This Is Our Lane: What the Physicians Have to Say About Gun Violence

I mean, really, who the hell do you think you are? That’s about as nice as I can put my thoughts about the National Rifle Association since their tweet in response to the ACP’s latest opinion on gun violence. It has taken me this long to write it out because every time I think about, my blood boils.

Like the last time I blogged about big news, we will start at the beginning. The American College of Physicians recently published a “position paper” about reducing firearm injuries and deaths in the United States. Unfortunately, the data we really need in order to adequately address the problem isn’t available because the NRA’s historical lobby efforts have basically made it impossible to study gun related violence in a scientific fashion.

The Data

But let’s go back even further and talk about the raw data regarding gun violence in the United States.

Of note: federal legislation passed in 1997 stated that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention (CDC) may be used to advocate or promote gun control.” The vague nature of this law, and its 2011 extension to the National Institutes of Health, has effectively prevented federal funding for firearms-related research.

The ACP Position Paper

Then we can talk about what the ACP asked for in its position paper:

A public health approach to firearms-related violence and prevention of firearm injuries and deaths. (I.e. let’s treat deaths from guns like we do any other disease or entity, likes deaths form car wrecks, deaths from diabetes and its complications, deaths from cancer, etc.)
The medical profession has a social responsibility to speak out on prevention of firearm-related injuries and deaths, just as physicians have spoken out on other health issues. (i.e. smoking, car wrecks, helmets, seat belts, drugs, etc).
Physicians should counsel patients on risk of having firearms in the home, particularly when children, adolescents, people with dementia, people with mental illnesses, people with substance use disorders, or others who are at increased risk of harming themselves or others are present.
Authorities should avoid enactment of mandates that interfere with physician free speech and the patient-physician relationship. (i.e. No, Florida and the NRA, you cannot prevent us from trying to keep our patients safe while not in our care).
Physicians are encouraged to discuss with their patients the risks associated with having a firearm in the home and recommend ways to mitigate such risks.
Physicians should become informed about firearms injury prevention and this should be incorporated into training curricula.
Physicians are encouraged to advocate for legislation to implement EVIDENCE-BASED policies to reduce the risk of preventable injuries and deaths from firearms, including, but not limited to, universal background checks.
Support of appropriate regulation of the purchase of legal firearms and that any such regulations should be consistent with the 2^nd Amendment.Sales of firearms should be subject to satisfactory completion of a criminal background check and proof of satisfactory completion of an appropriate educational program on firearms safety.
Keep guns out of the hands of felons, people with mental illness that put them at a greater risk of inflicting harm on themselves or others, substance use disorders, domestic violence offenders, and others who already are prohibited from owning guns.
Strengthen and enforce laws to prohibit convicted domestic violence offenders from purchasing or possessing firearms.
Establish waiting periods as a way to reduce incidence of death by suicide (2/3 of firearm deaths).
Consider that concealed-carry laws may create a greater risk of firearms injuries and deaths than protection.
Oppose concealed carry reciprocity laws.
Support appropriate training for concealed carry.
Ban on firearms that cannot be detected by metal detectors or standard security screening devices (3D printed firearms).
Strong penalties for those that sell firearms illegally and “straw purchases”.
Subject guns to consumer product regulations regarding access, safety, and design. (Like we do with all other human operated machines including cars and simple things like toys.) Required use of tracer elements on ammunition and weapons and identifying markings on weapons.
Child access prevention laws that hold firearm owners accountable for safe storage of firearms.
Diagnosis, access to care, treatment, and appropriate follow-up for mental illness.
Physicians should be trained to respond to patients with mental illness who might be at risk of injuring themselves or others.
Ensuring access to mental health services.
Community understanding of mental illness should be improved to increase awareness and reduce social stigma.
Safeguards to protect confidentiality and not create disincentive for patients to seek treatment for mental illness.
Ban manufacture, sale, transfer, and ownership for civilian use of semiautomatic firearms that are designed to increase their rapid killing capacity (“assault weapons”) and large-capacity magazines.
Make it more difficult to get a semi-automatic weapon “exempted”.
Narrowly define hunting and sporting purposes.
Increase minimum age to purchase semi-automatic firearms to 21.
Improve and modify firearms to make them as safe as possible (built-in safety devices like trigger locks and signals that indicate a gun is loaded), development of personalized guns.
Adequately fund research for the NIH, CDC, and NIJ to study impact of gun violence of public health and safety.
Enactment of extreme risk protection order laws which allow family members and law enforcement officers to petition a court to temporarily remove firearms from individuals at risk of harming themselves or others.

