Alexander Pomerantz, BS [1,2]
[1] Harvard Medical School Boston, MA 02115
[2] Harvard Kennedy School Cambridge, MA 02138
Correspondence should be addressed to A.P. (alexander_pomerantz@hms.harvard.edu)
Clay illustration by Lily Offit; Photographed by Ben Denzer
ABSTRACT: The following describes a personal experience from my hometown regarding physician standing in gun violence. The brief history of the physicians’ quest to establish credibility on gun violence is reviewed. In addition, the myriad ways in which violence affects all healthcare providers is discussed. In particular, three interventions are examined for their evidence: safe storage counseling, violence intervention programs, and extreme risk protection orders/risk assessments. To act on these evidence-based interventions and save lives, all healthcare providers need legitimacy to counsel their patients on firearm use.
Recently, the Freeholders of Cape May County, New Jersey passed a gun sanctuary resolution. Gun sanctuaries either symbolically condemn state gun regulations or direct police to disobey related state laws. The Cape May County resolution was a reaction to evidence-based gun reform (background checks, extreme risk protection orders, and magazine capacity limits) passed by the New Jersey State Legislature. As a Cape May County native who has published on gun violence previously, I drafted an op-ed opposing my county’s stance. Unfortunately, I received a rejection from a regional newspaper because I lacked “standing” on gun violence. As a local rising fourth year medical student applying into emergency medicine, I thought my standing was self-evident. The news was disheartening, but not shocking (although the piece was eventually published in another outlet) [1].
Unfortunately, many Americans agree with my regional newspaper about the role of physicians in gun reform. The most egregious example is the 2011 Florida Firearm Owners’ Privacy Act, known as the “Gag Rule”, which prevented physicians from asking screening questions related to firearm ownership and safety [2]. The law was eventually overturned, but doctors struggled to re-establish their legitimacy on this issue. As firearm violence rates continued to rise, physicians increased their presence in the public sphere [3]. In 2018, after the American College of Physicians published a position paper regarding gun violence [4], the National Rifle Association tweeted, “tell self-important anti-gun doctors to stay in their lane” [5]. A social media movement, dubbed “This is Our Lane”, led by doctors and nurses began telling stories of life-changing patients. Unfortunately, controversy regarding the role of doctors in gun violence reform remains unsettled.
Nearly all healthcare professionals are affected by gun violence. Trauma and plastic surgeons evaluating patients after firearm injuries must recognize their patients are at increased risk for repeat gun violence [6]. Psychiatrists, primary care providers, and emergency medicine physicians seeing suicidal patients must be conscious that owning a firearm increases risk of suicide by at least two-fold [7,8]. Pediatricians and obstetricians counseling families must acknowledge gun ownership significantly increases the risk of accidental deaths among youth [9].
As providers we recognize that our patients’ health is influenced by gun reform. Unintentional injuries, suicides and homicides are leading causes of death in Americans aged 1 year old to 44 years old [10]. Approximately 37,000 of these annual deaths are from gun violence [11]. There are evidence-based screening techniques and interventions that nearly all healthcare providers can apply to reduce deaths. In particular, there are three specific areas where healthcare providers play a role in decreasing violence: safe firearm storage counseling, post-incident violence prevention programs, and risk assessments/extreme risk protection order (ERPO) laws.
Evidence suggests physician directed safe storage training is successful. In one trial, 137 pediatric practices were randomly assigned to office-based intervention or an educational handout. The intervention arm displayed a 10% increase in safe firearm storage compared to a 12% decrease in the control group [12]. Another randomized study of 1,223 patients in which physician-directed counseling was compared to an educational brochure demonstrated a 25% increase in safe storage habits [13]. Conversely, a public health campaign directed via television and radio announcements did not show an effect [14]. When physicians play an active role in gun safety conversations, patients and their families are safer.
Second, healthcare worker directed violence intervention programs have shown promise although more research is needed to ensure the data correspond to morbidity or mortality benefits. The Boston Violence Intervention Advocacy Program (VIAP) matches each violence victim with family crisis support experts and violence intervention advocates. In a survey of twenty program participants, all reported positive experiences and felt networked to the support services they needed [15]. An Oakland hospital program focuses on bedside counseling of teenagers who are victims of violence. To study this program, 112 participants were selected in a case-control study and the results showed a significant decrease in criminal justice involvement over the following 6 months [16].
Lastly, physicians play an important role in risk assessments and by extension, some ERPO laws. Promising early data has led to increased efforts to better train physicians for this role [17]. In one nonrandomized study of 106 families with adolescents suffering from major depressive disorders, clinician-directed firearm counseling resulted in 27% of families removing guns from their homes [18]. Before exploring the interaction of ERPO laws and physician directed risk assessments, it is important to define ERPO policies. They allow family or household members, law enforcement, and, less commonly healthcare professionals to petition courts to temporarily remove access to firearms from people who are thought to pose an imminent risk to themselves or others [16]. While many states do not authorize healthcare providers as formal petitioners, providers may still use risk assessment techniques to inform family about serving as ERPO petitioners. Families and patients trust their physicians, and often present to their doctors for guidance in times of crisis. Moreover, these laws are effective at saving lives, likely more so than some medical interventions [19]. In a study of Connecticut citizens for whom ERPO laws were applied, researchers found 1 suicide death was averted for every 10 to 20 temporary firearm removals [20]. In Indiana, a quasi-experimental design using state-level data evidenced a 7.5% reduction in firearm-related suicides [21].
Healthcare providers have unique evidence-based skills at their disposal that can save lives. To achieve these gains, healthcare providers require legitimacy to have active conversations about gun safety. Physicians are guardians of public health – legislators and pro-gun advocacy leaders that demand physicians “stay in their lane” undermine this critical role. Now more than ever, we must continue to establish credibility in the gun violence sphere through evidence-based, socially sensitive care and advocacy.
ACKNOWLEDGEMENT: The author would like to acknowledge Nicole Bustos, Bridget Matsas, and Suhas Gondi for their thoughtful assistance during the editing process.
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