Wednesday, February 25, 2015

A doctor and lawyer walk into their Congressman’s office…

…And tell her they actually agree on something—no joke!

Think of it: two learned professions, which in popular lore don’t really like each other (thus, the dismissive jokes each make about the other), agreeing on a public policy response to a pressing national priority?  Two professions, often at loggerheads with each other, whether it is on tort reform or facing each other down in court of law, yet finding something they can agree on?

Well, this is precisely what happened this week when the American Bar Association joined with ACP and 7 other health professional organizations in a call to action, published in the Annals of Internal Medicine, on preventing deaths and injuries from firearms.   The physician organizations that co-authored the paper—ACP, American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American Congress of Obstetricians and Gynecologists, American College of Surgeons, and American Psychiatric Association, representing the vast majority of U.S. physicians, were joined by the American Public Health Association and the American Bar Association to “advocate a series of measures aimed at reducing the health and public health consequences of firearms. The specific recommendations include universal background checks of gun purchasers, elimination of physician ‘gag laws,’ restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths.”  

This paper is, to my knowledge, the first interdisciplinary agreement among the largest and most influential specialty organizations representing the medical profession, the legal profession, and the public health community to take on one of the most vexing problems facing this country:  that each year “more than 32,000 persons die as a result of firearm-related violence, suicides, and accidents in the United States; this rate is by far the highest among industrialized countries.”

Each organization approached the issue from a position of credibility on the aspects of firearms policies for which they had the most standing: physicians and public health advocates on the impact of firearms on the individual health of patients and on population health, the lawyers on the Constitutional issues involved.  The ABA confirmed that the policy recommendations proposed in the paper are well within the right to bear arms as established by the Second Amendment:

“These recommendations do not come solely from a group of health organizations without expertise in constitutional law but have been developed in collaboration with colleagues from the ABA, which has confirmed that these recommendations are constitutionally sound. For 50 years, the ABA has acknowledged the tragic consequences of firearm-related injury and death in our society and expressed strong support for meaningful reforms to the nation's gun laws, as well as for other measures designed to reduce gun violence that do not fall under Second Amendment scrutiny. Because the courts have repeatedly held that the Second Amendment is consistent with a wide variety of laws to reduce gun-related deaths and injuries in our nation (yet confusion exists among the public about whether the Second Amendment is an obstacle to sensible laws), 1 mission of the ABA has been to educate its members, as well as the public at large, about the true meaning and application of the Second Amendment. . . No ruling of the Supreme Court (or any other court, for that matter) calls into question any of the specific proposals that we recommend.”

The origins of the ABA joining with ACP and the other health professional associations go back to a year ago, when the ABA first informed ACP of its interest in the working with the College on firearms policy, following the publication in Annals of ACP’s own paper on reducing deaths and injuries from firearms, written on behalf of the College’s Health and Public Policy Committee, chaired by Dr. Thomas Tape.  At the ABA’s invitation, Dr. Tape presented at an educational seminar for lawyers at the ABA’s annual conference in August 2014 on 'Combatting Gun Violence, A Role for Lawyers and the Bar.' Renee Butkus, ACP’s Director of Health Policy and co-author (with me) of the ACP’s 2014 position statement, participated in the Fall of 2014 in the founding meeting of the  Prosecutors Against Gun Violence, prosecutors from 23 jurisdictions who “formed to combat gun violence by sharing information on programs that work and copying effective state laws,” reported USA Today.

Both the ACP and the ABA decided that it would be even more effective to broaden the effort to include other major physician membership organizations and public health advocates—leading to the joint statement published on Tuesday.  The plan now is to seek endorsements of the paper by an even broader universe of physician, public health, health services researchers, and consumer and public advocacy groups over the next several months.

I think the combined credibility of doctors and public health professionals on the health impact of firearms, and the lawyers on the constitutional issues, will give this new effort more credibility than any one organization, or any one profession, could bring to the firearms debate on their own.

