Should Doctors Talk To Patients About Guns? They Talk About Other Risks, Don’t They?

This week Dr. Garen Wintemiute and several colleagues published an article that detailed both the legal and clinical issues involved in counseling patients about guns. Not only did the article summarize the current legal environment surrounding doctor-patient communications, but it also presented a schema for helping doctors to determine how to respond to a patient’s access to guns based on factors such as depression, substance abuse and other known causes for violence against oneself or others.

docs versus glocks           The article received significant exposure both within and without the medical community, so it didn’t take long for a few physicians whose self-appointed task is to defend gun-owning America against the evil intrusions of gun-grabbing physicians to respond.  The first response was by a physician in California who claims that asking patients about gun ownership infringes on their 2nd-Amendment rights.  So, according to this logic, the 2nd Amendment only allows Americans to own guns, it prevents any discussion about guns.

This gun-loving doctor, Arthur Przebinda, agrees with Wintemute that doctors should be allowed to engage in gun counseling if the patient “shows signs of mental illness,” but he nevertheless finds Wintemute’s report ‘misleading’ because – are you ready for this one? – it is based on Wintemute’s own research. [My italics.]

Is this guy serious?  Does he expect a single medical professional to take him seriously because he claims that Wintemute’s article is in error because it is based on Wintemute’s own research?  What should a peer-reviewed article in a medical journal be based on?  No research?

But the truth is that Przebinda isn’t interested in communicating his nonsense to the medical community; his sole agenda is to try and influence the thoughts of gun owners, some of whom might otherwise be tempted to actually take seriously what medicine believes to be the problem with guns.  And the problem with guns is very simple: they constitute a risk.  How much of a risk?  This remains a subject of debate because thanks to the twenty-year freeze of CDC gun research, a freeze that Dr. Przebinda wholeheartedly supports, sufficient research has not been accomplished to determine exactly the degree to which gun ownership increases the possibility of deaths or injuries from intentional or unintentional use of a gun.

“They’re trying to identify gun ownership as a risk factor, the same way they would define smoking inside the house,” says Przebinda, and that’s exactly the point.  Because smoking is harmful. And so are guns. Period. End of story.  What does Dr. Przebinda think happens to human tissue when it is struck by an ounce of lead travelling faster than the speed of sound?

Now don’t get me wrong.  I’m not saying that it’s wrong to own a gun.  And if someone believes, massive evidence to the contrary, that keeping a gun in their home makes them safe from crime, then they can believe it all they want.  And they can also own a gun. But when was the last time doctors made a decision about what constitutes medical risk based on whether a marketing organization like the NRA agreed with them or not?  Did doctors refrain from asking patients whether they smoked before cigarette companies admitted that smoking causes cancer and other serious disease?

A rational and reasonable medical response to Pzrebinda’s pro-gun stance is provided by Dr. Eric Fleegler from Boston Children’s Hospital who says that discussions about guns should be “delicate conversations.”  But let’s remember that many discussions between doctors and their patients are delicate, which is exactly why such conversations are protected from public disclosure no matter what the NRA and their pro-gun acolytes would like gun owners to believe.

Physicians engage in very private and very delicate discussions all the time: an elderly parent is losing his mind, a teenage child is into drugs. These are medical risks that only doctors can evaluate and help patients to better understand. Which doesn’t mean the patient has to ever go along with what the doctor says. But it still has to be said. Guns are a risk.

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Where Do Crime Guns Come From? Not Necessarily From Where You Think.

My friends at The Trace have just published a document that has floated around gun circles since it first appeared in 2003 as an affidavit in a liability case against the gun industry that was one of a number of class-action torts which came to a crashing end in 2005.  Bob Ricker, the deposition’s author, had been an NRA attorney and gun-industry lobbyist who then went over to the ‘other side’ and began working in favor of more stringent industry regulations as a way to keep guns out of the ‘wrong hands.’

gun safe              Much of what is in this document was similar to what the Clinton Administration said about the gun industry when it tried to get gun makers to adopt better self-policing in return for an immunity from class-action suits.  This effort ultimately went nowhere, but much of what Ricker claims to have been standard practice in the industry has influenced discussions within the GVP community, along with shaping strategies that are followed by GVP advocate to this day.  Which therefore leads me to ask two questions: (1). What does Ricker actually say, and (2). Is what he says really true?