The NRA’s reaction to this paper:

The Responses

In fact, this is likely my favorite campaign, ever. I am so impressed by so many physicians taking a stand. And the twitter responses to the NRA and Ann Coulter’s equally uneducated remarks are equally great.

And if the NRA’s ridiculous tweet wasn’t enough, an article on The Federalist written by David Harsanyi backs up the NRA saying “And the NRA has every right to push back against groups that use science to conceal their political arguments.” (I won’t link to the Harsanyi’s article, you can find that trash for yourself.)

I guess that’s what physicians did when we called for laws banning smoking on planes too? And then when seat belts had to be in every car and are required by law? I guess that was all politics clouded in science as well.

Newsflash–if the science proves that we can protect people, then yes, it should be law. It is amazing that science and politics can overlap. (Oddly, science and religion can as well. But we are supposed to be separating church and state so I won’t let the politicians play with that too much.)

The Chicago Consensus

Then the American College of Surgeons-Committee of Trauma releases it’s “Chicago Consensus” asking for many of the same things without quite as much force. And this is all after sitting AT THE TABLE with the NRA. Yes, that same NRA that posted that terrible tweet above sat at the table with these guys before doing that! (What is this? Mean Girls 2018?) The Chicago Consensus includes:

Those that are a danger to themselves or others should not be allowed to purchase or receive a firearm as a gift or as a transfer from another person.
- Background checks for all purchases and all transfers of firearms.
A firearm should be transferred with registration in accordance to federal law. This would include private sale and transfer of property bequeathed from an estate or among family members. (like cars and homes)
- Development and implementation of an electronic database for all registered firearms.
Recommend formal reassessment of firearms designated within each of the National Firearms Act classifications. (High capacity, magazine fed, semi automatic, high velocity)
Endorse formal gun safety training for all new gun owners and endorse hunter safety and safe gun handling education.
Recommend direct adult supervision in the use of firearms for children under 12 and indirect supervisions for children ages 12-18, where not already state-regulated.
Standardize programs to remove firearms from those individuals deemed an imminent threat to themselves. (Extreme Risk Protection Order policies, Red Flag laws, and federal law.) Specific due process measures should be required for removal and return of firearms. Mandatory reporting to law enforcement and medical personnel for those threatening to themselves or others should be standard practice.
Treat mass shootings as terrorism and support and encourage domestic law-enforcement efforts and strategies (within the limits of the 4th Amendment protections) to predict, detect, and deter future mass firearm violence.
Encourage development of firearm technology that would significantly reduce the risk of self-harm, prevent unintentional discharge, and prevent unintended use by someone other than the registered owner of the firearm. (You know, make guns themselves safer.)
Federally fun research for firearm injury and firearm injury prevention.
Research must be conducted in a non-partisan manner. Should broadly address 1) firearm safety including safe storage and safe use, 2) violence intervention and control research, 3) serious mental illness and firearm violence, 4) improving treatment of patients injured from firearms. The research agenda should include:
- Root causes of violence.
- Effect of media content (i.e. social media, television, movies and video games) on interpersonal violence.
- Effective forms of safe storage and safe guns. Technologic changes (such as biometric locks) to firearms could prevent their unintended use by those other than the legal owner. Effective, safe storage mechanisms in the home or vehicle could prevent unintentional injury and death.
- Effective firearm safety counseling and training.
- Evaluate effectiveness of restricting access to firearms by violence-prone individuals.
- Epidemiology of highest risk populations for suicide, homicide, mass shootings, intimate partner violence, unintentional injury and other subsets of firearm violence
- Assessment of firearm lethality differences based on specific type of firearm and numbers of deaths and injuries per unit time.
The public, professionals in law enforcement, and the press should take steps to eliminate notoriety of the shooter and take an editorially muted approach to the coverage of these events.
Encourage recognition of mental health warning signs and social isolation by teachers, counselors, peers and parents, and when these warning signs are identified, immediate referral to appropriate mental health professionals.

