Gun Violence: Moving from Crisis to Action

A modern-day public health crisis, gun violence affects more than 100,000 Americans every year, resulting in 32,000 deaths, or 89 fatalities per day. Nearly two-thirds are suicides. In 2014, the U.S. firearm fatality rate—10.3%—matched that for sepsis and Alzheimer’s disease.

Increasingly, physicians outside of the emergency department are being urged to work "upstream" of these events, by paying attention to the risk factors that often precede a shooting. Unlike the traditional model of resuscitation and trauma care, the office visit presents opportunities for doctors to counsel and intervene, said speakers at “Preventing Gun Violence: Moving from Crisis to Action,” a program held in Chicago on March 24.

The half-day seminar looked at prevention strategies already being adopted by primary care physicians, and reported on new research and legislation that enables physicians to partner with legal and law enforcement. The event was hosted by the American Bar Association, the American Medical Association, and the Chicago Medical Society at the ABA’s downtown headquarters. Here are highlights:

Public Health Approach

Often the events that precede a shooting go ignored. But in the exam room, physicians have opportunities to counsel and intervene, said speaker Megan Ranney, MD, an associate professor of emergency medicine at Brown University’s Warren Alpert Medical School. “There’s a moment when physicians can intervene and it will thrill EM doctors,” she stated.

She advises physicians to be alert to certain risk factors, and the stages of escalation. Patients who have been assaulted or hospitalized for a firearm-related injury are at-risk since they may have PSTD or want to retaliate. Also at risk are victims of domestic violence. Alcohol abuse is strongly linked to misuse of firearms. Cognitive issues, another risk factor, affect a growing number of aging Baby Boomers.

Physicians can and must screen patients for firearm access when at least three of the high-risk conditions are present. The top three are suicide, assault and domestic violence, said Dr. Ranney.

One example she gave was of a woman who said she had been the victim of domestic violence and carried a gun in her purse for protection. For such a patient, the physician should counsel her that carrying that gun increases her risk of a gun-related incident. “In those moments of acute risk, it’s about reducing access,” Dr. Ranney said.

The federal law that prohibits the purchase and possession of firearms by certain individuals does not include everyone with these risk factors, however. Some states have filled in these gaps, preventing firearm access by people known to be dangerous.

In addition, federal law prohibits people with certain kinds of mental health histories from purchasing or possessing firearms, but this law misses many individuals who have been identified by mental health professionals as dangerous. As a result, several states such as Illinois have broadened the category of mentally ill persons who are prohibited from purchasing or possessing firearms.

Yet states with stringent rules for reporting disabilities make patients less likely to disclose gun ownership, said another speaker, Miriam Betz, MD. Contrary to popular belief, most mentally ill people are victims of gun violence rather than perpetrators, she added. Dr. Betz is an associate professor of emergency medicine at the University of Colorado School of Medicine.

Physician Gag Laws

In recent years, states have debated proposals to prohibit physicians from discussing gun ownership with their patients, notably Florida, which enacted a law in 2011. But in early 2017, the 11th U.S. Circuit Court of Appeals struck down key portions of the Florida’s “gun gag” law on grounds it infringed on the free speech rights of physicians.

The law was challenged by the Brady Center to Prevent Gun Violence, which sued the state on behalf of several doctors and more than 11,000 health care organizations.

Yet one speaker said the Florida law was never a major impediment to asking questions. The real challenge is knowing how to ask questions about gun ownership, and doing this in an effective way, argued Matthew Miller, MD, co-director of the Harvard Injury Control Research Center. Physicians, he said, need help figuring that out.

Beliefs and Opinions

Attitudes and personal beliefs about gun owner ship may interfere with asking questions about firearms. Dr. Miller was coauthor of a survey in which health professionals were asked whether a gun in the home increases the risk of suicide. Just 25% said they agreed with that statement while another 50% said they disagreed.

