Do Doctors Know What To Say To Patients About Guns? Not If You Believe That Guns Aren’t A Health Risk.

January 26, 2025

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Since the health care industry now racks up revenues in excess of $1.6 trillion each year, there are plenty of online publications and other venues which are used to promote (i.e., advertise) the services and products driving this economic juggernaut. And one such venture, an online publication called MD Magazine, caught my eye because it published a survey of subscriber attitudes towards guns and counseling patients about guns – a hot-button topic in the medical profession ever since Florida passed a gag order prohibiting doctors to talk to patients about guns.

conference-program-pic While the Florida law didn’t absolutely prohibit doctor-patient gun discussions, it just relegated such discussions to situations in which the physician had reason to believe that the health of the patient was at imminent risk. Of course since we are talking about behavior, it’s virtually impossible for a physician, or anyone else for that matter, to accurately predict imminent risk, which is precisely why doctors need the widest possible latitude in patient contacts, which is why doctor-patient relationships are circumscribed in every respect by the tightest degree of confidentiality, which is why the attempt to push the medical profession out of the discussion about guns is nothing more than pandering to the lowest, common intellectual denominator. But what the hell, if you can build an entire Presidential campaign around your ‘love’ of the 2nd Amendment, why not demonize doctors into the bargain?

The good news about Docs-Glocks, however, is that it did result in the beginnings of a recognition on the part of physicians that they will only get back into the gun game if they bestir themselves and begin to argue for that role. Last April all the major medical associations issued a ‘Call To Acton,’ which not only endorsed the usual menu of gun-control options (background checks, assault-rifle ban, etc.,) but also made a commitment to be “part” of the solution to gun violence. Which means that, like it or not, physicians must continue to advocate for the widest possible freedom in talking to patients about guns.

The problem with this more activist approach is that if physicians are going to engage in unfettered, candid discussions with patients about guns, they have to know how to frame the discussions in ways that are both understandable and meaningful to their patients. After all, the fact that the medical profession has decided that gun violence constitutes a serious medical issue does not, ipso facto, mean that doctors know how to explain the medical risks of gun ownership. Knowing that guns are the instrument used in 31,000 fatalities and 70,000 injuries each year is one thing; knowing how to use that information medically is something else.

This is the context in which the survey in MD Magazine needs to be understood because the results indicate that many doctors do not currently engage in gun counseling, nor do they consider gun ownership a proper issue about which they should be concerned. The survey, conducted online, was answered by 928 subscribers to the magazine. When asked if doctors should “play a role in curbing in gun violence,” 43% said ‘no,’ 40% said ‘yes.’ When asked if they had ever asked patients about gun ownership, 60% said ‘no,’ and 40% said ‘yes.’ It also turned out that 60% of the survey responders claimed to be gun owners which is a rather remarkable statistic for physicians, assuming that this magazine’s readership is at all representative of the medical profession as a whole.

If nothing else, this survey reflects the fact that, until now, medicine has not developed a clear and coherent medical response to gun violence at the level where it is needed most; namely, in discussions between care-givers and patients, which is ultimately where all medical responses to any kind of medical risk needs to start and end. The MD Magazine survey didn’t ask whether the survey respondents actually agreed that gun violence was a health issue. Maybe the magazine’s subscribers practice medicine on Mars.

 

Is Obama Correct When He Calls Gun Violence An ‘Epidemic?’ He Sure Is.

January 12, 2025

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Whenever there’s a terrible, mass shooting, like Umpqua or San Bernardino, leave it to the pro-gun gang to wait 48 hours or so, and then remind us that it’s not such a big deal because: a) mass shootings only account for a tiny fraction of all gun shootings; b) gun homicides continue to decline; and, c) there’s nothing we can do about it anyway, so who really cares? And in case a little more juice is necessary to push the argument away from the problems caused by guns, we can always count on Johnny-boy Lott to pronounce that, once again, a mass shooting took place in a gun-free zone.

white house But of course if you bother to look at the numbers on gun violence, and you take some time to understand what the numbers really mean, you don’t need to be a rocket scientist to quickly figure out that this whole notion that gun violence being on the wane is simply and irretrievably not true. And anyone who says otherwise either doesn’t know the facts or thinks that if you tell a lie enough times maybe someone will think you are telling the truth. So let’s start with the facts.

Gun violence is falls into five categories, according to the CDC: intentional homicide, unintentional homicide, intentional injury, unintentional injury and suicide. And I don’t care about the NRA nonsense that ‘guns don’t kill people, people kill people;’ the fact is that every one of the events which are counted in those five categories occurred because of the presence of a gun. Now obviously you can kill other people or yourself without using a gun; ditto for injuries suffered by yourself or someone else. But you can’t kill anyone as quickly as you can when you use a gun, and gun injuries are, medically-speaking, the most damaging and costly injuries of all. So now let’s really get to the facts.

