Firearm Injury Prevention: AFFIRMing That Doctors Are in Our Lane
Authors: Darren Taichman, Sue S. Bornstein, Christine Laine
Journal: Annals of Internal Medicine (2018)

Editorials18 December 2018Firearm Injury Prevention: AFFIRMing That Doctors Are in Our LaneFREEDarren Taichman, MD, PhD, Sue S. Bornstein, MD, and Christine Laine, MD, MPHDarren Taichman, MD, PhDExecutive Editor (D.T.), Sue S. Bornstein, MDChair, Health and Public Policy Committee, American College of Physicians (S.S.B.), and Christine Laine, MD, MPHEditor-in-Chief (C.L.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3207 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail On 8 November 2018, the National Rifle Association (NRA) took to Twitter to admonish doctors to "stay in their lane." The event that triggered the NRA's tweet was publication of "Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians" (1) along with editorials (2, 3) and a research report (4) that focused on firearm injury in Annals. We suspect the NRA is also perturbed by the other scholarly articles that Annals has published related to the U.S. public health crisis that firearm injury has become, as well as Annals and the American College of Physicians (ACP) urging physicians to talk with at-risk patients about firearm safety (5). The NRA does not believe firearm-related injury and its prevention is within the purview of physicians. We could not disagree more.If you are unconvinced and need examples of why firearms are a health issue, here are a few. People with accidental gun-related injury nearly always require acute medical care, and many go on to have chronic injury-related health issues. Almost 40% of individuals who commit suicide are seen by their primary care provider within the preceding month (6). Firearms are a frequent and very effective means of suicide. Thus, talking with patients at risk for suicide about their access to firearms is clearly "in our lane." The U.S. Preventive Services Task Force recommends that we screen all of our adult patients for alcoholism and women of childbearing age for intimate partner abuse. Patients with alcohol use disorder are at increased risk for firearm-related injury to themselves or others, and an abuser's access to firearms increases the risk for intimate partner homicide (7, 8). Patients with dementia may become confused or suffer delusions, increasing risk for harm to themselves or others when firearms are present in their homes (as is the case for an estimated 60% of such patients) (9). Recognizing these risks and counseling to reduce them is clearly "in our lane." What about applying pressure to bleeding bullet wounds? Emergency surgery to repair shattered bodies? Weeks of intensive care to support organ failure in gunshot victims? Telling distraught family members that their loved one is dead? The management of chronic pain, functional limitations, and psychological trauma for patients who survive firearm injury but never regain their preinjury health? Providing care for those who were not physically injured but suffer psychologically because they witnessed others being killed or hurt? And then there is caring for family members who grieve the loss of loved ones or who turn their worlds upside down caring for permanently disabled family members? These responsibilities are not only in doctors' lane, they are our job. Consequently, so is advocating for policies that reduce firearm injury and conducting research to better inform policies to keep our patients safer.Firearm-related injury in the United States is a public health crisis (10). In addition to caring for the clinical sequelae of gun-related injury, we need rigorous research to better understand the crisis, test solutions, and learn how best to implement and sustain those that work. To date, the ability to study important questions that might help reduce firearm-related injury has been hampered by a lack of funding and a worry among researchers that studying anything related to guns could put their research careers at risk. This needs to be fixed.As part of the fix, Annals and the ACP are collaborating with the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) (https://affirmresearch.org), a nonprofit organization of health care professionals and researchers working to provide funding for research to answer important questions related to firearm injury and its prevention. In addition to raising funds to support research, AFFIRM aims to sponsor the development of practice recommendations based on sound science and the education and training to implement them.Doctors have a responsibility as health care professionals and scientists to seek the answers to questions related