#ThisIsOurLane – Physicians and Gun Violence

November 17, 2018

Written by Clay Smith

Scars

Many of us carry the scars of patients we have seen, victims of gun violence. The image forever etched in my mind is that of a 7-year-old. He had just gone to his room for bedtime. A drive-by shooter aimed at the house. He was hit in the head while he tried to duck. He was wearing pajamas. There was blood everywhere.

What Is Our Lane?

The NRA stoked controversy last week with this tweet. The pent up response from physicians that erupted has been unified and forceful.

I have decided to review the article from Annals of Internal Medicine that caused this storm. It’s a position statement from the American College of Physicians (ACP).

Before I get into the Annals article, I’d like to comment on this statement by the NRA. I don’t write with a bias against guns or gun ownership. Guns were a big part of my childhood. I own guns. I favor legal gun ownership and recognize the need for regulation.

This Is Our Lane

In the U.S., the right to keep and bear arms as an individual is guaranteed by the Second Amendment. But this has always included reasonable restrictions. Even Scalia said, “Like most rights, the right secured by the Second Amendment is not unlimited (Section III).” The NRA is pressing to limit gun regulation, with the contention that this will allow legal defensive gun use and reduce or deter gun violence. Yet firearm mortality is increasing. Sadly, they posted this tweet just hours before yet another mass shooting in southern California.

The message from the NRA was provocative, telling physicians to “stay in their lane.” Physicians have responded. Whose “lane” is penetrating trauma if not ours? Whose “lane” is it to deal with a deadly public health epidemic if not ours? The tweet closes with, “Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.” Yet, of the 64 references in this ACP Position Statement, only 22 were from medical journals; the other 42 were from non-partisan sources like the FBI, ATF, other government sites, news stories, legal documents, SCOTUS decisions, or centrist think-tanks. In fact, the paper’s first point is, “The College supports the development of coalitions that bring different perspectives together on the issues of firearm injury and death.”

According to the NRA bylaws, one of its key objectives is, “To promote public safety.” So, why would they publish a tweet that undermines the physicians who are working toward one of their same stated goals?

I don’t know, but I found the following information concerning. As the country is grieving and weary from ongoing gun-violence deaths, NRA executive compensation has steadily increased in parallel with the mass shooting victim count.

I am not suggesting causation. I’m not even suggesting association. These two charts simply display two 6-year trends. The first chart shows that the NRA has been successful in increasing revenue from its membership. Use of social media to appeal to its members may explain last week’s tweet against doctors. The second chart shows that despite having increased resources to promote its agenda, which includes public safety, and to attract and retain top talent, the strategies of the NRA have not led to a reduction in casualties from mass shootings.

Instead of using personnel and funds to attack physicians, why not rather join us to fulfill our common mission to promote public safety and sit at the table together to find ways to save lives? Of course, we won’t agree on every point, but there are solutions where we can form consensus. That’s what the ACP is doing by publishing these common sense solutions.

Common Sense Is Uncommon

Here are the main points of the Annals article.

Take a public health approach to firearms related violence and prevention. This means forming a coalition of diverse people and interest groups to bring about social and legislative solutions.

Physicians should speak out – This includes avoidance of state or federal requirements preventing a doctor from discussing gun safety with patients. It is the right thing to remind people that firearms are particularly dangerous in the home, “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.” Firearm owners should lock up guns and use best practices to eliminate accidental use, especially by children or by theft. We need to be informed on best practices to reduce risk with individual patients but also to advocate for the broader community.

The statement calls for respect of the U.S. Constitution’s Second Amendment – They are clear that, “any such regulations must be consistent with the Supreme Court ruling establishing that individual ownership of firearms is a constitutional right under the Second Amendment of the Bill of Rights.”

Legislative Measures
There is a correlation between prevalence of guns per capita and gun violence as well as tighter gun regulation with reduced firearm-related death rate. So, it makes sense to pursue well-crafted legislative solutions.