It will need it, given the pervasive influence the gun lobby has over public policy in the United States.  In an editorial accompanying the joint paper, Drs. Darren Taichman, Executive Deputy Editor, and Christine Laine, Editor in Chief of the Annals of Internal Medicine, argue that it will take the engagement of the 500,000 plus members of the health professional organizations that signed the statement to make the difference:

“What if the more than one half million health care professional members of these organizations contacted their federal and state government representatives to tell them that they believe firearm-related injury is a public health crisis that we need to fix? We just did. It took less than 1 minute to find contact information for our state government legislators (we searched “e-mail my PA legislator”). You may contact your Congressional representatives at or We provide a copy of the letter we sent (Supplement), and you can modify it or write your own to convey your thoughts on the public health threat of firearms.

"We, as health care professionals, are trusted, expected, and paid to prevent harm to our patients and discover solutions to public health problems. Have we done our jobs? Can we? The answers are no and maybe: No, we have not sufficiently reduced the firearm-related harms our patients suffer, but maybe we can, if we demand the resources and freedom to do so.”

Today’s questions: What do you think of the joint paper by ACP, the seven other health professional organizations, and the ABA?  Do you agree with Drs. Taichman and Dr. Laine that physicians have not “sufficiently reduced the firearm-related harms our patients suffer, but maybe we can, if we demand the resources and freedom to do so?"  What are you willing to do?


John said...

Noble effort by the Bar Association to join in the effort to reduce gun deaths! I guess they didn't remember that their fellow attorneys who pack the Florida state legislature passed laws muzzling physicians from speaking to patients about gun safety.

While you are huddled with the lawyers, maybe you could politely ask them not to sue us docs for not turning in our patients who own guns. I'm sure that's the next growth area for their malpractice colleagues.

Now ACP is associated with two despised groups, politicians and attorneys. Have doctors benefited?

Jay Larson MD said...

I don't know if limiting firearms will result in lower deaths from firearms. What really needs to be determined are the risk factors that lead to firearm violence and then modifying those risk factors. How many firearm deaths are due to undertreated mental illness? If we did a better job at mental illness treatment, would we see a decline in firearm deaths?

Living in Montana, firearms are part of the hunting heritage so we get accustom to firearms being around. In high school it was common for the ranch kids to have a rifle in the gun rack against the back window of their pickup. We didn't worry about a kid coming into the school and start shooting, though we also could have been naïve back then.

Even though firearm deaths are tragic, so are the 480,000 annual deaths from cigarette smoking, 234,050 annual deaths from diabetes, and 18.5/100,000 deaths from hypertension.

Thomas R. Jackson said...

While some of the recommendations, such as improved background checks, make sense, others, such as the so called "assault weapon" ban or limits on magazine capacity are not based on science, or even rational analysis, and are an embarrassment to be coming from groups that see themselves as scientific societies. Most of all, it is sad to see such societies divorcing "gun violence" from the larger problem of violence against in America, and particularly from the issues of racism, poverty, and injustice, particularly urban injustice. These initiatives are political distractions, driven more by partisan divides, or emotional responses to dramatic events, not serious attempts to deal with the true causes of violence in this country. We only need to look at places like D.C., Oakland, Chicago, and L.A. To see how little impact such gun restrictions can be expected to have on entrenched violence in places where racism is so institutionalized, and law enforcement is so much a part of the problem. Gun control laws are cheap, and they come at little political cost to those who propose them. Tackling broken schools, abusive policing, defacto segregation, oppressive prison systems, institutional racism, lack of employment opportunities, that is hard. No wonder politicians look for scapegoats. Our medical societies shouldn't be better than that.

Thomas R Jackson, MD

Harrison Robinson said...

Dr. Larson and Dr. Jackson both voice concerns that limiting firearms will not or at least may not reduce deaths from firearms.

