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Mike Merrill, MD

I'm a doctor (internal medicine).

Interests: Crossfit Tae Kwon Do Philosophy Economics

Recent Activity

Why are hospital prices so confusing?

A new law requires hospitals to post their prices online. The prices vary quite a bit. Why is this? The main reason, I think, is that in a hospital it is difficult to do cost accounting. "Cost accounting" is figuring out what it costs to do something inside an organization.... Continue reading

Posted Feb 8, 2019 at Dr. Mike Merrill

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Metrics are based on humanness

In healthcare, we understand that metrics have limits. So when we measure diabetes control, we know we're not seeing all of healthcare quality. It's only part of the picture. And we know that each number has a story behind it. For example, diabetes control in a disadvantaged population means something... Continue reading

Posted Jan 30, 2019 at Dr. Mike Merrill

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"Social determinants of health" are macroeconomic, not micro

There's a lot of work on "social determinants of health" that involves helping individual patients get the things they need: secure housing, food security, transportation. But the real message of the literature on social determinants is that factors larger than the individual - factors on a society level - affect... Continue reading

Posted Jan 16, 2019 at Dr. Mike Merrill

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Three cuban professors define socialism (short videos), and other notes from a visit to Havana

My wife Melanie and I enjoy learning things while traveling. For example we had some great private tours from Ph.D.'s through Context Travel in Rome last year. I can't express how much the non-stop lecturing and question-answering added to our visit. This year, on a lark, we booked a cruise... Continue reading

Posted Jan 6, 2019 at Dr. Mike Merrill

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This is $1 million of the drug Eyelea

Eyelea is used to treat macular degeneration, a disease of the eye. This is about 500 vials of it, so about $2,000 a dose. There is a generic available, Avastin, that costs about $80 a dose. This is a stack that a Buffalo ophthalmologist made using the empty vials he... Continue reading

Posted Dec 17, 2018 at Dr. Mike Merrill

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The PSA test sounds so innocent.

It's possible to hurt a patient with a lab test. It's an innocent enough thing to order, but the downstream effects may not be useful at all. The test is done, it leads to an inconclusive result, further testing is done, maybe a referral, and eventually a treatment occurs that... Continue reading

Posted Dec 14, 2018 at Dr. Mike Merrill

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Is coronary angiography overused in Western New York?

Coronary angiography is the "gold-standard" test for coronary disease. It's considered the final word on whether or not you have it. It involves threading a catheter to the arteries that supply the heart. A liquid that x-rays don't penetrate is injected into the blood, and so with an x-ray (really... Continue reading

Posted Nov 16, 2018 at Dr. Mike Merrill

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Screening tests may not make sense from the individual's perspective

There's a big difference between how doctors traditionally think about screening and how patients should think about it. Let's say I'm a doctor, and I'm considering all my patients as a group. I have 1,000 men that I'm trying to save from prostate cancer. That's about this many guys: Source:... Continue reading

Posted Nov 9, 2018 at Dr. Mike Merrill

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Yeah, I'm diabetic and my sugar gets low sometimes. No big deal, right?

Actually it can be a pretty big deal, especially if you are older and you've had diabetes for a while. Hypoglycemia causes anxiety, tremors and sweating. In more severe cases, you can get confused, lose consciousness, have a seizure, or even die. Think about driving and having all that sneak... Continue reading

Posted Nov 2, 2018 at Dr. Mike Merrill

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Better medical tests: "normal" becomes "disease"

Human beings are smart, and we keep inventing new things. In medicine, that means more and better tests to analyze us in increasingly sophisticated ways. This trend will continue, so we need to get used to it, and be smart about it. Sometimes when tests get better, they are able... Continue reading

Posted Oct 26, 2018 at Dr. Mike Merrill

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Over time, disease definitions are expanded. Is that good?

A great many things are labelled diseases nowadays. "Caffeine withdrawal" is a formal diagnosis, for example. But there are also examples of existing diagnoses getting expanded, such that more people are classified as unwell. Pre-diabetes and "mild cognitive impairment" (basically pre-dementia) would be examples. This all creates higher risk of... Continue reading

Posted Oct 19, 2018 at Dr. Mike Merrill

1

Is it OK to say to your doctor, "I don't know what you're talking about"?