Here’s the key point as quoted from the affidavit itself: “The firearms industry has long known that the diversion of firearms from legal channels to the black market occurs principally at the distributor/dealer level.” Not only does the firearms industry know this, but so does everyone else.  And the fact that the industry, according to Ricker, had not taken “constructive voluntary action to prevent firearms from ending up in the illegal gun market” is, in and of itself, neither here nor there.  The reason it’s neither here nor there is that the one, voluntary action that Ricker mentions (Par. 12 of the affidavit) is that manufacturers and wholesalers could more closely monitor the sales practices of dealers, rather than just shipping guns to anyone with a valid FFL.

Ricker’s affidavit goes on to tie better policing of FFL business practices to the illegal diversion of guns to criminal hands through straw sales, gun shows and the like.  The only problem is that while we have all heard about ‘bad apple’ dealers as well as the proliferation of unregulated internet sales as two sources of illegal guns, nobody including the ATF has ever come up with an evidence-based number for exactly how many guns move from legal to illegal commercial channels each year.  Garen Wintemute estimates that as many as 40,000 straw sales were attempted annually, but he has no data on how many of those attempts actually result in a gun moving from an FFL’s inventory into illegal hands.

Let’s play devil’s advocate for a minute and pretend that all of those 40,000 attempted straw sales go through.  Sounds like a lot of guns going into the wrong hands, doesn’t it?  In fact, it’s a pittance compared to the way in which most guns in this country wind up in the wrong hands, and I don’t notice anyone talking about that issue at all.

Back in 1994, Philip Cook and Jens Ludwig published the most comprehensive survey on gun ownership that I have ever seen. Now if the Nobel Prize Committee decided to give an award for gun research, it would have to go to Phil Cook.  He not only practically invented the entire field of gun violence research, but his work, then and now, is impeccable and should be accepted without question as the best of breed.

And what did he learn about how guns get into the wrong hands?  He learned that perhaps as many as 600,000 guns were stolen every year, this at a time when the total number of guns owned by Americans was 50% less than it is now!  Are you telling me that we can have a substantive conversation about reducing gun violence without asking how to prevent the theft of guns? Gun theft isn’t the elephant in the GVP living room, it’s the whole house.

 

The Epidemiologists May Need To Dig Deeper To Understand The Problem Of Gun Violence.

If we want to advance some meaningful responses to gun violence, we need to figure out the what, who and where of the problem or, as public health researchers would say, the epidemiology of gun violence. A good start in this respect is a recent publication by one of our most prolific public health gun scholars, Garen Wintemute, whose summary of gun-violence data covering 2003-2012 appears in a symposium devoted to strategies to prevent gun violence in the Annual Review of Public Health.

Wintemute introduces the problem by noting that 313,045 Americans died from firearm-related injuries, a larger number than all the troops killed in World War II.  But on a White House gun violence website, the number for gun mortality between 2001 and 2013 is given as 150,000. How come there’s such a big difference?

conference program pic               Because to the public health community, gun violence means every kind of injury caused by gunfire, whether the gun is pointed at the user or at someone else.  The fact is that a majority of gun killings are suicides, not homicides, and among certain populations, such as elderly White men in certain Western states, suicides account for virtually all gun mortalities, with homicides contributing nothing to total gun mortality at all.  This is not the time or place to engage in a discussion about the causal/responsive differences between gun suicides and gun homicides; suffice it to say that Wintemute and other public health researchers clearly acknowledge that homicide and suicide are subsets of a generic problem – access to guns – each of which needs to be understood on its own terms.

Where Wintemute’s careful and thorough analysis of CDC violent mortality data bumps up against a serious limitation (which he acknowledges) is not in terms of defining gun violence to include both homicide and suicide, but in the fact that he is forced to create an epidemiology of gun violence without being able to utilize data on non-fatal gun injuries, the incidence of which is at least twice as high each year as the number of people getting killed with guns.