Well.....Australia did limit firearm ownership.
They instituted significant restrictions and a gun buy back program.
The result was cuts in homicide rates by half and cuts in suicide rates by gun by 75%.

Of course we would have push back from the NRA, and we would need brave politicians.
And we don't have brave politicians who work in the best interest of the public.

But limiting personal ownership of guns is very clearly in the best interests of the American Public. It is undeniably an important health issue.

Of course the impact pales in comparison to curing cancer or heart disease. But those cures are not matters of public policy and to the extent that they were, like encouraging smoking cessation and encouraging healthy diets, well we didn't challenge them as public health stances.

Sorry. Of course we did resist the smoking thing, now didn't we.
Funny how easy it is to forget.
JAMA ran cigarette adds for a decade and a half after the surgeon general's report.

Maybe I should check to be sure that organized medicine isn't politically linked to the NRA before I go further....



Harrison Robinson said...

I over stated the relationship between tobacco companies and JAMA
JAMA stopped accepting ads for cigs in 1953.
The AMA didn't public acknowledge the harms of tobacco until 1978.

It is easy to overstate things.


Jay Larson MD said...

It is not so much that a gun is the problem, but the reason behind pulling the trigger that is the problem. Most gun owners are responsible about gun safety. Should we start closing bars to reduce the rate of drunk driving or start to take away cell phones to reduce the number of accidents caused by texting and driving?

Harrison Robinson said...

Dr Larson
You jump to the solution that the government wants to take guns away from people.

You then compare it to closing bars and taking away cell phones.

Well, we do close bars. Every state has a closing time.
And where they don't, they have much higher drunk driving death rates -- Las Vegas.

And we used to let 18 year olds drink. I know because I was one. And the too caused more drunk driving problems. Now the age all across the country is 21.

And cell phone use, if spotted can levy $400 fines.
Just for looking at the damn things.

Guns are every bit as bad.
Gun owners have higher death rates than non-gun owners.
Sure, there may be responsible users, and they too will stupidly pick up their guns when they are scared and shoot stupidly.

More guns are not the solution.
Our Presidents are protected by the best trained gunmen in the world, and Kennedy was killed. Ford was shot at. Nixon was shot.
And Bush, well, he had to duck from a shoe.

That was fun.


Harrison Robinson said...

Reagan. Not Nixon.
I don't get to focus and write for very long during the day without distraction.

Thomas R. Jackson said...

Dr Robinson suggests that the Australia experience with gun control demonstrates that the gun control proposals endorsed by the ACP will be effective, and that my own concerns are unfounded. But the Australian restrictions were greater than what has been proposed here, and there is no clear consensus on there role in decreasing violence there. In fact, the U.S. Saw similar, even more dramatic, declines in firearm deaths for decades with very few gun restrictions.

There have been some studies that suggest positive effects of some gun regulations. Back ground checks appear to have a modest effect in some criminal activity. There is no evidence that restricting so called "assault rifles" reduces violence, and, considering how seldom they are used in criminal shootings, it is not rational to expect such restrictions to have any important effect. Such a recomendation would have to be rated "D", at best, in any scientific guideline for intervention.

In fact, firearm regulation show a very poor correlation to criminal shootings, with some of the least regulated jurisdictions having the lowest shooting and homicide rates, and some of the most restrictive with the highest rates. A wider look at the issue finds that the factors that have the most impact on violence include race (presumably from the violent and racist policies that persist in this country, and have been highlighted recently by the events in Ferguson and elsewhere), poverty, education, and economic opportunity. Responsible and scientific interventions need to concentrate on these areas of obvious pathology, rather than wasting so much time and energy with the peripheral concerns of banning cosmetic features on guns. Of course, addressing the massive injustices, violence, racism, and dysfunctions in the US is hard, while advocating for simple, if ineffective, solutions is easy.

I am disappointed in the ACP. It has neglected science for the sake of jumping on a safer political bandwagon.

