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By MarkPA

The National Academies of Sciences, Engineering and Medicine conducted a workshop in Washington DC (and on-line) on October 17-18, 2018, titled “Health Systems Interventions to Prevent Firearm Injuries and Death”.  The workshop was sponsored by Kaiser Permanente and the American Hospital Association.

This work, by healthcare systems, could be extremely encouraging. They bring to the field their of Electronic Health Records (EHR) databases together with economic incentive to use healthcare dollars with efficacy and efficiency. To anticipate the potential here, we must first try to understand: What is this work about?  What interests animate the effort?

To answer such questions, we need to study the terms used in their discussions, the semantics and rhetoric. Is this all about firearms? Should it be about firearms? Is it about injuries and death, or about preventive interventions?

One attendee contributed her team’s examination of how terminology influences focus. They reported that the term “gun owners” sometimes conveyed to some a disparaging connotation, that gun-owners were “stupid”. They chose to bridge off the military term “friendly fire”, choosing to characterize their concern as for “family fire”.

A panelist explained that his team adopted the presupposition that guns would continue to be an important part of our culture and environment. This conclusion served to “fix” one important factor, freeing their work to focus on others that might be amenable to influence. This insight raises a question about this work: Is the role of guns in society properly within the scope of the healthcare profession? At DRGO, we say no.

Much of the talk was about “partnering” with diverse parties equally invested in society, among them social workers and police. Yet, what immediately comes to mind is any conceivable relationship with the opposing partisans: gun-control vs gun-rights advocates. The possibility of any relationship with either of these groups is limited by the unfortunate use of the terms “firearm” (or gun) with “violence”—for want of any alternate term to encompass suicide, crime and accidents.

Language and rhetoric are always “loaded”, unfortunately. Habitual use of the term “violence” conflates accidents and suicide with criminal assaults. Thus, terminology such as “gun violence” serves to confuse and bias the conversation rather than to illuminate courses of action.

No one explicitly evidenced a partisan alignment with any other groups. Indeed, when collaboration with law-enforcement was mentioned the emphasis was on maintaining the trust of patients and the community. To maintain this trust by all stakeholders, healthcare must maintain both the substance and appearance of neutrality. I would suggest the healthcare community to consider adopting a posture which I will characterize with the phrase, “doctors without partisans”.

Gun-control and gun-rights advocates are polarized in their respective positions to limit access to guns on the one hand and, on the other, to popularize gun ownership and use for legitimate purposes. These positions are irreconcilable. Linking with either would unnecessarily bias research and development by healthcare professionals. Terminology and rhetoric casually chosen to describe the work can just as easily taint this promising effort.

What is the core interest and expertise of the health-care community? It seems to be the welfare, health and freedom from injury, of patients and their families. If so, then their rhetoric about “injury and death” from “gun violence” rhetoric misrepresents these purposes.

Panelists were perfectly clear that two-thirds of deaths by gunshot are suicides. And they understand that this phenomenon has up-stream root causes that are biological, psychological and sociological. Half of American suicides are by gunshot, half by other means.

Is this work about intervention at the moment of trigger pull? Or is it more general, to discover the root causes (depression, etc.) leading to despair. Does it include screening and diagnosing suicidal ideation and intervening long before suffering leads to suicide, regardless of means? Are patients at risk of suicide by suffocation or overdose outside the scope of their work? Would their goals be achieved by encouraging depressed firearm users to suicide by alternate means?

Likewise, panelists understood the magnitude of criminal firearm assaults. Yet, there was little mention of injury or death by criminals using other means: cutlery, clubs, fists or feet. Again, criminal assault phenomena have upstream root causes: biological, psychological and sociological.

Is their work about intervention at trigger-pull? Or are they equally concerned about the half of domestic violence deaths by other means? Are patients injured by bullying, knives or fists outside the scope of their work? Would the goals be achieved by encouraging violent patients to choose alternative weapons?

Many panelists were trauma surgeons. These practitioners are understandably moved by their immediate experience in the operating room. The rhetoric of several emphasized devastating bullet wounds, limiting their upstream root cause tracing to the firearm.