Not only is the non-fatal gun injury rate twice as high as the gun mortality rate (suicide and homicide), but while the overall gun mortality rate has been fairly steady over the years covered by Wintemute’s research, the non-fatal gun injury rate has shown a remarkable annual rise, from 14.11 per 100,000 in 2001 to 19.68 in 2013, an increase of nearly 40 percent!  Part of this increase is due to innovations in trauma surgery, also to the speed at which seriously-injured victims get moved from the incident site to a trauma unit and the fact that most of the jerks who use guns probably can’t shoot very straight.  Or is this increase simply due to the fact that more guns are where they shouldn’t be?  We don’t know.

Make no mistake. The costs of gun violence cannot be understood if we don’t factor in what happens when someone is shot but not killed with a gun.  Direct medical costs of treating non-fatal gun injuries are 30-40% higher than the costs of dealing with any other serious injury; these numbers don’t include the frequent, long-term costs of post-discharge therapies, as well as the excessive loss of wages that often are the result of the physical and mental damage resulting from guns. A recent estimate of the total annual cost of all gun violence – mortality and morbidity – as being around $229 billion, may be an underestimate by far.

One other point which emerges from Wintemute’s work deserves comment here.   Of the fourteen states that rank highest in suicides and homicides, eleven are located in the South.  Some of these states, like Alabama, Louisiana and Mississippi, experience gun violence similar to Panama and South Africa, not yet Honduras, but not far behind. If we construct an epidemiology to help us figure out gun violence, the answers and strategies for some may not be sufficient for all.

Want To Be Told That Guns Aren’t A Threat To Health? Publish Research Which Shows That They Are.

It didn’t take seventy-two hours following the publication of a reasoned and respectful JAMA editorial on physicians counseling patients about guns before the self-appointed NRA medical sycophant, Timothy Wheeler, issued his usual pronouncement that doctors represent the enemy when it comes to anything having to do with guns.  Actually, I blame the Hospital and Health Networks blog for letting Wheeler crawl out from underneath his proverbial rock, because the truth is that to present him as some kind of medical authority on gun violence is to grant him a level of professional credibility that he doesn’t deserve.

The JAMA editorial, co-authored by two noted gun researchers, Drs. Marion Betz and Garen Wintemute, represents a very important step forward in the discussion about doctors and guns.  It follows from a “call to action” issued in April by eight professional medical organizations (plus the American Bar Association) that urged physicians to become more engaged in the issue of gun violence,  notwithstanding the heavy-handed effort by the gun lobby to legally de-franchise medical professionals from any connection to this issue at all.

conference program pic                The NRA has been pissing and moaning about public health and clinical views on gun violence for more than twenty years, and Wheeler is often quoted whenever relevant research is published and, in time-honored fashion, the media needs a comment from the “other side.”  I wouldn’t mind if Wheeler had ever conducted any research at all to justify his views on guns, but in fact he is a polemicist pure and simple whose pro-gun opinions come right out of the NRA playbook but are delivered with heightened authority because his name is followed by the initials ‘M.D.’

His latest salvo, written in response to the JAMA editorial, asserts that, “Physicians get no training in firearm mechanics, safety, or tactics in medical school or residency. They simply are not qualified to counsel patients about firearms.”  There was a time when physicians didn’t focus on health risks like obesity and tobacco companies routinely showed doctors inhaling a Lucky Strike cigarette in their ads. When the medical community decided that enough research had been conducted to classify obesity and tobacco as risks to health, doctors learned how to counsel patients by asking questions and, based on responses, dispensing appropriate medical advice.  Wheeler has never attempted to deny the reams of medical research that shows that the risks of gun ownership far outweigh the gains. Instead, he pompously and falsely accuses physicians of using that research to promote a ‘political’ point of view.

What kind of advice does Wheeler feel is appropriate for doctors to share with patients about guns?  You can find the answers in a book he published, Keeping Your Family Safe.  Most of the book is devoted to a warmed-over version of NRA training materials that describe how guns work, how they should be cleaned and how they should be stored.  Wheeler, incidentally, has absolutely no professional credentials in any of these areas, nor in self-defense laws and self-defense tactics, both of which are covered at length in this book.

