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#ThisIsOurLane – Physicians and Gun Violence

November 17, 2018

Written by Clay Smith


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.

From IRS Form 990 Filings. Graphic by Clay Smith, MD, JournalFeed
From USA Today. Graphic by Clay Smith, MD, JournalFeed

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.

10 thoughts on “#ThisIsOurLane – Physicians and Gun Violence

  • I am very disappointed with this article. This emotion based argument is clearly unsupported by the available evidence.

    I used to believe this until I started looking at the sources of the gun control lobby’s "evidence". Even the correlation between gun ownership and violence falls apart unless you cherry pick the data. Ask yourself why these studies never include countries such as Russia and Yemen.

    Even the "fact" about the CDC not being able to study gun control, while having some truth to it, is not telling the whole story. Under Obama, the CDC did study gun control, and found that defensive gun uses far outweigh criminal uses. This data was never publicized and the media pretends it never happened.

    It’s OK to support gun band and gun control, but do not pretend that it is a neutral, bias-free, data driven argument, when it is clearly the opposite of that.

    • Dr. N, gun violence is certainly an emotional issue. It is right to feel sadness, even anger about this. But the ideas in the position statement are not based on emotion. It seems we share the same goal – to save the lives of people. It seems we both agree that people are valuable and deserve the chance to live. Maybe more lives would be saved by defensive gun use, as you mentioned. There is some evidence that may be the case, though it is survey-based and objectively low-quality. https://www.forbes.com/sites/paulhsieh/2018/04/30/that-time-the-cdc-asked-about-defensive-gun-uses/ But can we not agree that there are also some solutions with face validity and some evidence, albeit weak, advocated by the ACP that could reduce mortality? None of the ideas in the ACP statement would threaten defensive gun use by legal gun owners. What do you think about the ideas in the paper – bringing diverse groups together, freeing doctors to ask patients about guns, universal background checks, closing loopholes, better reporting, and funding for high quality research? These are rational, evidence-based solutions that both respect the Second Amendment and save lives. Are you not for that?

  • I appreciate your willingness to share your thoughts on the matter. I think the NRA’s comment is unnecessarily divisive, but I think there are interesting points to consider.

    I noticed many people in the comments mentioning GSWs as terrible experiences while on trauma rotations (which I too have experienced), and this being an impetus for their demanding change. Seeing the suffering of others often times compels us to passionate action, and it should, but we must bear in mind that our passion about a particular problem we see in society does not give us a free pass to conclude that the people that disagree with our method of addressing the issue do not care just as much. Fundamentally, nobody wants to see gun violence. Assuming otherwise is going result in unproductive conversations all around.

    As far as Australia and their forced gun confiscation… if you look at their violent crime statistics, the trend was falling pre-ban and continued on the same downward trend post-ban. It is probably not justifiable to draw strong conclusions from this single experiment.

    The article seems to paint a sort of dichotomy that you are either pro gun control or pro gun violence, which I hope you do not believe to be true. I think we could all benefit to assume positive intention from both sides. The NRA should understand that docs just want to quell violence and that gun control seems reasonable, but the NRA should also be given the benefit of the doubt. I think they likely want violence in general to decrease, but disagree with your suggested methods given the failure of gun control laws in Chicago, for example, (a city with the strictest of gun laws) fail to quell violent crimes. I think the NRA has seen some of the CDC data that Dr. N mentioned that conservatively estimates that guns prevent 450k crimes per year.

    On the whole I think it would benefit both sides of this issue to proceed with a healthy amount of respect and show a good bit of grace in believing that both sides want less violence and want to solve this problem.

  • Completely agree with Dr. N. This is the old, tired game — use words like "I support the 2nd BUTT BUT…." or "Hey, I own guns bla bla but" and then parrot all the same non-sensical and grossly manipulated faux "associations" and anecdotal information. Tell me Clay, where is your outrage about the number of children that drown in swimming pools? What have you done to increase "common sense" regulations about pool, or limiting who can own them, and how deep we should allow them to be? Oh, wait, I know — Swimming Pools and Cars were not "Made for killing" so, that a moot point right? I think the point the NRA was making (even though I’m not a fan of them) was, being a doctor and seeing the results of Gun Violence doesn’t make you a Gun or 2nd amendment expert. What’s more, this is not even a "gun issue", this is violence/criminal justice issue. Does you PHD give you an expert tag in that too?

  • My constitutional rights are NOT up for your emotional ideas. Life is hard and people die everyday. Some by doctors malpractice. The politicians of both parties don’t care about violence they want votes and control i.e. power over others. That is why the criminals are let back in to society.

  • Also the second amendment is not a granted right, but one which recognizes the natural right of self defense,or god given if you prefer. So get rid of it 2/3 of the congress and 2/3 of the states,and I still prevail. Spend more time being a doctor and less telling others how to live

    • You raise a good point about the Bill of Rights affirming and codifying inherent rights rather than granting them. Agree.

  • Regarding “common sense” gun control laws: My dictionary defines “common sense” as “sound practical judgment that is independent of specialized knowledge.”

    For any law to be “common sense” oriented, there must be a clear and well-defined end result, an expectation that it will/can be enforced, and some validation that the scheme has the desired effect. No proposal from the Brady Campaign, Violence Policy Center, or Criminals for Societal Manipulation (a.k.a. Michael Bloomberg’s Mayors Against Illegal Guns) meets the definition of “common sense.”

    The expressed expectations and desired results all depend on the assumptions that criminals will obey the new laws even though they are criminals who freely disobey other inconvenient laws.

    One may judge the honesty of an approach to solving the problem of gun violence by the degree to which the fact of human volition is ignored or evaded. In the case of the Democrats, the evasion is obvious. They do not consider evil or negligence to be the problem, but instead concentrate on inessential and irrelevant attributes of the weapons themselves, such as their appearance or the fact that they are considered "assault rifles." Human volition, which means the responsibility of an individual for his own actions, is the one issue that they dare not discuss.

    This is because the corollary of individual responsibility is individual rights, the very concept that they have set out to deny.

    Common sense requires incarcerating miscreants, thugs, and social deviants, not unviable and unprovable wishes expressed as laws.

    • I could not agree more that there is real evil in the world and people are absolutely responsible for their actions. And I agree that gun violence is due to people choosing to do wrong. It is a complex problem – with aspects that are moral, spiritual, mental health, etc. But on the theme of common sense, let’s consider some of the ACP ideas, since that is the topic at hand. It seems to show sound practical judgment independent of specialized knowledge that if this evil guy has to do a background check to buy a gun at the local big box store, and knows he won’t pass a background check that he will buy his gun at a gun show. How is it common sense to keep horses in a pasture with the main gate closed and side gate open?

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