My Own Two Cents

My own commentary isn’t exactly scientific. But here it goes. It’s become common place in the trauma world to say that we aren’t anti-gun. We’re anti-bullet holes. Trauma victims aren’t the only ones that get PTSD. Those of us that treat those victims, we get it too. The nurses, the doctors, the techs. We pour every ounce of energy we have into trying to save lives that often aren’t salvageable. We spend hours covered in blood, trying to save a young patient just to call time of death in the operating room, and then have the duty of saying “I’m sorry. Your son died. Merry Christmas.” Yes, people get shot/shoot themselves, and they die on Christmas. On New Years. On birthdays. On any damn day of the year that their family will forever remember. Or when you tell a fiancé that they’ll now be planning a funeral. Then you go home and your dreams are nothing but blood and what-ifs. The very best you can do is hold your loved ones a little tighter each time.

I am a gun owner. I have enjoyed some time at the gun range more than once. It’s cathartic and may even therapeutic. It’s also educational for me, especially as a trauma surgeon. I learned most of what I know about guns from another trauma surgeon who happens to own A LOT of guns, of all types. He’s an amazing man who taught me just much in the operating room. Yet, I have zero desire to own half of these weapons myself. I can’t speak for those that desire to own semi-automatic weapons. Personally, I think there’s simply no need and most of the data says that access to such things breeds bad things. We actually have three guns in our home. None of them are loaded. Honestly, I’m not sure anyone else but my husband even knows where they are. I’m the organization freak so I’m the one that decided where it all went. They are all locked in their cases on a shelf that is barely reachable for ME, much less my kid.

Yes, that’s right. I’m also a mom. A gun owning, trauma surgeon mother. I fear for my kids in school. I sort of fear football games, movie theaters, and anything where a large group of people might gather. There is something seriously wrong happening in the last decade for mass shootings to be occurring so often that we now do mass casualty drills at hospitals and schools across the nation so we can be prepared for things like Orlando, Las Vegas, Pittsburgh, or Sandy Hook. It used to occur so infrequently that we didn’t feel the need to do these things, but now with it happening 5-6 times a year, we are all becoming “numb” to it. We simply can’t do that. We can never become numb to gun violence. If so, the daily lives of gang members will be on all of our doorsteps. That is to say, we will all be dealing with gun deaths close to home each and every day. That’s what the NRA doesn’t understand. Guns are great for hunting, but they are also great for killing humans. And here in the US, more than 30,000 people a year are dying from gun related deaths and hundreds of thousands more are injured.

As physicians, we have a social obligation to put ourselves out of a job. Admittedly, we aren’t very good at it. We don’t always get it right on the first try. (Patients don’t always present like the textbooks say they will.) And a lot of the NRA tweet’s supporters like to bring up the fact that medical errors are the third leading cause of death in the US. That is a short-sighted opinion from one study out of Johns Hopkins in 2016 that needs a lot more research. I guarantee you we aren’t as severely out of proportion to other developed countries when it comes to medical errors. Systems and process errors happen that cost patient’s their lives. But we do a hell of a lot of root cause analyses and research to figure out why and how things went wrong so that it won’t happen again. Every country is doing the same. There’s not a physician out there that’s going to completely deny that medical errors happen. That’s where we are different than the NRA who continues to turn a blind eye to gun violence and the preventable deaths it’s causing each and every day. Our children our dying. Our spouses and friends are dying. And they (the NRA) don’t even want us to find out how we can improve on that. The tobacco companies didn’t want us doing that either. They spouted that cigarettes were good for you (and doctors even passed on that misinformation). They doubted the dangers. They knowingly denied the addictive properties. And look where that got them, with pictures of dead lungs on cigarettes boxes all over Europe, smoking bans on planes, in restaurants, in bars, near schools and hospitals.

So thank you, NRA, for opening the door to something we as physicians can unite behind. Thanks for lighting the fire.

Feel free to leave comments. Feel free to reach out on social media. This is a hot topic, but I hope it’s the topic that my generation of physicians can take the lead on. (This can be our anti-tobacco/cancer laws for a new generation.)