Implementing a Public Health Approach to Gun Violence Prevention: The Importance of Physician Engagement
Authors: Shannon Frattaroli, Daniel W. Webster, Garen J. Wintemute
Journal: Annals of Internal Medicine (2013)

Ideas and Opinions7 May 2013Implementing a Public Health Approach to Gun Violence Prevention: The Importance of Physician EngagementFREEShannon Frattaroli, PhD, MPH, Daniel W. Webster, ScD, MPH, and Garen J. Wintemute, MD, MPHShannon Frattaroli, PhD, MPHFrom Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and University of California, Davis, Davis, California., Daniel W. Webster, ScD, MPHFrom Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and University of California, Davis, Davis, California., and Garen J. Wintemute, MD, MPHFrom Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and University of California, Davis, Davis, California.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-158-9-201305070-00597 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The first month of 2013 brought more discussion about gun policy and more action from our state and national leaders than has occurred in decades. The release of the Vice President's task force report, the President's executive actions, and the bills in Congress and several state legislatures are all indications that the country is poised to change how it regulates access to guns.Whether and to what extent such change occurs will depend in large part on the response from the public. Health care providers, and physicians in particular, are an important source of information for the public and a valued constituency for policymakers. Therefore, as the details of different policy proposals unfold and the public and policymakers weigh the options, we present a case for the role of physicians in these discussions.A Role for Health Professionals in the Current Gun Policy DialogueFifteen years ago, Dr. Frank Davidoff, then editor of Annals, called on readers to reframe gun violence as a medical issue (1). He referenced survey findings indicating that most physicians viewed gun violence as a public health problem and that they supported a more active role for the profession in preventing it. Despite Dr. Davidoff's powerful call, the New Year's resolution offered by the current editors described the efforts since 1998 as "lackluster," citing evidence that efforts to treat gun violence as a public health problem have been undermined (2).That reframing gun violence as a public health problem is a point of contention is difficult to understand in light of the numbers that complement the regular media reports of gun violence and its victims. In 2010, more than 31 000 persons in this country died after being shot with a gun; an estimated 73 500 more were shot and survived (3). We treat or bury, on average, 286 persons every day who find themselves on the wrong end of a gun. Although treatment of the wounds is an essential role for health care providers, it should be our last line of defense. Many gun violence victims never fully recover from their physical injuries, and the emotional scars last a lifetime. Furthermore, few of those who die from gunshot wounds could have been saved by clinical intervention. Given that more than 95% of fatalities die within 24 hours of being shot and most die where they were shot, more or better treatment is unlikely to yield substantial reductions in gun deaths (4). A greater emphasis on preventing gun violence is needed. Evidence-based, well-implemented, and enforced policies can reduce gun violence in our homes and on our streets (5), and this vision can be realized with the help of physicians.Five Strategies for Physician EngagementPhysician as ClinicianPhysicians serve an important role in identifying and providing treatment for people in crisis. Given that most (61%) gun violence victims die by their own hand, the potential for clinical intervention is powerful (3). Efforts to ensure that mental health treatment is available and that it includes options for removing guns and prohibiting new gun purchases for people who desire or would benefit from such intervention while in treatment are important. California law establishes an infrastructure for clinical providers to work with law enforcement to limit gun access when a person in treatment has made a credible threat to harm themselves or others (6). Information about how California's law is being implemented, and to what effect, can help inform clinical practice and the systems available to support that work.Physicians can be an important voice for normalizing the dialogue around gun violence and gun policy. The latter is generally considered to be a polarizing topic, despite the fact that public opinion polls consistently show strong support among Americans for a wide range of gun policies. According to a recent survey, most people, regardless of their party affiliation or whether they own a gun, support new policies that would expand and strengthen our current regulatory approach to guns (7). For example, federal law requires licensed dealers to complete a background check on anyone who purchases a gun. This law covers an estimated 60% of gun sales but ignores the remaining 40% that are sold by unlicensed private sellers (8). As a result, buyers on the private market are not subject to the federal background check requirement. Ninety percent of the public, including 84% of gun owners and 74% of self-described National Rifle Association members, supports universal background checks for all gun sales (7). There seems to be a greater interest in what unites us on this issue. Physicians can help to encourage reasoned discussions by talking with patients and colleagues about guns and gun violence prevention.Physician as Manager of FearFear figures prominently in decisions people make about guns and has kept many quiet on this issue. Fear of strangers and chaos is the reason that some choose to