A Resolution for Physicians: Time to Focus on the Public Health Threat of Gun Violence
Authors: Christine Laine, Darren B. Taichman, Cynthia Mulrow, Michael Berkwits, Deborah Cotton, Sankey V. Williams
Journal: Annals of Internal Medicine (2013)

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. References: Laine C, Taichman DB, Mulro C, Berkwits M, Cotton D, Williams SV. A Resolution of Physicians: Time to Focus on the Public Health Threat of Gun Violence. Ann Intern Med 2013; 158(6): 493-494. Kates DB, Mauser G. Would Banning Firearms Reduce Murder and Suicide? A Review of International and Some Domestic Evidence. Harv. J.L. & Pub. Pol’y; 2007; Vol 30(2). What is in Obama’s Gun Control Proposal. www.nytimes.com/interactive/2013/01/16/us/obama-gun-control-proposal.html?_r=0 E. Michael Lewiecki, MD, FACPNew Mexico Clinical Research & Osteoporosis Center, Albuquerque, New Mexico8 April 2013 Physicians, Guns, and Suicide TO THE EDITOR: The editorial by Laine and colleagues (1) challenges physicians to take an active role in reducing gun violence. The message is both timely, in the light of recent horrendous mass murders, and long overdue, given that the scourge of gun violence has been well recognized for many years. Deaths, injuries, and the psychological aftermath of gun violence comprise a major public health concern in the US. As such, physicians have a right and a duty to intervene in guiding public policy and establishing meaningful regulations to reduce gun violence. An understanding of all components of gun violence is the first step toward developing solutions that work. Mass murders, as we have witnessed all too often in recent years, represent the small tip of a very large iceberg. Below the water and largely absent from the scrutiny of the national news media are single victim murders, accidental deaths with guns kept for “protection,” and suicides. Guns are the means of far more suicides than murders. Efforts to limit the availability of assault weapons and establish a requirement for universal background checks are welcome steps in the right direction, yet would do little to prevent suicides and many other common forms of gun violence. Most suicides are impulsive acts by vulnerable individuals, often carried out within minutes or hours of the first thought of suicide (2). A suicide attempt with a gun is far more likely to be lethal than alternative means, such as drug overdose. There is strong empiric evidence that limiting access to highly lethal means of suicide reduces suicides, not just by that means, but overall suicides as well (3). Death is not the inevitable outcome of one who survives a suicide attempt. In fact, the vast majority of suicide attempters do not later die by suicide (4). Simple measures to reduce suicides and other crimes of passion include a waiting period for purchasing guns, especially handguns, and safe gun storage in the home. A waiting period provides time for passions to cool and impulses to pass, saving lives for those who do not already have a gun. Safe gun storage can prevent non-gun owners in the household from having immediate access to a gun. Physicians can and should be leading efforts to reduce all forms of gun violence, including suicide (5). References 1. Laine C, Taichman DB, Mulrow C, Berkwits M, Cotton D, Williams SV. A Resolution for Physicians: Time to Focus on the Public Health Threat of Gun Violence. Ann Intern Med 2013; 158(6):493-494. 2. Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry 2009; 70(1):19-24. 3. Florentine JB, Crane C. Suicide prevention by limiting access to methods: a review of theory and practice. Soc Sci Med 2010; 70(10):1626-1632. 4. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry 2002; 181:193-199. 5. Lewiecki EM, Miller SA. Suicide, guns, and public policy. Am J Public Health 2013; 103(1):27-31. Jeffrey Johnson MDLong time ACP member19 February 2013 Distortions and Misleading Information The ACP has seriously overstepped it's bounds in advocating gun control. It tries to support it's point of view with statistics that are misrepresented and distorted. In the first place, the Bill of Rights guarantees the right to bear arms. It intentionally says nothing about what arms one can bear. When written, the ex-british colonists were better armed and mostly had better quality and more modern weapons than the military. Is there a problem with violence in our society? Of course there is. Gun control is not the answer. The Sandy Hook massacre could have been ameliorated or averted if school employees were able to be armed or an armed guard was present in the school. Look, for example, at the mall shooting in Oregon near the same time. The injury and death there was much reduced because of a responsible gun carrying citizen exerting his second amendment rights. There are plenty of examples to show that gun control does not reduce gun violence. Numbers of shootings involving rifles including semi-automatic military style rifles (so called assault weapon) did not go down during the Clinton era Assault Weapon Ban. In fact, FBI statistics show shootings with rifles have dropped since that ban expired. Another statistic often quoted is how many shootings there are each year. Most authors do not include the fact that almost all of those are shootings are by Law Enforcement Officers in the course of their duty.Should we have better mental health care and screening? Of course. Should we encourage safe use and storage of guns. Absolutely! Should we enforce existing penalties for misusing firearms? By all means. But history has shown over and over that gun control doesn't reduce gun violence. Creating gun free zones just allows a person with the intent to injure or kill others an unarmed group of targets in a killing zone. Just ask yourself what difference could a responsible