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7 August 2019

Firearm-Related Injury and Death in the United States: A Call to Action From the Nation's Leading Physician and Public Health Professional OrganizationsFREE

Publication: Annals of Internal Medicine
Volume 171, Number 8
Shortly after the November 2018 publication of the American College of Physicians' policy position paper on reducing firearm injury and death (1), the National Rifle Association tweeted:
Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.
Within hours, thousands of physicians responded, many using the hashtags #ThisIsOurLane and #ThisIsMyLane, and shared the many reasons why firearm injury and death is most certainly in our lane. Across the United States, we have daily, firsthand experience with the devastating consequences of firearm-related injury, disability, and death. We witness the impact of these events not only on our patients, but also on their families and communities. As physicians, we have a special responsibility and obligation to our patients to speak out on prevention of firearm-related injuries and deaths, just as we have spoken out on other critical public health issues. As a country, we must all work together to develop practical solutions to prevent injuries and save lives.
In 2015, several of our organizations joined the American Bar Association in a call to action to address firearm injury as a public health threat. This effort was subsequently endorsed by 52 organizations representing clinicians, consumers, families of firearm injury victims, researchers, public health professionals, and other health advocates (2). Four years later, firearm-related injury remains a problem of epidemic proportions in the United States, demanding immediate and sustained intervention. Since the 2015 call to action, there have been 18 firearm-related mass murders with 4 or more deaths in the United States, claiming a total of 288 lives and injuring 703 more (3).
With nearly 40 000 firearm-related deaths in 2017, the United States has reached a 20-year high, according to the Centers for Disease Control and Prevention (CDC) (4). We, the leadership of 6 of the nation's largest physician professional societies, whose memberships include 731 000 U.S. physicians, reiterate our commitment to finding solutions and call for policies to reduce firearm injuries and deaths. The authors represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, American Medical Association, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, joins these 6 physician organizations to articulate the principles and recommendations summarized herein. These recommendations stem largely from the individual positions previously approved by our organizations and ongoing collaborative discussion among our leaders (1, 5–10).

Background

In 2017, a total of 39 773 people died in the United States as a result of firearm-related injury—23 854 (59.98%) were suicides, 14 542 (36.56%) were homicides, 553 (1.39%) were the result of legal intervention, 486 (1.22%) were subsequent to unintentional discharge of a firearm, and 338 (0.85%) were of undetermined origin. The population-adjusted rates of these deaths are among the highest worldwide and are by far the highest among high-income countries (11, 12). Firearm-related deaths now exceed motor vehicle–related deaths in the United States (13, 14). Further, estimates show that the number of nonfatal firearm injuries treated in emergency departments is almost double the number of deaths (15). Firearm-related injury and death also present substantial economic costs to our nation, with total societal cost estimated to be $229 billion in 2015 (16).
While mass shootings account for a small proportion of the nearly 109 firearm-related deaths that occur daily in the United States (11), the escalating frequency of mass shootings and their toll on individuals, families, communities, and society make them a hot spot in this public health crisis. Mass shootings create a sense of vulnerability for everyone, that nowhere—no place of worship, no school, no store, no home, no public gathering place, no place of employment—is safe from becoming the venue of a mass shooting. Mass shootings have mental health consequences not only for victims, but for everyone in affected communities (17), including emergency responders. Studies show that mass shootings are associated with increased fear and decreased perceptions of safety in indirectly exposed populations (18, 19). Preventing the toll of mass firearm violence on the well-being of people in U.S. cities and towns demands the full resources of our health care community and governments.
Our organizations support a multifaceted public health approach to prevention of firearm injury and death, similar to approaches that have successfully reduced the ill effects of tobacco use, motor vehicle accidents, and accidental poisoning. While we recognize the significant political and philosophical differences about firearm ownership and regulation in the United States, we are committed to reaching out to bridge these differences to improve the health and safety of our patients, their families, and communities, while respecting the U.S. Constitution.
A public health approach will enable the United States to address culture, firearm safety, and reasonable regulation consistent with the Constitution. Efforts to reduce firearm-related injury and death should focus on identifying individuals at heightened risk for violent acts against themselves or others (20). All health professionals should be trained to assess and respond to those individuals who may be at heightened risk for harming themselves or others.
Screening, diagnosis, and access to treatment for individuals with mental health and substance use disorders is critical, along with efforts to reduce the stigma of seeking this mental health care. While most individuals with mental health disorders do not pose a risk for harm to themselves or others (21), improved identification and access to care for persons with such disorders may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.
In February 2019, a total of 44 major medical and injury prevention organizations and the American Bar Association participated in a Medical Summit on Firearm Injury Prevention. This meeting focused on building consensus on the public health approach to this issue, highlighting the need for research, and developing injury prevention initiatives that the medical community could implement (22). Here we highlight specific policy recommendations that our 7 organizations believe can reduce firearm-related injury and death in the United States.