to health and safety. And we won't be silenced in using what we learn to better care for our patients. Those who seek to silence progress toward finding solutions to the crisis of firearm-related injury are traveling a lane that leads, literally, to a dead end. We're going to stay in our lane and keep moving forward.References1. Butkus R, Doherty R, Bornstein SS; Health and Public Policy Committee of the American College of Physicians.. Reducing firearm injuries and deaths in the United States: a position paper from the American College of Physicians. Ann Intern Med. [Epub ahead of print 2018 Oct 30]. [PMID: 30383132]. doi:10.7326/M18-1530 LinkGoogle Scholar2. Kahn JS. What can I do as a physician to prevent firearm injury? Ann Intern Med. [Epub ahead of print 2018 Oct 30]. [PMID: 30383121]. doi:10.7326/M18-2756 LinkGoogle Scholar3. Cook PJ. Expanding the public health approach to gun violence prevention. Ann Intern Med. [Epub ahead of print 2018 Oct 30]. [PMID: 30383127]. doi:10.7326/M18-2846 LinkGoogle Scholar4. Morgan ER, Rowhani-Rahbar A, Azrael D, Miller M. Public perceptions of firearm- and non-firearm-related violent death in the United States: a national study. Ann Intern Med. [Epub ahead of print 2018 Oct 30]. [PMID: 30383115]. doi:10.7326/M18-1533 LinkGoogle Scholar5. Laine C, Taichman DB. The health care professional's pledge: protecting our patients from firearm injury. Ann Intern Med. 2017;167:892-3. [PMID: 29049687]. doi:10.7326/M17-2714 LinkGoogle Scholar6. O'Connor E, Gaynes BN, Burda BU, Soh C, Whitlock EP. Screening for and treatment of suicide risk relevant to primary care: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158:741-54. [PMID: 23609101]. doi:10.7326/0003-4819-158-10-201305210-00642 LinkGoogle Scholar7. Wintemute GJ. The epidemiology of firearm violence in the twenty-first century United States. Annu Rev Public Health. 2015;36:5-19. [PMID: 25533263] doi:10.1146/annurev-publhealth-031914-122535 CrossrefMedlineGoogle Scholar8. Campbell JC, Webster D, Koziol-McLain J, Block C, Campbell D, Curry MA, et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health. 2003;93:1089-97. [PMID: 12835191] CrossrefMedlineGoogle Scholar9. Betz ME, McCourt AD, Vernick JS, Ranney ML, Maust DT, Wintemute GJ. Firearms and dementia: clinical considerations. Ann Intern Med. 2018;169:47-9. [PMID: 29801058]. doi:10.7326/M18-0140 LinkGoogle Scholar10. 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;167:824-5. [PMID: 29052714]. doi:10.7326/M17-2657 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Adam KortowskiSolo Internist14 January 2019 Ruthless Business people NRA comment is outrageous.Unfortunately, in USA some businesses have to strong lobbying powers(case of Big Tobacco). We should not cease our efforts to get guns out of homes. Michael U. Antonucci, M.D.Department of Radiology and Radiological Science, Medical University of South Carolina19 December 2018 The View from My Lane With the recent mass-shootings in Thousand Oaks and at the Pittsburgh Tree of Life Synagogue adding to the increasing number of gun-related deaths in the United States, physicians promoting guidelines to reduce firearm-related violence1 have been instructed by the National Rifle Association to "stay in their lane." This subsequent editorial2 reflects a powerful refusal to be silenced and counters the NRA's tweet with both strong evidence and common sense. Data released since its publication reveals that 2018 saw a record number of school shootings,3 further clarifying the urgency of the issue. Against this backdrop, and contrary to its initial goal, the NRA's suggestion has motivated physicians across specialties to examine "their lane" and identify ways to combat escalating gun violence. As a neuroradiologist, "my lane" traverses behind the scenes. I am spatially removed from patients and indirectly evaluate them through images. While clinical colleagues (directly interacting with patients) typically have a more complete overview of a specific issue, the extent of damage from a bullet is a notable exception. Though I am spared emotional tasks like conveying prognostic information to victims' families, I have a more vivid first look at the pathology along ballistic trajectories. On clinical exam, superficial skin laceration and hematoma around a scalp entry (and, if present, exit) wound belie the more significant intracranial findings seen on medical imaging. This can include skull and metallic fragments within brain tissue, resultant hemorrhage in and damage to eloquent cortex and white matter tracts, edema, and herniation. In my lane, the prevalence of gun violence is alarmingly apparent. For example, over a particularly taxing