In 2001, the total body count for the five gun-violence categories was 92,031, of whom 29,821 ended up one way or another in the morgue, and the remainder, 62,210, lived to see another day. Now the physical and mental condition in which these survivors actually continued their lives has never been calculated in any general sense, but a not atypical example is provided by the experience of Antonius Wiriadjaja who was hit by a stray bullet in Brooklyn, from which he then endured seven months of physical therapy to regain basic functions, along with 18 months of psychiatric treatment to prevent the onset of PTSD. Gun injuries are devastating, the costs of gun morbidity is calculated to be at least 40% higher than the cost of treating any other kind of injury, and Wiriadjaja got off with less post-injury trauma than a lot of other victims of gun wounds.

The pro-gun nation is up in arms (hopefully not literally) because the President keeps referring to gun violence as an ‘epidemic.’ Would the same bunch argue with the notion that we had an outbreak of the Ebola epidemic in 2014? Of course not. Know how many people died worldwide from Ebola that year? Roughly 30,000. Isn’t that roughly the same number that have died from a gun injury in the United States every year over the past 30 years?

Not only do we suffer this carnage year after year, but the numbers keep going up! In 2001 all gun deaths and injuries totaled 92,031. It was 99,968 in 2005, dropped down to 97,550, then steadily increased to 117,146 in 2013. This 25% increase in the overall number is largely driven by intentional injuries, which since 2001 have exoanded by nearly 50%

Know who benefits from this trend in a rather perverse way? Trauma surgery residents get more training which means they can save more lives. It’s their skills that are keeping gun deaths fairly constant while overall gun violence continues to increase. The President isn’t wrong when he talks about a gun epidemic. If anything, he’s understating the case.

What The Gun Violence Numbers Tell Us And What They Don’t Tell Us.

January 11, 2025

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This is the first time in my lifetime (and I was born during World War II), that a President has used the bully pulpit to focus on the issue of gun violence. He’s issued executive orders, he’s held a Town Hall meeting, written an op-ed for The New York Times, and for sure will have plenty more to say when Congress and the American people gather to hear his State of the Union speech. So in preparation for that event, as well as in response to the veritable torrent of media content that has been flying around the last week, I thought I would publish the data on gun violence that should be used to evaluate what Obama and others are saying about the issue itself.

morbidity2

Here are the yearly numbers on gun mortality from the CDC. Note that gun suicides dropped between 1993 and 2000, then were fairly level until 2008, and then have moved upwards again at a fairly rapid rate. Gun homicides also declined substantially between 1993 and 2000, and have remained somewhere between 10,000 and 11,000 over the last thirteen years.

There’s only one little problem with these numbers – they hide as much as they show. In fact, notwithstanding the increase since 2008, gun suicides as a percentage of all suicides have declined to slightly less than 50%, the lowest percentage since these numbers were first tracked by the CDC. As for gun homicides, while there was a significant decline until 2000, the number has stayed stubbornly at that level ever since, with minimal variations between this year and that.

On the other hand, the homicide number is a total of both intentional and unintentional gun deaths, and if we break out the latter, we find a remarkable trend over the last 20+ years, namely, that unintentional gun deaths have dropped from 1,521 in 1993 to 586 in 2014, a decline of nearly two-thirds. Or to look at it another way, when intentional gun deaths dropped by 36% between 1993 and 2000, accidental gun deaths declined by more than 50% during the same period.

The decline in intentional gun homicides after the mid-90s paralleled an overall decline in violent crime and is presumed to be a factor of that latter trend. But while theories abound as to why violence in general and gun violence in particular decreased so dramatically until the early 2000s, I don’t notice anyone talking about the even greater drop in unintentional gun deaths over those years. And while the intentional death toll from guns has of late levelled off, unintentional gun deaths continue to decline, from 802 in 2001 to 586 last year.

In a New York Times op-ed debate about gun safety, Steve Teret pulls out a 2003 study conducted by some of his Johns Hopkins colleagues which indicates that smart gun technology, if available on all currently-owned firearms, might save upwards of 37% of the people who are killed by accidental shootings each year. That’s an impressive number, and even if it’s slightly overblown (because God knows how long it would take before smart guns are actually purchased by consumers), there’s no question that keeping guns away from kids and other unqualified folks would cut the accidental death toll to some extent.

