What You Can Do to Stop Firearm Violence
Authors: Garen J. Wintemute
Journal: Annals of Internal Medicine (2017)

Ideas and Opinions19 December 2017What You Can Do to Stop Firearm ViolenceFREEGaren J. Wintemute, MD, MPHGaren J. Wintemute, MD, MPHFrom UC Davis School of Medicine, Sacramento, California. (G.J.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M17-2672 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail See who has committed to talk to their at-risk patients about firearm safety. Make your commitment now.Mass shootings are reshaping the character of American public life. Whoever we are, they happen to people just like us; they happen in places just like our places. We all sense that we are at risk.Yet even as we focus on the latest tragedy in Las Vegas, we must remember that these horrific mass shootings have accounted for no more than 1% to 2% of deaths from firearm violence in recent years. The 2 mass shootings with the highest fatality counts in modern U.S. history, in Las Vegas on 1 October 2017 and Orlando on 12 June 2016, resulted in 107 deaths. Yet nationwide in 2016, there was an average of 97 deaths from firearm violence per day: 35 476 altogether (1). In the 10 years ending with 2016, deaths of U.S. civilians from firearm violence exceeded American combat fatalities in World War II.Calls for action in the wake of Las Vegas have been made not just with profound sadness and outrage but with a here-we-go-again sense of futility. This is entirely appropriate if action by Congress and the White House is being called for—those institutions have abdicated their responsibility on this complex and pressing problem as on so many others.But there is a critically important and beneficial action that we physicians can take, right now and on our own initiative. Fundamentally, it's quite simple. We need to ask our patients about firearms, counsel them on safe firearm behaviors, and take further action when an imminent hazard is present (2).This can be a focused intervention, because violence is not distributed at random. People who commit firearm violence—whether against others or themselves—and people who sustain it often have well-recognized risk factors. As a result, firearm violence can to some extent be predicted. What's more, these factors often bring high-risk individuals into contact with physicians. They include abuse of alcohol (3) and controlled substances, acute injury (4), a history of violence (including a suicide attempt), poorly controlled severe mental illness (5), an abusive partner, and serious life stressors.The relationship between fatal violence and recent contact with a health professional is clearest for people who commit suicide: As many as 45% have seen their primary care provider within a month of their deaths (6). Particularly at older ages, these persons frequently disclose their intent to kill themselves, and they are most likely to do so when they have coexisting health problems (7). Unintentional injury is a concern, too; are there children or impaired adults exposed to firearms, creating a risk for unintended harm to themselves or others?We already acknowledge that we should talk about firearms with patients, and patients agree with us (8); however, we don't do it (2). There are barriers, to be sure. We may be concerned that we don't know enough about firearms, or about the benefits and risks associated with owning and using them. We may think that we don't have time. We may even believe that such conversations are prohibited by law, which is a myth.In fact, there is a growing literature on when such conversations are most appropriate, how to ask the questions, and what to do with the answers (9). The key, as always, is to make clear that we are asking because we care about our patients' health and well-being. Materials for both physicians and patients are available (2), and more are in development. Many professional societies, including the American College of Physicians, have agreed that talking about firearms is something a physician should do (10).With all that in mind, here is what you can do right now to help stop firearm injury and death: Make a commitment to ask your patients about firearms when, in your judgment, it is appropriate, and follow through. If you need to study up in advance, so be it.As we know, commitments to change health-related behaviors mean more when they are made in public. The Figure is the template to post a comment at http://go.annals.org/commit-now in response to this commentary. Fill it out and post it. If you give us permission to contact you, we will follow up to see how you're doing, let you know what others have done, and provide new resources as they become available. By all means, e-mail this commentary