) workforce under 24/7 monitoring; monitoring which even alerts authorities if someone is ANGRY: working hard all day, and falling into bed at night, exhausted.
For anyone interested, this book by a shy, unassuming author, Mary Baxter, is still available. If a comment this long is allowed, I’ll place it here: but the takeaway is that mankind doesn’t have the morals to handle the power we now possess; and it will turn upon us:
Mary K. Baxter: Surveillance & mind-control by the beast: “A Divine Revelation of Hell” 1983
I haven't read the article yet. But thinking about the title, we've never had a problem with detecting hypertension.
"Primary care needs to get out of the preventive care business." It is nice to see a common sense solution to the shortage of primary care physicians. The task of primary care medicine is to differentiate health from disease for people that have symptoms or questions concerning their physical health. If disease is found, they can recommend options for treatment and/or refer the patient to a specialist. If no disease is found, they can give reassurance. Doctors don't know the cause of most diseases and don't know how to prevent hardly any of them. The recommendations of those that think they do usually revolve around management of "lifestyle" factors that are impossible to verify or falsify with any scientific validity. We have grandmothers that have traditionally filled that role.
What’s striking here is the sharp distinction drawn between reassurance and prevention. I partly agree that primary care is overburdened by speculative lifestyle counseling with weak falsifiability. However, I think abandoning prevention entirely risks widening inequities, since not everyone has a “grandmother” buffer. The challenge is redefining prevention as targeted, evidence-driven triage rather than moralized lifestyle policing.
If it’s as good at detecting blood pressure as it is at falls it’s NBG. Mine would routinely allow me when I was sitting in a chair, listening to the patient’s story. I had to turn the thing off and I love my watch. I do more EKGs on it than on the 12 lead.
This highlights the human–machine mismatch more than algorithm failure. Context blindness, sitting still versus falling, creates noise that clinicians quickly learn to ignore. I agree the tech is impressive yet intrusive. In my view, wearables currently function best as clinician-facing adjuncts (like quick ECGs), not autonomous screening tools imposed on everyday life.
“Primary care needs to get out of the preventive care business.”
Huh? This statement casts the entire essay into serious doubt.
Primary prevention using well supported methods is the best way to reduce morbidity and mortality in the future, and should be the goal of primary care family docs, pediatricians and internists.
The solution to overloading primary care doctors with new patients is not to stop providing preventative care. It is to continue to increase the number of primary care physicians.
What this critique surfaces is a definitional clash, not a factual one. I agree prevention matters, but primary care cannot absorb unlimited population screening triggered by consumer tech. In my opinion, the real fix is tiered prevention: broad public health measures upstream, while clinicians focus on evidence-based prevention for clearly stratified, high-risk patients, not every alerted wrist.
Spot on. I also lost some faith when I read that sentence
Thanks. I know how that sentence sounds, but my take is from someone in clinic having to prioritize interventions for a complicated underserved panel. Our current model both in medical training and public health approach has been undifferentiated and medicalizes everything. My point is this version of an unfocused primary care model takes away or distracts from other interventions that might be higher value. (Education, food chain, public transportation, employment etc). Not to mention that model leads to administrative burden and "burnout" at mass scale of providers.
Instead of giving healthy people the flu vaccine or colonoscopy referrals we need to prioritize those with comorbidities who are acutely ill.
I completely agree that it is not a doctor’s job to somehow prevent a society-wide problem of terrible lifestyles. Does anyone think that it is doctors or hospitals that caused an obesity rate in France that is less than 25% of what we have in the US? Exactly how could that happen? Diabetes, hip and knee replacements, heart disease, and related illnesses are overwhelmingly the result of a problem in our society.
The problem is not in the doctor’s office.
Sorry, JD. Opportunistic screening causes more harm than good. It’s evidence based is essentially non existent. Try colonoscopy. NORDICC study says no good. Ditto modern Canadian mammogram study. How about PSA screening? Do you prefer impotence or incontinence? And you won’t live a minute longer.
We doctors can’t prevent much. That’s your job to do. Eat healthy. Stay this. Exercise. Listen to your body and report any change to your doctor.
I agree opportunistic screening often disappoints and can harm, yet dismissing prevention entirely overshoots. In my view, medicine should pivot from blanket screening to informed choice: transparent tradeoffs, symptom vigilance, and selective prevention where benefit is demonstrable, not hope-driven testing.
I agree that most screening is pretty useless (except cervical cancer- despite the lack of trials). However, BP and Hba1C are essentially diagnostic in their own right. With a few caveats there are very few false positives or false negatives, so they shouldn't be seen as opportunistic screening. They are more like opportunistic diagnosis. I'm not aware of the evidence for opportunistic diagnosis but it makes a lot of sense.
According to ChatGPT 48% of Americans have hypertension/high blood pressure. I'm one of them. I take Losartan. Everytime I go to any Dr for anything, they take my BP. I think having it on the watch is a not needed feature. Having to check it and see it would make my BP rise!
I've had the thought recently: If you could have a full body monitor/scanner/tester that was constantly evaluating the state of your entire body, would you want such a device? Would such a device be "healthy" for you? I think certainly not. Constantly fretting over every little variation or deviation from mean would not make a happy, full, well-lived life.