But rather than trying to come up with a vague number that might or might not represent the saving in human lives from smart-gun technologies, why don’t public health researchers try to figure out the reasons for a two-thirds decline in accidental gun deaths over the last two decades? One answer I won’t accept is that the decline in gun accidents is due to the NRA or NSSF safety campaigns, for the simple reason that neither has ever been evaluated in honest, no-nonsense terms. But until a GVP-minded researcher tries to figure out why accidental gun mortality keeps going down, we are forced to sit back and wait for smart guns to hit the shelves. And wait.

 

Crime Rates Go Down And Of Course It’s Because Of All Those Guns.

January 10, 2025

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Ever since the gun industry realized back in the 1990s that hunting was becoming a relic of the past, we have been inundated with the message that guns are necessary because they protect us from crime. The ‘research’ which allegedly showed this to be the case was published in 1995 by Gary Kleck, who used telephone interviews with 213 respondents to argue that people walking around with guns were preventing two to three million crimes from being committed every year.

conference program pic Kleck has recently admitted that even though his estimate of defensive gun use (DGU) may be too high, nobody else has come up with better numbers, so we might as well accept his numbers anyway. In fact, David Hemenway and Sara Solnick have come up with better numbers because their research was based on 90,000 interviews, and what they found was that DGUs accounted for less than 1% of all victims protecting themselves from crimes, on the order of perhaps 70,000 instances every year. But Hemenway, like Obama, is from Harvard, so we know what he’s saying can’t be true.

The good news for the gun industry is that coincident with the idea that more guns equals less crime, beginning in the mid-90s, violent crime rates began to fall. And they fell so dramatically that the national crime rate today is roughly half of what it was back in 1994. Meanwhile, over the same twenty years, the size of the civilian gun arsenal has increased by somewhere around 50 percent. And leave it to another pro-gun mouthpiece posing as a scholar – John Lott – to ‘prove’ that as gun ownership and concealed-carry go up, crime rates go down.

Everything else being equal, whenever I substitute a salad for a banana split at the dinner table, my weight goes down. But that’s because there is a proven connection between the number of calories I ingest each day and what then happens when I step on a scale. There has never been any such connection ever demonstrated between crime rates and the legal ownership of guns. But that doesn’t stop the gun industry from pretending otherwise, even if they have to misstate the data they use to support their case.

My father used to say that figures don’t lie but liars sure can figure, and here’s the latest example of that adage direct from the NRA. According to the FBI, violent crime in 2014 dropped another 0.9%. This included a 1% decrease in murder and a 6% decline in robbery, the two of four violent crime categories in which guns are “more likely to be used.” Assault increased 1.3%, but guns are less likely to be used in assaults, according to the NRA. And not only are murders down, but the percentage of murders committed with guns also fell by 1.6%.

Actually, not only did aggravated assault go up, but so did the percentage of assaults committed with guns. And the real reason that murder went down is because trauma centers are increasingly adept at saving the lives of gun-shot victims who previously would have ended up dead. If the percentage of aggravated assault and the percentage of aggravated assaults with guns both go up, which they did, then the way in which trauma teams deal with gunshots is a much more compelling way to explain why gun murders go down.

The NRA and the NSSF can celebrate the alleged link between decreases in crime decline and increases in gun ownership all they like, but the real truth is that 95% of the drop in violent crime occurred between 1994 and 2003. Since that time there has been a slight continuing downward trend, but it is also over the past decade that gun sales have soared. Which means there may not be any necessary connection between gun ownership and protection from crime. But why let facts get in the way of a story that continues to sell?

 

 

 

Want To Be In A Movie With Kevin Bacon? Everytown Just Produced One And It’s Great.

December 9, 2024

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I always wanted to be in the movies. I mean, who wouldn’t want to be in the movies? And I want a speaking part. Doesn’t have to be a big part, a few words will do. And I want to be in a movie with a big star – someone I really like. Well now my dreams have come true. I can go to a new website posted by Everytown, download a video cam and say, “We can end gun violence.” Then I shoot the file up to the website and I’m in the same video as Kevin Bacon. Kevin Bacon! I mean we’re not talking about some nobody. We’re not even talking about President Obama, who also appears in the video. We’re talking about Kevin Bacon. Wowee - kazowee.

After I get done writing this column I’m going to get ready for my cameo appearance: need to put on a different shirt, comb the little hair I still have left, stand in front of the mirror and say the line again and again until I have it right. Should I emphasize the word ‘we?’ Or put a little juice into the word ‘end?’ Or just run off the whole string but change my expression when I get to the word ‘violence?’ Decision, decisions. Look, it’s not every day that my family and every friend I have in the whole world can see me and Kevin Bacon go at it, right?

I have spent the last two years waiting and hoping that the GVP community would get into the video environment big time. Because this is the way that an increasing number of people get their information, particularly the up-and-coming generation whose decisions about what to buy and how to behave will set the tone in the years ahead. And it seemed to me that until I saw this new video, that the pro-gun gang seemed to understand this issue much better than the other side.