to your colleagues or send the link (http://annals.org/aim/article/doi/10.7326/M17-2672); encourage them to make a commitment similar to yours. The form closes on 16 April 2018.Figure. Template for commitment to help reduce firearm-related injuries and deaths. Download figure Download PowerPoint You won't be acting alone. I frequently hear from physicians who have reached a personal tipping point and decided to stay on the sidelines no longer. For the first time in more than 20 years, a growing group of clinical and basic science researchers is providing new information on the risks and benefits of firearm ownership and the prevention of firearm violence at the individual and societal levels. The Centers for Disease Control and Prevention is still not in the game, but the National Institutes of Health had a formal program of firearm violence research funding from 2013 to 2016 and remains open to proposals. The National Institute of Justice, which has been providing support at least since the 1990s, made 4 grants totaling $2.9 million in early October. California has just established the nation's first publicly funded firearm violence research center, and New York may follow suit.These activities and others in the background will help create the knowledge base and infrastructure to make your efforts as effective as possible. But in the end, it all comes down to what happens between you and your patient in the office, or the hospital, or the emergency department.Please make your commitment. There is no better time, and it's the right thing to do.References1. Centers for Disease Control and Prevention. Web-based interactive surveillance query and response system (WISQARS). Accessed at www.cdc.gov/injury/wisqars/index.html on 8 October 2017. Google Scholar2. Wintemute GJ, Betz ME, Ranney ML. Yes, you can: physicians, patients, and firearms. Ann Intern Med. 2016;165:205-13. [PMID: 27183181]. doi:10.7326/M15-2905 LinkGoogle Scholar3. Wintemute GJ, Wright MA, Castillo-Carniglia A, Shev A, Cerdá M. Firearms, alcohol and crime: convictions for driving under the influence (DUI) and other alcohol-related crimes and risk for future criminal activity among authorised purchasers of handguns. Inj Prev. 2017. [PMID: 28137977] doi:10.1136/injuryprev-2016-042181 CrossrefMedlineGoogle Scholar4. Rowhani-Rahbar A, Zatzick D, Wang J, Mills BM, Simonetti JA, Fan MD, et al. Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study. Ann Intern Med. 2015;162:492-500. [PMID: 25706337]. doi:10.7326/M14-2362 LinkGoogle Scholar5. Swanson JW, McGinty EE, Fazel S, Mays VM. Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Ann Epidemiol. 2015;25:366-76. [PMID: 24861430] doi:10.1016/j.annepidem.2014.03.004 CrossrefMedlineGoogle Scholar6. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159:909-16. [PMID: 12042175] CrossrefMedlineGoogle Scholar7. Choi NG, DiNitto DM, Marti CN, Kaplan MS. Older Suicide Decedents: Intent Disclosure, Mental and Physical Health, and Suicide Means. Am J Prev Med. 2017. [PMID: 28985982] doi:10.1016/j.amepre.2017.07.0218. CrossrefMedlineGoogle Scholar8. Betz ME, Azrael D, Barber C, Miller M. Public opinion regarding whether speaking with patients about firearms is appropriate: results of a national survey. Ann Intern Med. 2016;165:543-50. [PMID: 27455516]. doi:10.7326/M16-0739 LinkGoogle Scholar9. Betz ME, Wintemute GJ. Physician counseling on firearm safety: a new kind of cultural competence. JAMA. 2015;314:449-50. [PMID: 26241594] doi:10.1001/jama.2015.7055 CrossrefMedlineGoogle Scholar10. Weinberger SE, Hoyt DB, Lawrence HC, Levin S, Henley DE, Alden ER, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162:513-6. [PMID: 25706470]. doi:10.7326/M15-0337 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Darren Taichman-4 December 2018 MY COMMITMENT MY COMMITMENT: When risk factors for harm to my patients or others are present, I will ask my patients about firearm ownership and safety. Christine Laine-4 December 2018 MY COMMITMENT MY COMMITMENT: When risk factors for harm to my patients or others are present, I will ask my patients about firearm ownership and safety. Fatima Cody Stanford, J. Drew Payne, Anita Vanka, Heather F. Sateia, Robert K. Cato, Joel Armitage, Ryan R. Kraemer, Wilson W. Lam, Lili Shek, Luis A. Taboada, Martha L. Hlafka, Andria P. Medina, Kapil Mehta, Michael S. Kern-30 October 2017 Letter to the Editor In his article, What You Can Do to Stop Firearm Violence(1) Wintemute speaks to the proliferation of mass shootings in the United States and captures the alarming number of firearm related deaths (~35,476) in the United States in 2016 alone. (2) He charges us to speak to our patients about firearms, counsel them on safe firearm behaviors, and take further action when an imminent hazard is present.