I have absolutely no issue with anyone pushing guns as a means of self-defense; what offends me is the notion that guns represent the only or even the most effective way to respond to a possible or actual criminal event.  It’s not true, and there is no evidence-based research that proves it to be the case.  In fact, the latest research demonstrates that using a gun for self-protection is not only a rare event, but is no more effective than other protective actions, such as running away or calling 911.

After medicine took the lead in anti-smoking campaigns, the end result was that one out of two adults who smoked dropped to one out of five. Imagine what would happen to the gun industry if gun ownership followed a similar trend. If Wheeler wants to save the gun industry, he should stop pretending to be a medical expert and do what he does best, which is to figure out ways to sell guns.

What Do Doctors Need To Tell Patients About Guns? That Guns Are Lethal No Matter How Safe You Are.

This week the online version of JAMA contained an important editorial by two noted gun violence researchers.  Their editorial followed from a February “call to action” issued by the eight leading professional medical organizations promoting the idea of greater physician engagement in dealing with gun violence, notwithstanding the attempts by the NRA to legally de-legitimize the ability of doctors to talk to patients about guns.

The authors of the editorial, Drs. Marion Betz and Garen Wintemute, believe that physicians need to develop what they refer to as better ‘cultural competencies’ in order to overcome the alleged suspicions that gun owners harbor about medical professionals who try to talk about their ownership and/or use of guns.  I say ‘alleged’ because I have yet to see a single, bone-fide survey that actually quantifies the anti-physician attitudes the NRA has worked so hard to stir up. The fact that a group of red-meat Florida legislators say “yip’ every time that the NRA lobbyist Granny Hammer says ‘yap,’ doesn’t prove anything at all about how the average gun owner would feel if his doctor initiated a conversation about guns.

jama                Betz&Wintemute present no data on the attitudes of gun-owning patients but there are surveys of physicians which indicate that the majority of medical professionals don’t know enough about guns to feel comfortable raising the issue of gun violence within the context of clinical care.  And the authors are certainly correct in calling for the medical community to find ways to remedy their lack of communication skills. But with all due respect to the very important research conducted by Betz&Wintemute over the years, I am still not convinced that a growth of cultural competence in the area of gun violence should primarily focus, as they suggest, on counseling about the safe use and storage of guns.

In 2013, as the authors note, 117,894 men and women were killed or wounded with guns. But less than 15% of these injuries were considered accidents, or what the CDC calls unintentional events. Now don’t get me wrong: 17,369 accidental shootings is a serious health issue in and of itself.  And anything that can be done to lessen the impact of these events on the victims, their families and the medical system which has to respond to the problem should certainly be put into effect.  But what makes gun violence such a disturbing social and medical phenomenon is the fact that each year at least 100,000 among us make the conscious, often impulsive decision to pick up a gun and use it to shoot ourselves or someone else.  Last year the CDC called 24,000 Ebola cases in Central Africa an “epidemic.”  What do you call 100,000 cases of gun violence in the U.S. every year?  A day at the beach?

If the medical community is going to take a more dynamic approach to gun violence, I think that increasing communication skills regarding safe storage and gun safety is putting the cart before the horse.  Betz&Wintemute are correct in suggesting that effective counseling has to reflect the individualized nature of every clinical interaction, but the real problem that physicians face is not learning how to tell a gun-owning patient to lock up or lock away the guns; it’s learning how to identify patients who are prone to engage in gun violence, regardless of how they store their guns.

Adam Lanza’s mother dragged him from one shrink to another.  At no time did a medical professional ask why her home was virtually littered with guns.  Elliott Rodger, who shot 17 people in Isla Vista, California, had been seeing therapists since he was eight years old.  Not a single medical society has yet to adopt clinical guidelines to help physicians identify at-risk patients before they pull out a gun. Doctors are hardly the only group who can give advice on safe storage of guns.  But what only they can do is identify and treat risks to health.  And anyone who believes that a gun doesn’t represent a health risk doesn’t know much about either one.