be armed, whereas fear of the government is the motivation for others. Fear has also shaped the gun policy debate. Whether to muster support for "stand your ground" laws or rally in opposition to proposals that would track gun purchases to aid law enforcement investigations, fear is an element of how we talk about guns. Physicians are accustomed to helping people manage their fear of disease and death, and bringing that skill set to the current conversation about gun policy may help people manage their fear of victimization and an overreaching government.Physician as ResearcherOn 16 January 2013, President Obama directed the Centers for Disease Control and Prevention to conduct research into the causes and consequences of gun violence. With that action, the President confronted the agency's 17-year silence on gun violence prevention research, which was prompted by warnings from Congress that federal funding could not be used to advocate for gun control. Ensuring that money is appropriated and that physician researchers are a part of what we predict will be a robust and effective research agenda to inform future gun violence prevention efforts are 2 ways for physicians to participate in building the evidence to inform our understanding of this problem.Physician as Policy AdvocateA growing body of literature offers several options for evidence-based and evidence-informed policies on gun violence prevention. Those findings are described in other editorials (9, 10) and publications (5), and we encourage readers to review and use them to inform their own advocacy.Physician as LeaderOne way to move beyond the calls to reframe gun violence and acknowledge the "raised voices" in the physician community is through leadership from within. There is a need for more physicians to talk and write about their interactions with patients and colleagues and to lead by example in the statehouses and halls of Congress.In a democracy such as ours, the public is ultimately responsible for the state of its country. Although there are powerful and well-financed efforts that have subverted the ability of the American people to realize the common-sense gun policies they have long supported, we do not believe the public will has yet been asserted on this issue. Perhaps that is changing with the new interest being expressed, and perhaps that interest will be helped along by a physician community ready to declare that medicine and public health must be part of the response to the violence that has become such a defining feature of American life. In the words of Martin Luther King, Jr., "In the end, we will remember not the words of our enemies, but the silence of our friends."References1. Davidoff F, et al. Reframing gun violence [Editorial]. Ann Intern Med. 1998;128:234-5. [PMID: 9454533] LinkGoogle Scholar2. 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;158:493-4. LinkGoogle Scholar3. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta: Centers for Disease Control and Prevention; 2005. Accessed at www.cdc.gov/ncipc/wisqars on 30 January 2013. Google Scholar4. Kellermann AL, Rivara FP, Lee RK, Banton JG, Cummings P, Hackman BB, et al. Injuries due to firearms in three cities. N Engl J Med. 1996;335:1438-44. [PMID: 8875922] CrossrefMedlineGoogle Scholar5. Webster DW, Vernick JS, eds. Reducing Gun Violence in America: Informing Policy with Evidence and Analysis. Baltimore: Johns Hopkins Univ Pr; 2013. Google Scholar6. Cal. Code § 8100–8108 (2008). Google Scholar7. Barry CL, McGinty EE, Vernick JS, Webster DW. After Newtown—public opinion on gun policy and mental illness. N Engl J Med. 2013;:. [PMID: 23356490] CrossrefMedlineGoogle Scholar8. Cook PJ, Ludwig J. Guns in America: Results of a Comprehensive National Survey on Firearms Ownership and Use. Washington, DC: Police Foundation; 1996. Google Scholar9. Vittes KA, Vernick JS, Webster DW. Common sense gun policy reforms for the United States. BMJ. 2012;345:8672. [PMID: 23262660] CrossrefMedlineGoogle Scholar10. Wintemute GJ, et al. Tragedy's legacy. N Engl J Med. 2013;368:397-9. [PMID: 23268646] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Shannon Frattaroli, PhD, MPH, Daniel W.Webster, ScD, MPH, Garen J. Wintemute, MD, MPHJohns Hopkins School of Public Health21 June 2013 Author's Response We appreciate the diversity of responses to our article. Dr. May's empirical work provides a patient perspective on the physician's role in gun violence prevention and is an important complement to the five strategies we discuss. As other readers of this Journal consider whether and how to incorporate more gun violence prevention strategies into their professional practice, the relative importance of such an approach is heightened by Congress' recent decision not to expand background checks to include all Internet and gun show sales. In a political climate where lawmakers fail to legislate the systemic reforms that a majority of the population supports, education to raise awareness and influence behaviors is one of the few tools that remain.That said we do recognize the limited time available for such outreach, the challenges of promoting safe behavior, and the different perspectives about the role of clinicians in gun violence prevention efforts. As we continue our collective efforts to realize a less violent society, we are encouraged by the willingness to discuss and debate the best course forward. And we remain optimistic that physician engagement in gun violence prevention will lead to fewer firearm-related deaths and injuries. With regard to Dr. Gould's letter, we are saddened by his response, and thank him for his decades of service. Stephen SandroniDepartment of Medical Education, Paul L. Foster School of Medicine, El Paso11 June 2013 Gun Violence Frattaroli et al note the role that fear plays in decisions about gun ownership and gun policy. They also call for more physician leadership. It would be instructive