Background Checks for Firearm Purchases

Comprehensive criminal background checks for all firearm purchases, including sales by gun dealers, sales at gun shows, private sales, and transfers between individuals with limited exceptions should be required.
Current federal laws require background checks for purchases from retail firearm sellers (Federal Firearms License [FFL] holders); however, purchases from private sellers and transfer of firearms between private individuals do not require background checks. Approximately 40% of firearm transfers take place through means other than a licensed dealer; as a result, an estimated 6.6 million firearms are sold or transferred annually with no background checks (23). This loophole must be closed. In 2017, of the 25 million individuals who submitted to a background check to purchase or transfer possession of a firearm, 103 985 were prohibited purchasers and were blocked from making a purchase (24). While it is clear that background checks help to keep firearms out of the hands of individuals at risk of using them to harm themselves or others, the only way to ensure that all prohibited purchasers are prevented from legally acquiring firearms is to make background checks a universal requirement for all firearm purchases or transfers of ownership.

Need for Research on Firearm Injury and Death

Research to help us better understand the causes and consequences of firearm-related injury and death and to identify, test, and implement strategies to reduce these events is important.
Research to understand health-related conditions underpins the modern practice of medicine. In brief, medical research saves lives and improves health. Yet, despite bipartisan agreement that there are no prohibitions on the CDC's ability to fund such research, research that would inform efforts to reduce firearm-related injury and death has atrophied over the last 2 decades. Consequently, we lack high-quality nationwide data on the incidence and severity of nonfatal firearm injuries (25). It is critical that the United States adequately fund research to help us understand the causes and effects of intentional and unintentional firearm-related injury and death in order to develop evidence-based interventions and make firearm ownership as safe as possible. Research should be nonpartisan and free of data restrictions to enable robust studies that identify robust solutions. Many of our organizations have affiliated with the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), a nonprofit organization of health care professionals and researchers working to provide private funding for research related to firearm injury and its prevention. Both private and public funding are key to building a powerful evidence base on this important issue. Research for firearm injury and its prevention should be federally funded at a level commensurate with its health burden without restriction. To move from atrophy to strength requires not just allowing research, but also naming, appropriating, and directing funding for it and for the establishment of comprehensive data collection platforms to document the epidemiology of this growing public health crisis.

Intimate Partner Violence

Offenders who have been adjudicated guilty of a crime of violence against a family member or intimate partner, including dating partners, cohabitants, stalkers, and those who victimize a family member other than a partner or child, should be reported to the National Instant Criminal Background Check System and be prohibited from purchasing or possessing firearms.
Currently, federal laws prohibiting domestic abusers from accessing firearms do not apply to dating partners, even though almost half of intimate partner cases involved these relationships (26). Federal law restricts firearm purchases by individuals who have been convicted of a domestic violence misdemeanor or have protective orders against them if they are a current or former spouse; a parent or guardian of the victim; a current or former cohabitant with the victim as a spouse, parent, or guardian; are similarly situated to a spouse, parent, or guardian of the victim; or have a child with the victim. It does not apply to dating partners, stalkers, or individuals who commit violence against another family member. This loophole in the background check system must be closed.

Safe Storage of Firearms

Safe storage is essential to reducing the risk for unintentional or intentional injuries or deaths from firearms, particularly in homes with children, adolescents, people with dementia, people with substance use disorders, and the small subset of people with serious mental illnesses that are associated with greater risk of harming themselves and/or others.
Keeping a firearm locked, keeping it unloaded, storing ammunition locked, and storing it in a separate location have all been associated with a protective effect (27–29). A 2018 study found that an estimated 4.6 million U.S. children are living in homes with at least 1 loaded and unlocked firearm (30). A large number of unintentional firearm fatalities occurred in states where firearm owners were more likely to store their firearms loaded, with the greatest risk in states where loaded firearms were more likely to be stored unlocked (31). Therefore, our organizations support child access prevention laws that hold accountable firearm owners who negligently store firearms under circumstances where minors could or do gain access to them. These laws are associated with a reduction of suicides and unintentional firearm injuries and fatalities among children (32, 33).