(3) In an accompanying Annals of Internal Medicine editorial Editor-in-Chief Laine and Deputy Editor Taichman address the Journal’s and the American College of Physician’s (ACP) long term commitment to addressing firearm violence.(4, 5) As the Academic Advisory Board of the ACP, we strongly support the ACP’s commitment to addressing this issue, and we have taken steps at our respective institutions to carry out this mission. Here are a few examples of how we are addressing this: 1. Ask about firearm ownership on patient intake forms or incorporate an algorithm during history to counsel about firearm safety 2. Screen high risk groups (alcohol and drug abuse, history of violence, uncontrolled mental illness) for gun ownership and counsel appropriately 3. Ask and counsel about child access to firearms and how to prevent injury/fatality 4. Educate trainees about health policies to reduce firearm injuries 5. Contact legislators about policies for universal background checks and improved firearm safety We recognize that the climate surrounding firearm safety varies drastically in different parts of the country, but we also recognize that if we don’t take action regarding this issue, our patients will continue to succumb to this harsh reality. Regardless of one’s belief about owning firearms, we can all agree that the harm inflicted is a public health crisis that can be ameliorated in apolitical ways. Research evaluating gun violence patterns would be a tremendous boost to understanding further how to better approach gun safety issues, and we should encourage our representatives to help with CDC funding that was stripped in 1997. On the individual patient level, we view the risk for gun violence in the same manner as other threats to our patients’ health and accordingly, have made the commitment to counsel our patients when appropriate. We urge you to also make the following commitment: “When risk factors for harm to my patients or others are present, I will ask my patients about firearm ownership and safety.” at go.annals.org/commit-now References 1. Wintemute GJ. What You Can Do to Stop Firearm Violence. Ann Intern Med. 2017. 2. Prevention CfDCa. Web-based Injury Statistics Query and Reporting System- WISQARS™. In: Prevention CfDCa, ed; 2017. 3. Wintemute GJ, Betz ME, Ranney ML. Physicians, Patients, and Firearms. Ann Intern Med. 2016;165(12):893. 4. Taichman DB, Bauchner H, Drazen JM, Laine C, Peiperl L. Firearm-Related Injury and Death: A U.S. Health Care Crisis in Need of Health Care Professionals. Ann Intern Med. 2017. 5. Butkus R, Doherty R, Daniel H, Health, Public Policy Committee of the American College of P. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014;160(12):858-60. Author, Article, and Disclosure InformationAffiliations: From UC Davis School of Medicine, Sacramento, California. (G.J.W.)Disclaimer: The funding sources had no role in the preparation of this article.Grant Support: California Wellness Foundation (grant 2014-255) and the Heising-Simons Foundation (grant 2016-219).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2672.Corresponding Author: Garen J. Wintemute, MD, MPH, Violence Prevention Research Program, UC Davis Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817; e-mail, [email protected]edu.Author Contributions: Conception and design: G.J. Wintemute.Drafting of the article: G.J. Wintemute.Final approval of the article: G.J. Wintemute.Obtaining of funding: G.J. Wintemute.This article was published at Annals.org on 17 October 2017. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byClinical strategies for reducing firearm suicideCalifornia Public Opinion On Health Professionals Talking With Patients About FirearmsFirearm Injury PreventionSarabeth Spitzer, MD, Vishnu Muppala, MPH, and Abigail Solomon, BSReducing Firearm Injuries and Deaths in the United StatesJames Webster, MD, MSPsychiatric Disorders and Gun Carrying among Adolescents in the United StatesWanted: Local Medical Experts/Champions to Prevent Gun ViolencePatients’ Perceptions of the Role of Physicians in Questioning and Educating in Firearms Safety: Post-FOPA Repeal EraWhat Can I Do as a Physician to Prevent Firearm Injury?James S. Kahn, MDGun Violence: A Biopsychosocial DiseaseFirearms and Suicide: Finding the Right WordsThe Health Care Professional's Pledge: Protecting Our Patients From Firearm InjuryChristine Laine, MD, MPH and Darren B. Taichman, MD, PhD 19 December 2017Volume 167, Issue 12Page: 886-887KeywordsBehaviorDisclosureFirearm injuriesGamesHealth care providersMedical risk factorsPatient advocacyPatientsResearch fundingSuicide ePublished: 17 October 2017 Issue Published: 19 December 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...