and trained gun carrying individual have made at the Ft. Hood shootings, the Virginia Tech shootings, or Sandy Hook? All of those gun free zones just kept the good people from carrying guns. It didn't stop those with evil or misguided ambitions from carrying out their deadly missions.The ACP should concentrate on better educating people about guns, on identifying and treating those with violent mental illnesses, and on investigating and mitigating the causes of violence; not on unconstitutionally eliminating the tools people use to perform those acts in what has been shown to be ineffective in the past. I will not continue to support an organization that stands for tearing down my constitutionally given and my God given freedoms. If the ACP continues down this misguided path of advocating the ban of certain kinds of weapons or magazines I will have no choice but to leave the organization and continue to fight against that point of view from outside the organization. Ron Vallejo, MDnone9 January 2013 Gun Control How come the medical profession, the AMA, the government, and etc., have not proposed a ban on alcohol, sugar, fat, and smoking? Alcohol-related illnesses, diabetes, cardiovascular diseases, and lung CA have claimed more lives than guns. What about improving access to psychiatric care? Before getting involved in the politics of gun control, ACP should address problems in our own backyard first. Gun laws only affect law-abiding citizens, not criminals. The rights of law abiding citizens should be protected. James F Bush MD, FACPState Government9 January 2013 We need to improve Mental Health There are few other topics that arouse such immediate and visceral reactions as the mention of gun control. Two sides polarize and do not listen to each other. Yet in this editorial there is in passing reference made to the issue of mental health, and I think that is the discussion that we as Physicians should be leading. There are 3 instances of people being killed by firearms (excluding suicide)1) Accidental- even the NRA tries to promote improved gun safety, safe storage of firearms, proper training, etc.2) Criminal - Here the data is very interesting, according to UNODC data there is no good correlation between the numbers of guns in a country and the Homicide by firearm rates. If there was a direct correlation between the presence of firearms and murder one would expect the US to lead the list and we are far from the top. Even within our country there is no correlation between numbers of firearms and murder by guns. Again according to the UNODC , we range from a high firearms murder rate of 24/100,000 to a low of 0.8/100,000. As one examines the list of States it is clear there is no correlation to the numbers of firearms in each State to the murder rate. Indeed the states with the more stringent gun control seem to have higher murder rates. As physicians we would not accept any medical hypothesis that shows no correlation. 3) Mental health- Each of these recent tragedies not only involved a gun, but a seriously disturbed person with Mental Illness. As health professionals it is our duty to point out the challenges we face rendering appropriate treatment and safeguarding society. The delicate balance between civil rights and protecting the public must be weighed, but at this time, as the Aurora, CO shooting showed the ability to proactively safeguard the public is handicapped by our current rules and laws regarding privacy. The Newtown case shows the challenges in placing people for treatment even with family support. These are legitimate areas for a professional Society to address, and these must be addressed. Gun control laws are outside the mandate of the ACP, and because of everyone's strong passions it would divide the College. I strongly urge us to focus on the medical aspects of these tragedies , an area where there is not enough discussion, and try to create something positive- better care for the patient and more protection for Society. Kent R. Corral,M.D.ACP member7 January 2013 A response Sometimes it is difficult to sort through our responsibilities as citizens and those as physicians. The writings of the early founding fathers are often interpreted that the militia were the arms bearing citizens. As well many of the founding fathers believed that gun ownership was necessary to thwart tyranny. I agree. The greatest mass murderers in history (Mao,Stalin,Hitler) turned the armed power of the terroist state against unarmed citizens. That is the fear that drives many thoughtful citizens to oppose limitations on gun ownership. The citizenry needs to be armed to the extent that the government fears them. Kent R, Corral,M.D. David Nichols, MDCastleview Hospital, Price, Utah7 January 2013 Immediate Action Plan for Combating Gun Violence Thank you for allowing me to voice my ideas for combating gun violence: (1) Limit children’s access to violent movies and video games. Go “TV/Video free” for a week or two with our kids and play ball, games, or go target shooting instead. Ask about home viewing habits. Do parents know what kids are watching? How about formal registration, non-transferability, and a $200 tax stamp for the truly gruesome movies and videos that glorify gratuitous violence and teach our kids to kill? (2) Advocate for gun safety. It’s not my business to know if my patients own guns, but I can advocate for keeping firearms locked up (with ammo, ready for immediate use if needed) and readily available in a GunVault or similar device. Teach kids about guns and gun safety at an early age. Take kids shooting. Teach them to respect firearms and to understand there is no “reset button.” (3) Want to follow evidence-based data? Looks like “Gun Free Zones” are free fire zones that kill helpless Americans. Let’s advocate to get rid of them. Co