call weekend, with gunshot victims treated by multiple clinical teams, the neuroradiologist interprets imaging of every head, face, and spine impacted by a firearm. Individually, these are not pretty pictures; the collective catalog is devastating. I do not envy my clinical colleagues who deal with this directly—whose literal blood-soaked hands invoke the ire of the NRA. Nonetheless, my lane affords me with an opportunity and responsibility to share what I see. The accompanying figure (http://annals.org/ImageLibrary/the-view-from-my-lane.jpg) includes imaging from three victims of gun violence. These are only a fraction of the many now indelible in my memory and stored in our imaging archive. They are an objective, unfiltered look at the reality of gun violence in modern medicine and underscore our frustration as we attempt to bandage the wounds of the unfortunate victims who enter our lane. References: 1. Butkus R, Doherty R, Bornstein SS, for the Health and Public Policy Committee of the American College of Physicians. Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians. Ann Intern Med. 2018; 169(10):704-707. 2. Taichman D, Bornstein SS, Laine C. Firearm Injury Prevention: AFFIRMing That Doctors Are in Our Lane. Ann Intern Med. [Epub ahead of print] doi: 10.7326/M18-3207. 3. Riedman D, O'Neill D. "CHDS – K-12 School Shooting Database." Center for Homeland Defense and Security. www.chds.us/ssdb. Accessed December 16, 2018. R. Chris Jones, M.D. TriStar Centennial Medical Center 11 December 2018 Persuasion: Doctors in Their Lane Persuasion: Doctors in Their LaneThe National Rifle Association (NRA) posted this tweet on November 7, 2018: "Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves." The post was in response to a position paper from the American College of physicians in the Annals of Internal Medicine regarding reduction in firearm injuries. Not surprisingly, the medical community quickly responded with a flurry of tweets, most of which expressed indignation at being asked to stay out of the gun safety debate. What was surprising, however, was the content and tone of some of the most re-tweeted posts. The following tweet by Judy Melinek M.D. (@drjudymekinek) was either liked or reposted over 700,000 times:"do you have any idea how many bullets I pull out of corpses weekly? This isn't just my lane. It is my [expletive] highway." The most significant advantage held by physicians in any public policy debate is that we hold the moral high ground. When we employ profanity, exaggeration, or angry tones to make our arguments, we weaken our trust with the citizenry and cede the moral standing granted to us. Our arguments then risk blending with the noise from pundits. Moreover, we need to recognize the power of social media. An angry post by a single physician has the potential to undermine the moral authority for a multitude of our profession. When engaging in policy deliberation, it is paramount that we remember our target audiences. It is easy to direct anger towards a presumed monolithic NRA, but a more effective strategy is to make a case to sympathetic members of the NRA, the public, and policymakers. Gandhi asked his followers to "honor our opponents for the same honesty of purpose and patriotic motive that we claim for ourselves". Although many physicians are repulsed by the November 7 message from the NRA, the NRA does have physician members. Some of these members may be sympathetic to gun safety initiatives, and could serve as an internal movement to push the NRA towards a different stance. Direct attacks towards the NRA as a whole may only serve to galvanize the organization into further Groupthink mode, and eliminate any chance to obtain internal support. If instead we respond in strong but compassionate terms, we have a chance to find common ground with those with whom we disagree. Despite best efforts, no accord may be possible between gun safety proponents and the NRA. Nevertheless, it is the public and the policy makers that will ultimately effect change in this debate. Both of these groups listen to doctors. We know that people are more likely motivated to action by positive speech than negative. Positive, action-directed messaging by physician groups to these two audience sets may not be as immediately gratifying as an angry tweet, but is much more likely to inspire change of minds, and thus policy. The NRA gave a gift to the physicians who advocate for gun safety. Their inflammatory tweet is a perfect opportunity to educate the public, but to do so using emotion to the advantage of the gun safety position. Physicians are human, and we can be susceptible to anger, but our messaging needs to be smart if we wish