Thomas R Jackson, MD

Elisabeth Varner said...

Consuming foods that contain animal protein and processed foods is the #1 killer of people in the United States. That doctors are to cowardly to make the public aware of this is what puts them in the same character classification as lawyers. Both doctors and lawyers are capitalist first and no longer deserve respect.Doctors are legalized drug dealers. Right is right and wrong is wrong.

Elisabeth Varner said...

Psychotropic drugs given to children are the reason for each and every one of the school shootings. Why is this not mentioned in the news? Lawyers representing the shooters in these cases can verify this. The documentary, "The War on Kids" might be of interest.

Jay Larson MD said...

I agree with Dr. Jackson. It is socioeconomics and racism that needs to be addressed to lower the deaths by violence (not only gun related deaths). There was a study of gun ownership and homicide rates across 192 countries. The US is the most heavy armed country with an estimated 89 guns per 100 people. Looking at homicide rate of about 5 gun related deaths per 100,000, the US is below both the median and the mean compared to other countries in regards to gun related deaths, despite its high gun ownership. Honduras had the highest gun related death rate at 60 per 100,000 and yet the gun ownership is only about 10 guns per 100 people. If you look at Australia (Dr. Robinson's example of success with limiting firearms), there is actually a higher gun related death per gun ratio than the US. Most gun owners are responsible. The trigger happy yahoo that Dr. Robinson refers to is a rare.

Harrison Robinson said...

Dr. Larson,
Where are you getting those numbers.

The Kaiser Family Foundation reports US gun related death rate as a little over 10 in 2012.

I've seen this rate as 10.3 or 10.4 from different sources.
But it is pretty consistent.

Australia's gun related death rate was 0.86 per 100,000 in 2011 and it was 1.03 in 2012.

I'll concede that the gun death rates are higher in Central and South America, where there is a serious problem with Narco terrorism, and conflicts between drug gangs and the governement.
Honduras, El Salvador, Guatemala. They all have big problems with that.

I am also willing to concede that there are good arguments to be made that gun control alone is not a solution.
There are places that have gun availability and ownership equal to the US, with lower gun death rates. Much lower.
Canada I think qualifies for this.
Maybe Israel too.

And I'm willing to concede that there are responsible gun owners.

But it is also true that a gun in the home statistically makes the people in that home less safe.
They are at higher risk of gun related death.


Jay Larson MD said...

Dr. Robinson,
The link for the study on homicide rates and gun ownership across countries is:

I agree with you that having guns at home does increase the risk of gun related death, but that is a risk that is left up to the household to decide. Despite our best efforts at counseling and significant consequences, there are people that continue to smoke cigarettes, drive drunk, text and drive, not wear seat belts in motor vehicles or helmets on a motorcycle.

Jay Larson MD said...

Dr. Robinson,
The US does have a 10/100,000 death rate from guns but I was referring to homicides by gun only. By looking at another source there are about 3 homicides by gun per 100,000. Suicide by gun was about 6 per 100,000. Having a gun in the house of a suicidal person is very hazardous. That is why we send family members into the household of suicidal patients to gather all the guns and knives and get them out of the house. If we were better able to diagnosis severe depression and treat it before patients get to the point of being suicidal, we could significantly reduce gun related deaths.

Thomas R. Jackson said...