Take a look at the NRA website. It’s all about video – a message from Wayne-o that tells you why the 2nd Amendment can protect you from anything and everything; a video of Colion prancing around saying something I can’t understand, some men and women sitting in front of a Sig-Sauer logo with this one guy lamenting that kids don’t learn about the ‘real’ American history; i.e., the value of guns. I can’t imagine anyone actually sitting all the way through any of these insipid, boring commentaries, most of all because they are completely contrived. The scripts come right out of the NRA marketing department even though there’s an announcement that tries to make you believe that you’re getting some kind of personal opinion from the spokesperson him or herself. But if you are an NRA member, every time they post a video you receive an email linking you to the latest missive which all have one thing in common, namely, that guns are a food thing.

Well maybe they are and maybe they’re not, but I’ll tell you this. When the NRA says that “guns don’t kill people, it’s people who kill people,” what they conveniently forget is that the easiest and most efficient way for one person to kill or injure another is to use a gun. And if you take the guns away, there would still be plenty of violence, there would still be plenty of crime, there would still be plenty of people who would want to end things without waiting for nature to take its course. But the annual death and serious injury toll in this country would be minus 100,000 because that number represents what happens with guns.

What makes this new Everytown effort so powerful and so different from the video contrivances posted by the NRA is that these are real people, many related to someone who was shot with a gun, and their message is so simple and so direct that there’s nothing more that needs to be said. Don’t want to end gun violence? Kevin Bacon’s got plenty of other co-stars.

 

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

November 26, 2024

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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.

Why Should Doctors Ask Patients About Guns? Here’s Why.

July 18, 2024

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Over a period of three days in June 2014, an agitated and obviously extremely upset young man named Christopher Hampton showed up seven times at hospitals in Fargo, ND, claiming that his roommate, who was also his cousin, was trying to poison him. During one of the visits, Hampton was tested for poisons in his system but the tests showed only traces of marijuana and amphetamines. He was told on several of these visits to seek psychiatric care but was not considered to be a danger to himself or anyone else.

On June 26, shortly following his last encounter with medical practitioners, Hampton went back to his apartment, grabbed a gun and shot his cousin to death. At his trial, which is going on right now, Hampton had obviously regained his composure to the point that he was claiming self-defense and may testify that a series of arguments led up to a serious fracas in which he was victim, not assailant, and had no choice but to defend himself with a gun. But the last witness to testify for the prosecution was a pathologist, Dr. Mark Kaponen, who noted that the entry wounds were in the back of the victim’s head, which is a pretty interesting way to shoot someone if you’re using a gun in self-defense.

docs versus glocks The way things are going, it looks like there will be somewhere between 11,000 and 12,000 homicides committed this year with a gun. And most of these shootings will involve perpetrators and victims who not only knew each other, but had been engaged in an argument or a series of arguments for hours, days or weeks leading up to the fatal event. As Dr. Lester Adelson put it in a classic article: “With its peculiar lethality, a gun converts a spat into a slaying and a quarrel into a killing.” I actually prefer Walter Mosley’s more prosaic statement: “If you carry a gun, it’s bound to go off sooner or later.” Either way, the bottom line is that what we have in the Fargo homicide is a classic mixture of drugs, an argument and a gun.

But there was something else about this case that needs to be addressed and understood. The fact is that the shooter, Christopher Hampton, certainly tried to draw attention to himself in the days leading up to the tragic event. He visited health facilities six or seven times, he made it clear that he was concerned about his own welfare and safety, he may have made some pretty nutty statements about his cousin, but that was exactly the point. People who walk into a medical facility under their own free will and say crazy, delusional things need to be taken seriously, not just told to ‘go home and relax.’ In fact, Hampton had previously been diagnosed as having bipolar disorder but stated that he had stopped taking his prescribed meds. How many red flags did this young man need to wave?

In fact, he waved one more, the reddest flag of all, because he told a cop just before the shooting that there were guns in the apartment and asked the cop to take them away. The police officer decided there was no criminal activity going on and declined Hampton’s request to seize the guns. Two hours later, Hampton shot his cousin to death.

According to the NRA, there’s no reason for physicians to even ask patients about gun ownership unless the patient poses a clear health risk. But how does a clinician know that a patient has stepped across that line? How could anyone know for sure that Christopher Hampton’s delusional behavior would lead to a life-ending event? The point is we don’t know, which is why doctors need the widest possible latitude in asking questions about the presence and use of guns. And anyone who truly believes that physicians should not be concerned about guns is as delusional as Christopher Hampton the night he ended his cousin’s life.

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