for medical school leadership to determine how many faculty and students possess guns, even in households with small children. While many of them will clearly state that fear is a motivation in their decisions, far fewer will give a direct answer to the question, Who or what are you afraid of? Further internal exploration of this issue may be necessary if more effective physician leadership is to be developed. John P. May, MD, FACPArmor Correctional Health Services17 May 2013 Physician Counseling about Gun Injury Physician engagement and a public health approach to gun violence as outlined by Frattaroli, Webster and Wintemute (1) and sought by the editors of the Annals (2) includes preventive counseling about guns during routine clinical encounters. We interviewed 53 African American men aged 18-34, the group for whom firearm injury is the leading cause of death (3), following an ambulatory care encounter unrelated to violence. During the visit, the physician briefly counseled the patient about six preventive health issues: alcohol, smoking, drugs, safe sex, guns, and seat belt use. In a post-encounter interview, the discussion of firearms was the issue most commonly recalled by the patients. Eighty-one (81) percent believed that it is important for a doctor to talk with them about guns. (4) The discussion can be within the context of a routine health exam wherein the physician alerts the patient to situations that increase risk. A mnemonic device developed by the Chicago Medical Society uses the word GUNS (5) to prompt questions for patients pertaining to risks: (6) G – Is there a Gun in your home? U – Are you are around Users of alcohol and other drugs? N – Do you feel a Need to protect yourself? S – Do any of these Situations apply to you: - Seen or been involved in acts of violence? - Sadness? - School-aged children at home? Physicians ought not ignore or hold reservations about assessing and counseling their patients' risk of gun injury or death. Frattaroli S, Webster D, Wintemute GJ. Ann Intern Med. 2013; 158(9):697-698. Laine C, Taichman DB, Murlow C, Berkwits M, Cotton D, Williams SV. Ann Intern Med. 2013; 158(6):493-494. Centers for Disease Control and Prevention. Leading causes of death. Atlanta: Centers for Disease Control and Prevention; 2009. Accessed at www.cdc.gov/men/lcod on 13 May 2013. May JP, Martin KL. A role for the primary care physician in counseling young African-American men about homicide prevention. Journal of General Internal Medicine.1993;8:380-382. Voelker R. Taking aim at handgun violence. JAMA. 1995; 273(22):1739-1740. May JP, Christoffel KK, Sprang ML. Counseling patients about guns. Chicago Medicine. 1994;97(7):13-16. James R. Gould, MD, FACPOncology Associates of W. Kentucky7 May 2013 Gun Violence Prevention: A Pathetic Proposition Who put you up to this? As a physician of nearly 40 years experience, I have no role in gun violence prevention. First, I don't get paid for my current tasks. Second, the kind words I offer to the obese, underactive, and medically uncontrolled already fall on deaf ears. Advice to pathologic psyches? Third, the system of mental health support collapsed decades ago. Don't shift the burden of 'prevention' to those who can't get their primary jobs done. Fourth, the criminal justice system is not allowed to do its job: Punish and restrict the freedoms of the convicted. We have known for decades that the cost of rehabilitation is wasted. [My high school debate focus in 1969...] If I am obligated to become part of the gun violence debate (how about PQRI), I WILL throw in the towel. I will abdicate the responsibility I have for so many medical problems over the issue of violence. I will burn my license on the steps of the U. S. Capitol with as much fanfare as I can create. Your manuscript is a specious and shameful effort to involve 'healthcare' in the debate over gun violence. Take it home. Focus your attention on mental health funding, mental health homes, background checks, sales prevention, and criminal justice. Encourage those who are tasked with the problem to complete their tasks. Let the docs be physicians and healers, one poor soul at a time. Author, Article, and Disclosure InformationAuthors: Shannon Frattaroli, PhD, MPH; Daniel W. Webster, ScD, MPH; Garen J. Wintemute, MD, MPHAffiliations: From Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and University of California, Davis, Davis, California.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0283.Corresponding Author: Shannon Frattaroli, PhD, MPH, Associate Professor, The Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205; e-mail, [email protected]edu.Current Author Addresses: Drs. Frattaroli and Webster: The Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205.Dr. Wintemute: UC Davis Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817.Author Contributions: Conception and design: S. Frattaroli, G.J. Wintemute.Drafting of the article: S. Frattaroli, D.W. Webster.Critical revision of the article for important intellectual content: G.J. Wintemute.Final approval of the article: S. Frattaroli, D.W. Webster, G.J. Wintemute.Administrative, technical, or logistic support: S. Frattaroli.This article was published at www.annals.org on 12 February 2013. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoA Public Health Approach to Gun Violence John P. May A Public Health Approach to Gun Violence James R. Gould A Public Health Approach to Gun Violence Shannon Frattaroli , Daniel W. Webster , and Garen J. 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Gould, MD 7 May 2013Volume 158, Issue 9Page: 697-698KeywordsFearFirearm injuriesHealth care providersHealth surveysPrevention, policy, and public healthPsychiatry and mental healthPublic policyScarsViolent crimeVision ePublished: 7 May 2013 Issue Published: 7 May 2013 Copyright & PermissionsCopyright © 2013 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...