Many patients think they will get better care from doctors if they are nice. Some think it's better to be aggressive. Many just want to get away as soon as possible. Of the ones who try to be nice, there's a risk that they will not get what they need.... Continue reading

Posted Oct 12, 2018 at Dr. Mike Merrill

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Overdiagnosis is an error in prognosis

In overdiagnosis, a clinician identifies an abnormality that would never have hurt the patient, and treats it as an actionable pathology. You can never know who is overdiagnosed in real time; it only becomes apparent after the fact, while examining populations. In a way, the term "overdiagnosis" is misleading. It... Continue reading

Posted Oct 5, 2018 at Dr. Mike Merrill

1

Lab tests before surgery: not always useful

Partly out of habit, physicians frequently order lab tests before surgery, to make sure everything is OK. But this is not always useful. The purpose of pre-operative testing is to figure out what risks there are, and to minimize those risks. If you are going through a low risk surgery,... Continue reading

Posted Sep 14, 2018 at Dr. Mike Merrill

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How do you explain overdiagnosis?

You can't know if an individual has been overdiagnosed. You only see it at the aggregate level. The decision point is the choice to seek a diagnosis. After that point, overdiagnosis can occur. By definition, overdiagnosis will not improve prognosis - it's not going to make you live longer or... Continue reading

Posted Sep 5, 2018 at Dr. Mike Merrill

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In overdiagnosis, harm looks like benefit

It's hard to explain the concept of overdiagnosis to the public. Think of overdiagnosis as "pseudo-disease," in which something innocuous is labelled as a disease, and leads the patient down a pathway of unnecessary testing and treatment. An example would be finding and treating a prostate cancer in a 75-year-old... Continue reading

Posted Aug 27, 2018 at Dr. Mike Merrill

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Why do doctors order unnecessary imaging of the back?

Imaging for low back pain (LBP) is only recommended in certain situations. The Choosing Wisely campaign suggests avoiding imaging during the first six weeks in the absence of red flags, like weight loss, a history of cancer, recent trauma, osteoporosis or age greater than 50. And imaging for LBP is... Continue reading

Posted Aug 24, 2018 at Dr. Mike Merrill

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Avoid testicular self-exams

I still see some physician offices recommending testicular self-examination for males, adolescent and older. This isn't the right thing to do. According to the U.S. Preventive Services Task Force, if you have no symptoms, there is no evidence doing self-examination prolongs life or reduces suffering (the two main goals of... Continue reading

Posted Aug 24, 2018 at Dr. Mike Merrill

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Mammograms if you're 90?

Most people want to live a long time, and many people want to be good patients. So they do their screening tests, like mammograms and colonoscopies. Unfortunately, sometimes these tests are done for too long. At an advanced age, these tests are unlikely to be beneficial. For example, the American... Continue reading

Posted Aug 17, 2018 at Dr. Mike Merrill

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Fewer fingersticks for type 2 diabetics

Pricking your finger for blood is one of the worst things about having diabetes. It hurts, it's messy, and you have to maintain and carry around a glucometer. it's tremendously important for type 1 diabetes, in which the body does not make enough insulin. The therapy for type 1 is... Continue reading

Posted Aug 10, 2018 at Dr. Mike Merrill

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Choosing Wisely: with back pain, don't rush to an MRI

Someone out there may completely understand back pain, but I haven't met them, and it's not me. But there are things we do know. And one of them is that in most cases, an MRI is not useful. The low back is a weak spot in human anatomy because we... Continue reading

Posted Aug 3, 2018 at Dr. Mike Merrill

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Can't hear well? You're probably isolated and unhappy

When my grandmother got hearing aids at age 75, I suddenly realized she was a very intelligent woman. She started making timely, incisive comments in the middle of fast conversations. She started paying attention to things more. And she became funnier. She apparently had had hearing loss for many years.... Continue reading

Posted Sep 27, 2016 at Dr. Mike Merrill

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At the end of life, how do you tell if it's time?

The last years of life can be filled with a repeating cycle of serious illness, and recoveries that seem to restore us to a reasonable state. We can find ourselves moving from one episode of congestive heart failure, or COPD exacerbation, to another, and returning to our homes, back to... Continue reading

Posted Sep 5, 2016 at Dr. Mike Merrill

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One of my ways to avoid back pain

Probably somebody out there completely understands back pain, but I haven't been able to find them, and it's not me. Nonetheless, certain things are obvious. The low back is a weak spot in human anatomy, because we vertically load weight on it. It's originally designed to hang weight anteriorly (think... Continue reading

Posted Aug 29, 2016 at Dr. Mike Merrill

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old man in hospital

I'm taking care of a very old, frail man. He can only whisper. I ask him what he needs and he says, "Don't leave." He grabs my hand, weakly. I hold it for a few minutes. Is he going to die tonight? A few minutes later his daughter comes in... Continue reading

Posted Aug 21, 2016 at Dr. Mike Merrill

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