A Resolution for Physicians: Time to Focus on the Public Health Threat of Gun Violence

Abstract

Editorials19 March 2013A Resolution for Physicians: Time to Focus on the Public Health Threat of Gun ViolenceFREEChristine Laine, MD, MPH, Editor in Chief, Darren B. Taichman, MD, PhD, Executive Deputy Editor, Cynthia Mulrow, MD, MSc, Senior Deputy Editor, Michael Berkwits, MD, MSCE, Deputy Editor for Annals and annals.org, Deborah Cotton, MD, MPH, Deputy Editor, and Sankey V. Williams, MD, Deputy EditorChristine Laine, MD, MPH, Editor in ChiefSearch for more papers by this author, Darren B. Taichman, MD, PhD, Executive Deputy EditorSearch for more papers by this author, Cynthia Mulrow, MD, MSc, Senior Deputy EditorSearch for more papers by this author, Michael Berkwits, MD, MSCE, Deputy Editor for Annals and annals.orgSearch for more papers by this author, Deborah Cotton, MD, MPH, Deputy EditorSearch for more papers by this author, and Sankey V. Williams, MD, Deputy EditorSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-158-6-201303190-00586 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The December 14th shooting rampage in a Connecticut suburb that left 20 children and 8 adults dead (including the gunman and his mother) should motivate physicians to be vocal participants in discussions about U.S. gun policy. Many physicians see our primary role as maintaining health and treating disease in individual patients. Yet, physicians have been powerful voices in discussions about issues that threaten public health. We have mitigated these threats by helping to shape policies and practices regarding air pollution, bicycle helmets, drunk driving, motor vehicle restraints, secondhand smoke, tobacco advertising, water contamination, and vaccination. We are long overdue in directing our expertise, commitment, and passion to another public health danger—gun violence.Why does gun violence deserve physicians' time and energy? Guns maim and kill. Even when we can repair torn tissue and prevent death, bullets permanently diminish the quality of life of persons caught in the line of fire. Gun violence also harms those close to the victims who often endure grief, depression, anxiety, and sometimes posttraumatic stress disorder. Furthermore, whether they experience single shootings or massacres, persons in affected communities and the widening circles around them suffer when gun violence makes them feel unsafe in their schools, streets, stores, workplaces, and recreational venues. Evidence documenting the gravity and prevalence of the problem—the same type of evidence that drives clinical decisions—tells us that gun violence warrants physicians' attention. The Centers for Disease Control and Prevention (CDC) reported that in 2009, firearms were used in 11 493 homicides (3.7 per 100 000 persons) (1) and 18 735 suicides (6.1 per 100 000 persons) (2). Sadly, this means that the U.S. rates of firearm-related homicide, suicide, and unintentional death are higher than in other high-income countries (3).Just as physicians worked to safeguard public health by promoting smoking bans in public places, we should draw on similar motivations and strategies to promote sensible, evidence-based laws to decrease the harms associated with gun violence. It is our responsibility to do so. The American College of Physicians (ACP) Ethics Manual outlines physician responsibility regarding violence this way: “Physicians should help the community and policy-makers recognize and address the social and environmental causes of disease, including human rights concerns, discrimination, poverty, and violence” (4). The American Medical Association declares it our professional responsibility to “[a]dvocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being” (5).Advocates for fewer restrictions on firearms often invoke some version of the statement, “Guns don't kill people, people kill people.” Taken literally, this statement is true. However, without easy access to guns, people would be far less lethal. Also, many people who commit gun violence have mental health conditions. A 1990 survey found more than half of respondents reporting violent behavior during the prior year met Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), criteria for at least 1 psychiatric disorder (6). Those reporting substance abuse disorders were more than twice as likely as those with schizophrenia to report violent behavior. A 2009 systematic review confirmed these associations (7). Because mental health is so often implicated in gun violence, it is logical that physicians and other health professionals engage in discussions to better identify individuals suffering from mental health conditions and make guns less easily and effective treatment more easily available to them. Requiring mental health screenings before gun purchases may seem overly invasive. Yet, our society is quite comfortable requiring a medical assessment before granting privileges for other activities, such as driving. It seems incongruous that we prohibit an individual with epilepsy from driving while allowing an individual with psychosis to purchase firearms and ammunition. Given the difficulty in identifying individuals at risk for violent behavior (8), defining policies that balance personal freedom and public safety will not be easy and must not be left to politicians alone. Regardless of whether our views about guns align with the National Rifle Association, Doctors for Responsible Gun Ownership, the National Physicians Alliance (http://npalliance.org), or somewhere between, we will have better policies if physicians who understand the interrelationship of mental health and violence actively engage in the policymaking that President Obama has promised in the aftermath of the Connecticut massacre.The relative silence of the health profession on matters related to gun violence