This raises a crucial psychological dimension often overlooked in tech-driven health. I agree, hyper-surveillance can amplify anxiety and reduce quality of life, even if medically informative. In my view, health tech should balance insight with peace of mind: intermittent, context-aware monitoring may empower without obsession, preserving both mental wellness and genuine preventive benefit.
The watch is only as good as a flea collar worn by a dog.
It reminds me of the "move fast and break things" mentality of silicon valley. It sounds like those testers I see at drug stores would be more reliable as a prescreening* and then the pharmacy could send someone home with a proper tester and some instructions for a small fee or just as a public good.
I work in a factory big enough place to have nurses on site that in the past have done BP testing. Not everyone is so lucky but it's such a simple test that there should be more options that don't tie up doctor time while reaching more people.
Love my Garmin watch, 24/7 wearer but from what I understand about BP monitoring I don't expect a watch will replace the cuff tester in my time. Sometimes I am wrong though.
*Assuming if you have BP below target while out shopping you are probably ok.
I think it's reasonable for everyone to have their BP check formally once in their 20s, once in their 30s and every 5 years after that. It's a simple and cheap test. You don't need a doctor or a nurse
I agree the problem is getting them to a test. I had mine measured in my late teens before a surgery and then didn’t give it much thought until my 40’s. My dentist has measured it but that’s not a great environment to get a normal reading. Optometrists might play a bigger role in screening. I find that a more relaxed environment.
Just thinking now it’s good to know when a paramedic asks if it’s normally low in the ambulance. Many people wouldn’t know one way or another.
Dr. Folmsbee,
Regarding your interesting comment on the usefulness of the Apple Watch for the detection of hypertension, in our department we have taught that there are at least five aspects to consider when deciding whether to use a diagnostic test. Four of them go well beyond its operational performance (sensitivity, specificity, overall accuracy, Youden index, post-test diagnostic probabilities, even the number needed to test for a true positive or a false negative, and the diagnostic help-to-harm ratio).
It is worth noting that the detection of hypertension using the Apple Watch shows a very modest overall diagnostic odds ratio (DOR) of 10.6; in other words, it is a diagnostically weak test.
The first of these additional aspects is the user’s pre-test probability of hypertension. Assuming some hypothetical validity of hypertension detection by Apple Watch PPG, and given its relatively higher specificity, such a tool would be indicated not as a screening test, but rather as a confirmatory test—used in the clinic or in a primary care setting, not in the community.
The second aspect concerns ease of use, immediacy, intrinsic safety, comfort, innocuous, costless. From this perspective, the Apple Watch would be close to an ideal test for detecting hypertension. We should not forget that there is a growing group of patients with sympathetic hypertonia associated with metabolic syndrome (highly prevalent in the USA) who develop induced “hypertension” (false positives) simply due to the pressure exerted by the sphygmomanometer cuff during measurement—a phenomenon that years ago we referred to as “white-coat hypertension.” Because the Apple Watch sensor is imperceptible, this particular source of error would likely be eliminated.
However, the third—and perhaps most important—element to consider is whether the use of the Apple Watch hypertension sensor would alter the natural history of the risks inherent in so-called “chronic and pathological esencial” arterial hypertension. This question may ultimately be impossible to answer, because medicine continues to suffer from a profound ignorance and conceptual distortion regarding hypertension itself: is it a sign, a symptom, a risk factor, a prognostic marker, an abnormality, a disease, an illness?
In practice, hypertension is instead defined as a pair of numbers—120/80—applied normatively and universally (why could 123/77 or 125/81 not be normal for a given individual?), which have been arbitrarily established using risk-based criteria (because those risks do indeed decrease modestly when such numbers are controlled). Consequently, clinical management becomes centered almost exclusively on prescribing one or more “antihypertensive” drugs, titrated according to those numerical targets.
But what if essential hypertension is, in fact, a homeostatic sympathetic response to mitochondrial distress caused by hypoperfusion secondary to an underlying endotheliometabolic disease that continues to progress unchecked within the organism? In that case, what would truly be the value of having “controlled hypertension”?
A warm embrace,
Really appreciate the comment. I'm still digesting it. Interesting point about white-coat HTN.
I really wish people would stop using sensitivity and specificity to define tests. They are among the most outdated and over-rated statistics in testing. Also, when you quote a PPV or NPV you MUST quote the prevalence - in this example 20%- otherwise it makes no sense whatsoever. Much better to use likelihood ratios with pre and post test probabilities. Bottom line, this is a crummy test that has been improperly studies but will probably make Apple another fortune.
Sensitivity and specificity can be more easily described to laypersons than likelihood ratios. E.g., "if you're like the people in this study who had hypertension, your watch will fail to detect high blood pressure about 59% of the time" (or something like that).
I completely disagree. What people want to know is the probability of having hypertension if the watch gives an alert. In this case, 71%, and if the test is negative it is 23%. This is patient informative. You can't get those numbers if all you know is the sensitivity and specificity.
All the caveats aside, I really like the thinking and the approach. I also agree with the conclusion that a watch reminder is not a solution to hypertension.
One question I have is as follows:
Given the age distribution of the digitally misdiagnosed population, what would be the potential spillover benefit of a primary care visit to diagnose other possible undetected cardiometabolic (or even neoplastic) conditions? Could there be a spillover benefit here and would this benefit justify the primare care system overload?