Mental Health

The organizations represented in this article support improved access to mental health care and caution against broadly including all individuals with a mental health or substance use disorder in a category of individuals prohibited from purchasing firearms.
The great majority of those with a mental illness or substance use disorder are not violent. However, screening, access, and treatment for mental health disorders play a critical role in reducing risk for self-harm and interpersonal violence. This is particularly of concern for adolescents, who are at high risk for suicide as a consequence of their often impulsive behavior. Access to mental health care is critical for all individuals who have a mental health or substance use disorder. This must include early identification, intervention, and treatment of mental health and substance use disorders, including appropriate follow-up. Those who receive adequate treatment from health professionals are less likely to commit acts of violence (34, 35) and individuals with mental illness are more likely to be victims rather than perpetrators of violence. Early identification, intervention, and access to treatment may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors (8).

Extreme Risk Protection Orders

Extreme risk protection order (ERPO) laws, which allow families and law enforcement to petition a judge to temporarily remove firearms from individuals at imminent risk for using them to harm themselves or others, should be enacted in a manner consistent with due process.
Several states have enacted ERPO or ERPO-style laws, and numerous other states are considering them. We support the enactment of these laws as they enable family members and law enforcement agencies to intervene when there are warning signs that an individual is experiencing a temporary crisis that poses an imminent risk to themselves or others while providing due process protections.

Physician Counseling of Patients and “Gag Laws”

Physicians can and must be able to advise their patients on issues that affect their health, including counseling at-risk patients about mitigating the risks associated with firearms in the home and firearm safety.
Confidential conversations about firearm safety can occur during regular examinations when physicians have the opportunity to educate their patients and answer questions. Such conversations about mitigating health risks are a natural part of the patient–physician relationship. Because of this, our organizations oppose state and federal mandates that interfere with physicians' right to free speech and the patient–physician relationship, including laws that forbid physicians from discussing a patient's firearm ownership (36). Patient education using a public health approach will be required to lower the incidence of firearm injury in the United States. Our organizations are working on programs and strategies that engage firearm owners in devising scientifically sound and culturally competent patient counseling that clinicians can apply broadly.
In the privacy of an examination room, physicians can intervene with patients who are at risk for injuring themselves or others due to firearm access. They can also provide factual information about firearms relevant to their health and the health of their loved ones, answer questions, and advise them on the best course of action to promote health and safety. Providing anticipatory guidance on preventing injuries is something physicians do every day, and it is no different for firearms than for other injury prevention topics. To do so, physicians must be allowed to speak freely to their patients without fear of liability or penalty. They must also be able to document these conversations in the medical record just as they are able and often required to do with other discussions of behaviors that can affect health.

Firearms With Features Designed to Increase Their Rapid and Extended Killing Capacity

A common-sense approach to reducing casualties in mass shooting situations must effectively address high-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity.
The need for reasonable laws and regulations compliant with the Second Amendment regarding high-capacity magazine–fed weapons that facilitate a rapid rate of fire is a point of active debate. Although handguns are the most common type of firearm implicated in firearm-related injury and death, the use of firearms with features designed to increase their rapid and extended killing capacity during mass violence is common. As such, these weapons systems should be the subject of special scrutiny and special regulation. There are various strategies to consider, and our organizations look forward to a greater engagement and partnership with responsible firearm owners to determine how best to achieve this goal (37).

Conclusion

Physicians are on the front lines of caring for patients affected by intentional or unintentional firearm-related injury. We care for those who experience a lifetime of physical and mental disability related to firearm injury and provide support for families affected by firearm-related injury and death. Physicians are the ones who inform families when their loved ones die as a result of firearm-related injury. Firearm violence directly impacts physicians, their colleagues, and their families. In a recent survey of trauma surgeons, one third of respondents had themselves been injured or had a family member or close friend(s) injured or killed by a firearm (38). As with other public health crises, firearm-related injury and death are preventable. The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society. Our organizations are committed to working with all stakeholders to identify reasonable, evidence-based solutions to stem firearm-related injury and death and will continue to speak out on the need to address the public health threat of firearms.