Another study he coauthored with Dr. Betz asked physicians and nurses at eight emergency departments how they approached suicidal patients. In an analysis, which separated patients whose suicide plans involved a firearm from those who had no specific method, 64% asked patients whose suicide plans did involve firearms about guns in the home. Only 21% discussed guns when patients said they had no specific method.

Gun Ownership and Suicide

In 2010, suicide was the 10th-leading cause of death in the United States, claiming 38,364 lives, with more than half of people using firearms. As the method of choice, guns surpass all other intentional means of suicide combined, which includes hanging, poisoning or overdose, jumping,or cutting.

Quite simply, states with high gun ownership rates have high firearm suicide rates, said Dr. Miller. From 2008 to 2009, states with high-gun-ownership had 7,275 suicides, compared with states with low gun ownership rates, at 1,697. Non-firearm suicides in high-gun and low-gun states were nearly identical—4,153 and 4,341, respectively.

Looked at another way: 19,392 people committed suicide with guns in 2010, compared with 11,078 who were shot dead by someone else.

To date, there is no large study showing that safe storage training works, Dr. Miller said. In fact, he noted, those with training are more likely to store unsafely. States with storage laws and child access prevention are well-intended, but not that effective, he added.

Often the crisis underlying a suicide is temporary; the person acts on impulse and uses whatever means is readily available. But a gun is far more likely to result in death, at 90%, compared to the 10% who succeed using some other method, speaker Dr. Betz pointed out.

Among those who do survive a self-inflicted gunshot, less than 10% go on to try again. Bottom line: “If you save someone’s life today, you’ve actually saved their life in the long run, Dr. Miller said.

Dr. Betz reported one survey showing that 70% of patients said they don’t object to questions and counseling, if it is individualized. Instead of lecturing, or telling patients they must get rid of their guns, she said to ask, “what about getting the gun outside of the home?”

Evidence-Based Research

Keeping conversations grounded in fact, using data instead of ideology will move these conversations forward, a point that highlights the need for research, both Drs. Miller and Betz agreed. Both physicians would like to see the Centers for Disease Control and Prevention collect data and study the causes and consequences of firearm violence and unintentional injuries. This could help lead to evidence-based strategies and interventions.

Current law, however, bans CDC research into gun violence, with language that specifically for bids use of federal funding to advocate or promote gun control.

Learning from Auto Safety

Rather than trying to change individual behavior, a public health approach takes a broad population-based view. Here, the focus is on shared responsibility, and on prevention.

A good example can be found in motor-vehicle safety. Over the decades, fatalities have been cut by 85% per mile driven, even though drivers today aren’t thought to be any more careful or law abiding. Instead of changing behavior, vehicles and highways changed, Dr. Miller said.

Advances such as collapsible steering columns, shatter-proof glass, airbags, and seat belts have saved countless lives. These environmental changes, or systems improvements, reduce the consequences of error and dangerous behavior.

Likewise, advances in design and engineering, including "smart" guns, are all vital to reducing firearm injury and death.

Bonus Content: The Financial Burden of Firearms

Firearm violence takes a tremendous toll on the nation’s health care system. Counting both medical expenditures and lost productivity, the Journal of the American College of Surgeons arrived at an annual cost of more than $70 billion. Authors of the December 2015 article estimated total costs from all firearm injuries at $123 billion, a figure that includes direct costs from injury, plus the costs of pain, suffering, and lost quality of life.

A May 2017 article in the American Journal of Public Health, reported costs for 2006-2014. During that period, costs for the initial inpatient hospitalization totaled $6.61 billion. The largest proportion was for patients with governmental insurance coverage, totaling $2.70 billion (40.8%) and was divided between Medicaid ($2.30 billion) and Medicare ($0.40 billion). Self-pay individuals accounted for $1.56 billion (23.6%) in costs. Thus, from 2006 to 2014, the cost of initial hospitalizations for firearm-related injuries averaged $734.6 million per year, with Medicaid paying one-third and self-pay patients one-quarter of the financial burden. These figures substantially underestimate true health care costs.