is disturbing. The ACP last issued a position paper on firearm injury prevention in 1998 that identified gun violence as a public health issue, called for internists' involvement in firearm injury prevention, favored strong legislation to ban automatic and semiautomatic assault weapons, supported law enforcement measures to help identify weapons used in crimes, and called for restrictions on the sale and possession of handguns (9). A survey published at the same time demonstrated support for these recommendations among internists and surgeons (10). Yet, what followed has been lackluster. A search of the National Guideline Clearinghouse revealed no guidelines focused on firearm injury prevention. Firearm safety is not directly addressed in any current U.S. Preventive Services Task Force recommendation. There are many reasons for this unimpressive record, but one of the more important ones is politics. Before politics intervened, the CDC received funds for research related to gun violence. Reinstitution of funding to support evidence-based guideline efforts to reduce violence and gun-related injuries and deaths could be valuable components of the nation's response to these relentless and tragic shootings.Within the medical profession, pediatricians have been the leaders. The American Academy of Pediatrics policy on youth violence recommends an organized approach beginning with counseling parents to reduce child access to firearms starting at age 6 months and continuing with firearm counseling during adolescence (11). We hope recent events energize those whose focus is the care of adults to advocate for screening for the risk for firearm injury and counseling to reduce this risk. The ACP's recent announcement about revisiting its 1998 policy is heartening in this regard (12). For such guidelines to be developed and implemented, the profession will need to fight legislative attempts to restrict research on firearm safety and to constrain physician–patient conversations about guns.In the past, Annals has encountered difficulty in convincing experts who are passionate about public safety to write commentaries after mass shootings. These thoughtful people revealed that they declined to write about guns for fear that public funding supporting their research programs (which were not directly related to gun violence) might dry up if they advocated for stricter gun control. This situation raises the ominous possibility that our Second Amendment rights may be jeopardizing our First Amendment rights.Developing effective policies to prevent gun violence will require review of existing evidence, new research to fill evidence gaps, thoughtful discussion to balance the risks and benefits of potential strategies, and evaluation of implemented policies. In other matters of public health, the medical profession has proved that it is up to these tasks. In the wake of the horrific deaths of 20 children, all of the other gun-related massacres, and the daily individual tragedies, physicians should resolve as we begin 2013 to raise our voices on the matter of guns.Christine Laine, MD, MPHEditor in ChiefDarren B. Taichman, MD, PhDExecutive Deputy EditorCynthia Mulrow, MD, MScSenior Deputy EditorMichael Berkwits, MD, MSCEDeputy Editor for Annals and annals.org Deborah Cotton, MD, MPHDeputy EditorSankey V. Williams, MDDeputy EditorReferences1. Centers for Disease Control and Prevention. FastStats: Assault or homicide. Accessed at www.cdc.gov/nchs/fastats/homicide.htm on 26 December 2012. Google Scholar2. Centers for Disease Control and Prevention. FastStats: Suicide and self-inflicted injury. Accessed at www.cdc.gov/nchs/fastats/suicide.htm on 26 December 2012. Google Scholar3. Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003. J Trauma. 2011;70:238-43. [PMID: 20571454] CrossrefMedlineGoogle Scholar4. Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156:73-104. [PMID: 22213573] LinkGoogle Scholar5. American Medical Association. Declaration of Professional Responsibility Medicine's Social Contract With Humanity. 4 December 2001. Accessed at www.ama-assn.org/resources/doc/ethics/decofprofessional.pdf on 26 December 2012. Google Scholar6. Swanson JW, Holzer CE, Ganju VK, Jono RT. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hosp Community Psychiatry. 1990;41:761-70. [PMID: 2142118] MedlineGoogle Scholar7. Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 2009;6:1000120. [PMID: 19668362] CrossrefMedlineGoogle Scholar8. Fazel S, Singh JP, Doll H, Grann M. Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24 827 people: systematic review and meta-analysis. BMJ. 2012;345:4692. [PMID: 22833604] CrossrefMedlineGoogle Scholar9. American College of Physicians. Firearm injury prevention. Ann Intern Med. 1998;128:236-41. [PMID: 9454534] LinkGoogle Scholar10. Cassel CK, Nelson EA, Smith TW, Schwab CW, Barlow B, Gary NE. Internists' and surgeons' attitudes toward guns and firearm injury prevention. Ann Intern Med. 1998;128:224-30. [PMID: 9454531] LinkGoogle Scholar11. Committee on Injury, Violence, and Poison Prevention. Policy statement—Role of the pediatrician in youth violence prevention. Pediatrics. 