• Universal background checks – This is, “to keep guns out of the hands of felons, persons with mental illnesses that put them at a greater risk of inflicting harm to themselves or others, persons with substance use disorders, domestic violence offenders, and others who already are prohibited from owning guns.” One glaring loophole in the requirement for background checks is gun shows. Did you know that to buy a rifle at a local store already requires a criminal background check in my gun-friendly home state? And I have to give my thumbprint and pay $10. But all this doesn’t happen if I go to a gun show. So, where would I go buy a gun if I were a person who would fail a background check? In fact, “22% of gun sales take place without a background check through private sales.”
• Domestic violence loophole – Federal law prohibits possession or purchase by a person convicted of DV, but not a stalker or dating partner and not under a temporary restraining order. They also would like to see enactment of extreme risk protection order (ERPO) laws, which would, “temporarily remove firearms from individuals who are determined to be at imminent risk of harming themselves or others while providing due process protections.”

• Better reporting – “Federal law currently prohibits convicted felons; persons who use or are addicted to unlawful substances; those who have been involuntarily committed to inpatient mental health institutions; and those who have been deemed incompetent to stand trial, found not guilty on the grounds of serious mental illness, or otherwise deemed adjudicated mentally defective from receiving or possessing a firearm.” However, reporting to the national database, NICS, is voluntary, slow, and inconsistent. Does it not seem naive to think states will voluntarily report, which requires of them time, effort, and personnel – all of which costs money? It’s the old adage – people don’t do what’s expected; they do what’s inspected.

Other Safety Measures
The ACP also discussed several other potential measures to make our patients safer.

• Consider waiting periods – Evidence for waiting periods is not strong and is inconclusive. It may reduce suicide rate.
• Weigh the risk vs benefit of concealed-carry – Again, evidence is inconclusive on whether injuries occur less often or more often when concealed-carry of handguns is allowed.
• The College calls for a ban on firearms that can’t be detected with metal detectors; they also call for stronger penalties for illegal sales of any firearms.
• The ACP favors a ban on assault weapons and favors making existing firearms safer.

Research Anyone?
They ACP also calls for more firearms-related injury research. The Dickey amendment essentially froze funding for the CDC to conduct research on gun violence. The 1996 amendment stated, “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

But Dickey, author of the amendment – Republican and life member of the NRA, changed his mind before he died. He wrote an op-ed together with his former “mortal enemy”, Mark Rosenberg, director of the National Center for Injury Prevention at the CDC at the time of the amendment.

Together, they wrote in 2012, “We were on opposite sides of the heated battle 16 years ago, but we are in strong agreement now that scientific research should be conducted into preventing firearm injuries and that ways to prevent firearm deaths can be found without encroaching on the rights of legitimate gun owners.”

If self-styled “mortal enemies” can come together and agree, there is hope. Just as research on car crashes prevented the death of 366,000 people from 1975-2009 without banning cars, so, research into firearms-related deaths can do the same – without banning guns.

Keeping Our Oath

The NRA tried to put us in our place with this tweet. What they have done is to galvanize doctors of all political stripes and to unify us to act against gun violence. Physicians see and feel the human toll of gun violence on patients and families, and this transcends partisan differences. This is our lane. Who better than physicians to discuss the impact of firearms-related injuries o
n patients, the staggering mortality rate, or the terrible toll on family members when we tell them their loved one has died? We are the voice of our patients. We are the ones who touch the injured, maimed, and dying people affected by gun violence. We cry with their families. We cry as we silently drive home from work. We are the ones who peek in at night and hug our kids, glad it wasn’t one of them. We are the ones haunted by our patients’ faces and the blood and the destruction. We see their scars. We bear the emotional scars. We are sick and worn out with the violence. We care about our patients’ safety. In fact, I took an oath, “to consecrate my life to the service of humanity,” and that, “the health and life of my patients will be my first consideration.” I will keep my oath. We will not stop doing what is right for our patients. We invite the NRA to fulfill their stated mission to promote public safety and join us.