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James R Webster MD,MS, MACP5 November 2019
Reducing Gun Violence in the U.S.
It is wonderful and so appropriate to see the ACP President continuing to lead our profession proposing evidence based interventions to reduce gun violence (GV) in the U.S. (1). Clearly the current collaborative, multi-organizational approach is a great strategy to achieve results. As further recommendations, I would suggest serious consideration of:

• A nationally enforced waiting period for gun ownership. Currently available evidence (2) is that this significantly reduces gun suicides, which are currently the cause of the majority of gun deaths in the U.S. (1).This intervention may even reduce gun homicide rates as well (3). Hopefully more such data will be obtained, soon!
• A national gun registry for semiautomatic handguns and rifles (AR-15’s, AK-47’s etc.). It could exempt hunting rifles, antique guns and such non-automatic handguns such as revolvers, to blunt any second amendment critics. The evidence from Australia suggests that this approach alone significantly reduces the total number of gun related deaths (4).
• More physician education about guns and GV nationally and locally. A pressing need (5)! Knowledgeable physicians, especially former military members and gun owners are a great untapped resource. A speaker’s roster could be developed for presentations to medical students, house staff, grand rounds, national and hospital staff meetings.

Unfortunately eliminating this epidemic is a marathon, not a one and done sprint. Fortunately, the ACP is clearly up to the challenge.

BIBLIOGRAPHY
1. McLean RM, Harris P, Cullen J, et al. Firearm-related injury and death in the United States: A call to action from the nation’s leading physician and public health professional organizations. Ann Intern Med. 2019; 171:573-579
2. Anestis MD, Anestis JC. Suicide rates and state laws regulating access and exposure to handguns. Amer J Pub Health. 2015;105:2048-2058
3. Luca M, Deepak M, Poliguim C. Handgun waiting periods reduce gun deaths. Proc of the Nat Acad of Science 2017;114:262-265
4. Chapman S, Alpers P. Gun related deaths: How Australia stepped off the American path. Ann intern med 2013;158:770-771
5. Webster JR. Wanted: Local medical experts/champions to reduce gun violence. Amer J Med, 2019;132;376-77
DocJacob14 November 2019
Who's Highway

"It seems pretty clear to me we have emotionally and/or (worse) politically entered into this arena under the guise of bringing in some kind of well meaning professionalism to the debate. We should be able to do so, but I think we need to be careful. We have enough liabilities regarding wrongful death to volunteer for more. As physicians it appears we have taken the emotional bait, allowing ourselves to be sucked into this arena merely because the NRA made a statement for us to mind our own business. If not but for the recent mass shootings to draw us in emotionally like everyone else, things would not be much different than they have been for years: years of criminals shooting each other, and suicides. Should we set ourselves up for this potential liability if we do not sound an alarm?If we somehow do not do our due diligence as the patient's physician to have prevented a death, are we not foolish for volunteering to do so. We also should not volunteer thinking we are going to be some sort of hero by heading off a mass shooting. This merely allows us to get potentially sucked into social media's false "5 minutes of fame game"; something even we are not immune!.

Thank you

Dr.Pevsner

Michael Tulloch5 November 2019
Common Sense Firearms Policies Proposed
This article has not done a thorough job of understanding firearms ownership in the United States. How can you defend your home, family and self if your firearm is locked up? What about a persons right to bear arms? Most shootings occur with handguns and many are owned illegally. I favor uniform state firearm education and training including the law of self defense as well as background checks. Many people have protected themselves legally with guns. When seconds count we see again and again police are only minutes away.
Robert McLean16 October 2019
Call to Action Sign-On: Organizations added
TO THE EDITOR:
In August 2019, the American College of Physicians joined with 6 other physician and public health professional organizations, in publishing a “Call to Action” regarding firearm injury and death as a major public health problem in the U.S. We advocated for measures and impactful legislation that would reduce firearms-related injuries and deaths and protect patients and the communities physicians serve.

We have subsequently invited a wide variety of organizations to endorse the article. In addition to the organizations represented by the authors of the article, the following organizations are officially endorsing the article and its recommendations:
Alliance for Academic Internal Medicine
American Academy of Allergy, Asthma, and Immunology
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Physical Medicine and Rehab
American Association of Clinical Endocrinologists
American College of Cardiology
American College of Chest Physicians
American College of Obstetricians & Gynecologists
American College of Preventive Medicine
American Geriatrics Society
American Medical Group Association
American Medical Women's Association
American Psychological Association
American Society of Hematology
American Thoracic Society
Association of American Medical Colleges
C. Everett Koop Institute at Dartmouth
Doctors for America
Everytown for Gun Safety
Giffords
Institute for Patient- and Family-Centered Care
Manhattan District Attorney’s Office
National Council of Asian Pacific Islander Physicians
National Hispanic Medical Association
National Partnership for Women & Families
Newtown Action
Prevention Institute
Renal Physicians Association
Scrubs Addressing the Firearms Epidemic
Society for Adolescent Health and Medicine
Society of Critical Care Medicine
Society of General Internal Medicine
Society of Interventional Radiology
States United to Prevent Gun Violence