2009;124:393-402. [PMID: 19520726] CrossrefMedlineGoogle Scholar12. Bronson DL. Statement of the ACP: Reducing Firearms-Related Deaths and Injuries [news release]. Philadelphia: American Coll of Physicians; 20 December 2012. Accessed at www.acponline.org/pressroom/reduce_firearms_deaths.htm on 26 December 2012. Google Scholar Comments0 CommentsSign In to Submit A Comment James Webster, MD, MS, MACPProfessor of Medicine Emeritus, Feinberg School of Medicine of Northwestern University7 June 2013 In Response To the Editor: I was both saddened and depressed by the tone and inappropriate use of statistics in some of the letters (1) that responded to the editorial by Laine et al. (2). To begin; the vast majority of studies show that lax gun regulations do correlate quite positively with the number of gun related deaths. The 10 states with the highest murder rates per 100,000 residents all have minimal or virtually no gun regulation (3). Incidentally, according to the CDC, Wyoming had 92 gun deaths in 2010 16.3/100,000 residents (4), not the 5 reported (1). Even more to the point, on average, 196 individuals are shot each day in the U.S. and survive, many with lasting physical and emotional wounds. Eighty-six more will die from guns, 51 of these are suicides, many impulsively successful because of an easily available firearm (5). These daily recurring numbers are the awful reality that overshadows even the horrific mass shootings, which are a byproduct of a culture of violence and the ready access to guns by those who clearly should not have them. The mortality and morbidity of gun violence certainly qualifies as a public health problem that demands relief. We should make no mistake; the vector of this epidemic is the handgun. Legislation that keeps guns away from criminals and those with serious mental health issues will contribute to solutions, even ‘tho such measures will not be a “magic bullet”. On a day to day basis individual physicians can also be active in solving this problem. For example: by assuring that guns and seriously depressed individuals are not under the same roof (The weapons can be stored with the local police or at the home of a friend with a locked gun cabinet). They can also identify and arrange for or mandate help for those they identify as being dangers to themselves or others. Rather than making us “snitches” this is part of our duty to society as physicians. What is needed is a long term cultural change regarding guns and violence in our country. Meanwhile the ACP is very well advised to continue to lead by encouraging evidence based interventions to tamp down this epidemic. Universal background checks, waiting periods, improved mental health access and physician involvement are good starts. 1. Bush JF, Johnson J, Murray EL. (letters) Is it time for physicians to focus on the public health threat of gun violence? Ann Intern Med. 2013;158:850-852. 2.Laine C. Taichman DB, Berkowitz M, et al. A resolution for physicians; Time to focus on the public health threat of gun violence, Ann Intern Med. 2013;158:493-494 3. Gerney A, Parsons C, Posner C. America under the gun: A 50 state analysis of gun vio9lence and its link to weak state gun laws. Center for American Progress Report, April 2013. Accessed at: www.Americanprogress.org. Washington, DC 4. Ibid. Page 7, table 2 5. The gun rampage next time. New York Times, 6/1/13 Page 16A Christopher J. Matt, MDnone9 January 2013 thank you thank you for making the decision NOT to renew my membership to this organizaiton an easy one. I was honestly logging in to may my dues for the year when this article popped up in my face. I guess there no longer exists a politic neutral organization that strictly lobbies for the medical profession. Where were you when we needed you. Continue to be a lapdog of the administration and you will go the way of the AMA. Oh, BTW, you got it, I just put my dues money in the coffer of the NRA. Good Day. E. Lee Murray, MDWest Tennessee Neuroscience and Spine16 April 2013 Physicians and gun control...not the correct combination I read the Laine et al. editorial (1) with great interest; however, was disappointed a well respected scientific journal is taking a polarizing stand on such a divisive political issue—gun control. While the recent massacres have torn the hearts of all people across this country and around the world, this is not a reason to push physicians to participate in gun control. One argument made by the editorial is reducing the number of guns will lead to a decline in murder and suicide rates. While commonsense reasoning would seem to validate this argument, it simply isn’t true. A study published in the Harvard Journal of Law and Public Policy (2) found that basic socio-cultural and economic factors contribute to murder rates, not the availability of a particular weapon. There is no correlation between counties with strict gun control laws and those with low violent crime rates. The study also showed countries with high crime rates that ban guns end up with strict gun laws and continued high crime. Countries with low crime rates and who don’t have restrictive gun laws continued to have low violence rates. Another argument proposed by the government this that physicians should be ‘gatekeepers’ to screen patients for mental illness then reporting them to a federal agency (3), thus preventing these individuals from purchasing guns or confiscating their current firearms. I argue this will actually harm over all public health. If patients perceive their physician is a ‘snitch’, this will violate the unique confidential relationship a patient has with their physician and will lead a patient to think twice about coming to the clinic for treatment of their preventable/treatable diseases and cancer screenings out of fear they may lose their guns. Practicing medicine is already difficult enough with burdensome regulations and cuts in reimbursement. The last thing we need is more government intrusion into our examination rooms dictating what we ask our patients. While something needs to be done to curb violence, sharply restricting gun ownership will not achieve this. Man has been killing man since the beginning of time. We need to address the core reasons why murder and violence occur in the first place and not become so focused on a single avenue people use to carry out violence. Using physicians to push a largely political argument diminishes our ability to practice medicine in the most objective and evidence based manner. E. Lee Murray, MD West Tennessee Neuroscience, Jackson, TN Nothing to disclose.