It easy easy to get lost in the study and statistics cafeteria. A few points: a) I think that conflating suicides and homicides is misleading. They each are very different from both a public health and public policy perspective. b) we don't have to compare the US to other countries. We have fifty states with a wide variety of policies to compare. In fact some of our states have homicide rates quite in line with European countries, despite few gun restrictions and high ownership rates, while some jurisdictions have horrific rates of violence despite strict regulations. Even within jurisdictions, high rates of violence is often confined to specific geographic areas. c) when comparing gun related deaths between countries, or even states, to focus predominately on firearm regulation as the distinguishing factor shows an incredible amount of tunnel vision. This makes for atrocious science, and is unworthy of the ACP. Income, safety net systems, ethnocultural homogeneity, social integration, institutionalized violence, all these and more are worthy to consider. d) there is an incredible amount of equating association with causality in gun policy discussion. I would hope that most medical discussions would be above that sort of thing. E.g. Women who purchase guns are more at risk for violence than those who don't. Does that mean that buying a gun endangers women, or that women who are at greater risk of violence in their lives are more likely to purchase guns? Likewise for comparing different denominators, eg. deaths per unit of population vs death per firearm or firearm owner. All measure different things, as we remind our residents regularly.

The debate about gun control is dominated by ala carte selection of statistics and studies, with little out there that really rises to the level of being able to guide an informed public policy. This has been made worse by the debate being adopted as a front for our partisan political wars. Democratic urban leaders love the chance to blame their woes on Republicans in other states. And of course Red state leaders love rallying the troops against the Blue state gun grabbers. Great theater, great distractions, great way to raise money. But helpful to address violence? Not so much.

Thomas R. Jackson, MD

Harrison Robinson said...

Dr Jackson,
What started this discussion was Florida's NRA driven legislation making it illegal for physicians to ask about gun ownership, and therefore hampering research efforts that might help to clarify a lot of what you accurately criticize.

There really is one political side to this argument that is driven by corrupt motives. The other side is not driven by any end game. There is no side seeking to confiscate all guns. There is a side that finds it lucrative to scare supporters that the other side does want that. And it is that side, that very very well funded side with a very big profit motive that does not want data collected.

It seems to me that the ACP is trying to support efforts to do research.

Why is that controversial?

Thomas R. Jackson said...

Dr Robinson,

I think that what actually started this discussion was an ACP action endorsing several policies. Increased research, and removing so called "gag" rules were positive. The so called "assault weapon" ban is without merit, and even universal background checks is vague enough to be questionable, as few recent proposals to improve the system have merit. It is ironic that the most substantive improvements in background check systems in recent years have come by lobbying by gun rights groups.

I disagree with your characterization of only on side having bad motives in the gun control debate. That is really what both sides (if we are going to accept such a dualist model) preach, in their respective propaganda pieces. It is naive to believe that when Democrats push gun control, they are above bad motives. So much of the dialogue is truly dishonest political theater, done to raise money, garner votes, attack the opposition, and, most importantly, distract from massive policy failures. Perhaps you do not consider such manipulative motives corrupt, but I do. I have no interest in helping political groups change the subject from poor governance, racial violence and injustice, poor educational systems, and other difficult, but important issues, to policy distractions such as "assault weapon" bans that are merely cheap feel good measures that will do nothin no to make us safer. In the light of the widespread government violence highlighted by recent events in Ferguson, Rikers, and with the NYPD (though by no means isolated to them), and the appallingly unjust and ineffective responses to those outrages, we should be taking a serious look at the real causes of viol nice in our society, and not enable opportunistic politicians. This is he side that wants to scare people with assault weapons that contribute little to violence in the US. The ACP lessened itself by aligning with such self serving forces.

I hope this answers your question on why the ACP position is controversial, even is select parts of it we can agree with.


Thomas R Jackson, MD

Harrison Robinson said...

Dr Jackson,
I think we agree on a lot.
I know you are right that it is a mistake to give in to the "two sides" propaganda.
It is distracting to limit views to one side or the other.
And we are missing a lot of opportunities to work together on things we could all agree on.

I find it ironic, and very sad, that when a piece of legislation does make it through our Congress, and that is rare, it usually enjoys overwhelming support from both political parties and it rarely faces a veto.

But in order to get that kind of agreement, we get very weak legislation and too many issues get ignored.

And a lot of that comes from political parties protecting their voting blocks in Congress, and making sure that candidates are as safe as they can be, and making sure further that the candidates who break through will know to whom they owe fealty.