to effect societal change. Sarabeth Spitzer, Vishnu Muppala and Abigail Solomon Stanford School of Medicine, Florida Atlantic University College of Medicine, Tulane University School of Medicine30 November 2018 Medical Students Demand Firearm Education Physicians across the country have responded to the National Rifle Association's statement that doctors should "stay in their lane" by sharing heart-wrenching stories and images of scrubs soaked with gunshot victims' blood. In addition, the Annals of Internal Medicine, the American College of Physicians and the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) have responded by announcing a collaboration to increase firearm research[i]. We medical students are grateful for such efforts, but know more must be done. As future physicians, our views span the political spectrum. But, we are unanimous in one belief – we must stop the epidemic of firearm injury and death in the United States. This call does not come from baseless idealists, but rather from impassioned students who understand that firearm violence is a public health crisis that desperately requires intervention. We seek to apply the same approach to firearm safety as the medical community has used to successfully mitigate other public health problems such as motor vehicle accidents and smoking: identifying root causes, conducting population research, and implementing evidence-based changes. As medical students, we rely on our schools' faculty to prepare us to handle our community's health challenges. However, although we see victims of firearm violence in emergency rooms, operating rooms and, at worst, the morgue, we are without any formal guidance or training about how to address or prevent this epidemic. In addition to doing research, physicians can counsel their patients directly on the topic of firearm safety and storage. This opportunity uniquely positions doctors to intervene on this tragic public health issue. We come together now to ask the Deans of our medical schools, the developers of our curricula, and all members of our medical community to provide us the education, knowledge and counseling skills regarding firearm safety to properly fulfill our duties as healthcare providers. Immediately, this involves implementing curriculum dedicated to teaching the practical knowledge and patient counseling skills about firearm safety that have shown to be effective in preventing firearm violence.[ii] In the longer term, this requires dedicating appropriate resources to firearm safety research, an area that remains drastically under-studied due to decades of national funding limitations. We call on the medical community now to equip us with the tools we need to live up to the Hippocratic oath we made upon entering this profession. Each of us pledged to "prevent disease whenever I can, as prevention is preferable to cure." Prevention is not only in our lane- it is our duty.[i] Taichman, Darren, Sue S. Bornstein, and Christine Laine. "Firearm Injury Prevention: AFFIRMing That Doctors Are in Our Lane." Annals of internal medicine (2018).[ii] Wintemute, Garen J. "What you can do to stop firearm violence." Annals of internal medicine 167.12 (2017): 886-887. Author, Article, and Disclosure InformationAffiliations: Executive Editor (D.T.)Chair, Health and Public Policy Committee, American College of Physicians (S.S.B.)Editor-in-Chief (C.L.)Disclosures: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3207.This article was published at Annals.org on 20 November 2018. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals Graphic Medicine - #ThisIsOurLane Christopher L. 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DeLong, MDTurning value into action: Healthcare workers using digital media advocacy to drive changeFirearm Injury Prevention in the Emergency DepartmentA National Research Strategy to Reduce Firearm-Related Injury and Death: Recommendations from the Health Policy Research Subcommittee of the Society of General Internal Medicine (SGIM)Comorbidity Profiles Identified in Older Primary Care Patients Who Attempt SuicideFirearm Injury PreventionSarabeth Spitzer, MD, Vishnu Muppala, MPH, and Abigail Solomon, BSFirearm Injury PreventionMichael U. Antonucci, MDCommunication, learning and assessment: Exploring the dimensions of the digital learning environment 18 December 2018Volume 169, Issue 12Page: 885-886KeywordsAlcoholismCareers in researchFirearm injuriesHealth carePrevention, policy, and public healthResearch fundingSafetyScientistsSuicideSurgery ePublished: 20 November 2018 Issue Published: 18 December 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. 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