Robert McLean, M.D., MACP
President, American College of Physicians
Jeffrey Reynolds12 August 2019
Inconsistency on respect for life in the medical profession?
While the medical profession is speaking out against gun violence, and it should, while there have been 1,196 people killed since 1966 in mass shootings in America, there have been >50 Million babies killed in abortions since just 1973, at a rate of >600K per year. What puzzles me is the lack of outrage and outcry re the latter, in contrast to the former.
Gilbert A Handal, MD8 August 2019
Shootings
The issue of shootings is not just guns!! Certainly appropriate registration and background checks and elimination of high power war instruments have no place in civilian life,  but I believe the problem is a more deep issue and I do not believe it is related to mental health as such, people are looking for simple solutions to complex problems and that never works!
I believe is a societal problem as we forget about God, as family is redefined and frequently absent in its real role and as our educational systems prepare the students to take tests and not real life issues education. I believe if we are serious about this issue we have to look at all these issues which have profound implications well beyond the shootings

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 171Number 815 October 2019
Pages: 573 - 577

History

Published online: 7 August 2019
Published in issue: 15 October 2019

Keywords

Authors

Affiliations

Robert M. McLean, MD
American College of Physicians, Philadelphia, Pennsylvania (R.M.M.)
Patrice Harris, MD
American Medical Association, Chicago, Illinois (P.H.)
John Cullen, MD
American Academy of Family Physicians, Leawood, Kansas (J.C.)
Ronald V. Maier, MD
American College of Surgeons, Chicago, Illinois (R.V.M.)
Kyle E. Yasuda, MD
American Academy of Pediatrics, Itasca, Illinois (K.E.Y.)
Bruce J. Schwartz, MD
American Psychiatric Association, Washington, DC (B.J.S.)
Georges C. Benjamin, MD
American Public Health Association, Washington, DC (G.C.B.)
Acknowledgment: The authors thank Renee Butkus for her invaluable role in developing the document. They also thank the persons who reviewed and provided input about the document for their professional organization, including Robert Doherty; Debra Cohn, JD; Andrea Garcia, JD; Julie Wood, MD; Shawn Martin; Mike Munger, MD; Douglas Henley, MD; Kristin Kroeger; Colleen Coyle; Alison Crane; Eileen M. Bulger, MD; Deborah A. Kuhls, MD; Christian Shalgian; David B. Hoyt, MD; and Ronald M. Stewart, MD.
Corresponding Author: Robert M. McLean, MD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected].
Current Author Addresses: Dr. Harris: American Medical Association, 330 North Wabash Avenue, Suite 39300, Chicago, IL 60611-5885.
Dr. Cullen: American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2680.
Dr. Maier: American College of Surgeons, 633 North Saint Clair Street, Chicago, IL 60611-3295.
Dr. Yasuda: American Academy of Pediatrics, 345 Park Boulevard, Itasca, IL 60143.
Dr. Schwartz: American Psychiatric Association, 800 Maine Avenue SW, Suite 900, Washington, DC 20024.
Dr. Benjamin: American Public Health Association, 800 I Street NW, Washington, DC 20001.
Author Contributions: Conception and design: R.M. McLean.
Analysis and interpretation of the data: J. Cullen.
Critical revision for important intellectual content: J. Cullen, R.M. McLean.
Final approval of the article: G.C. Benjamin, R. Butkus, J. Cullen, P. Harris, J.E. Jackson, R.V. Maier, R.M. McLean, B.J. Schwartz, K.E. Yasuda.
Administrative, technical, or logistic support: R.M. McLean, B.J. Schwartz.
This article was published at Annals.org on 7 August 2019.

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Robert M. McLean, Patrice Harris, John Cullen, et al. Firearm-Related Injury and Death in the United States: A Call to Action From the Nation's Leading Physician and Public Health Professional Organizations. Ann Intern Med.2019;171:573-577. [Epub 7 August 2019]. doi:10.7326/M19-2441

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