Are surgeons similarly moved by knife wounds, auto accidents and diverse other causes of injury? Are they unmoved by strangulation and overdoses? If gunshot wounds were the root cause of concern, then Department of Defense can tell us everything we need to know.

The panelists subdivided their concerns into suicide, assaults and accidents. This classification seems more useful to a search for upstream root causes as compared with gunshot vs. non-gunshot.

This mission is poorly described by the headline, “. . . Interventions to Prevent Firearm Injuries and Death” because it emphasizes gunshots to the exclusion of other means. Worse, it neglects entirely the biopsychosocial upstream root cause interventions that should constitute the work itself.

What is the added value of participation by healthcare systems? These actors are ideally positioned to take evidence-based approaches to patient — and therefore social — welfare. The emphasis here is on “healthcare systems” as distinguished from the older model of individual practitioners or small practices. And it is still more important to focus on integrated, longitudinal, patient record-keeping systems as distinguished from the older model of a paper record of discrete consultations. From a public health perspective, we are interested in mitigating morbidity and mortality from any important root cause.

Healthcare systems professionals are becoming able to track through their records patient morbidity/mortality incidents through the entire history of contacts with a single individual.  What observations were recorded that might have been predictive of the traumatic incident?

Suppose an EHR contains a database of attempted suicides, whether or not successful. Antecedent consultations may contain a treasure trove of signs or symptoms that, properly mined, would reveal the motivation for the attempts. This may include depression, loss of job or spouse, diagnosis of terminal disease, etc.

These discoveries could inform screening, diagnosis and intervention strategies for other patients exhibiting the corresponding constellation of signs and symptoms. Most important is to find and treat the root cause. Accessibility to means (firearm, cutlery, poison, drugs, etc.) is important, but follows those. Patient welfare is not about just-in-time suicide intervention.

Alternatively, suppose an EHR contains a database of domestic violence incidents.  Again, earlier consultations may reveal a telltale record of “accidental” trauma. Discovery of the patterns could inform strategies applicable to other patients.

EHR databases couldn’t be nearly so predictive of the considerable number of non-domestic violence incidents (nor, for that matter, accidental gunshot wounds). Yet, such is not necessarily the case in the experience of panelists. A criminal attack trauma may be preceded by a patient history of consultations, some of which can foretell a path to a violent end.

Patient interviews can reveal domestic turmoil, bullying in school, substance abuse, gang activity and the like. An accidental gunshot wound in an urban setting implies a set of circumstances that may be very different from a rural hunting or range accident.

One panelist’s “Project Ujima” found an illuminating example. A 16-year-old patient died of a gunshot wound. From that description, the incident seems like a one-off, isolated scenario. Reviewing the antecedent records for this patient revealed that he presented at ages 8, 11, 13 and 15 with injuries from stabbings, assaults, or gunshots. Clearly, the hospital had ample and accumulating evidence of this patient’s risk of violence. Had they intervened at age 8 and escalated at age 11 they might have spared the expense of his injuries at age 13 and 15, to say nothing of preventing his death at 16.

In any case, is the applicable intervention informed by whether a suicide is attempted by gunshot or drug overdose?  Would the intervention vary according to whether a domestic homicide was executed by cutlery or club?  In such cases, the primary and secondary intervention protocols are apt to be bio-psycho-social.  Sequestering likely means of execution are most apt to be tertiary considerations.

The foregoing healthcare-system model—data driven and neutral as to the operative mechanism—promises to yield much more useful results compared to a process driven by partisan agendas.  To be sure, nuances about means will still emerge from the data gathered from a purely neutral perspective.

How do suicides by gunshot compare to suicides by strangulation, suffocation, overdose, jumping, etc.?  Do cops suicide by gun, mariners by hanging, pharmacists by drug overdose?  Do the adolescent children of parents in these occupations use the same or different methods?  What is the evidenced-based pattern that might inform parents, merchants and legislators that promise the most efficacy?  Might it be vigilance for signs of despondency?  Or to regulate the sale and storage of specific means?

How do gunshot attacks compare to those committed with cutlery, blunt-force or fists?  Is the pattern similar or different in domestic versus non-domestic contexts?  What are the evidenced-based patterns that might inform parents, schools and society generally?

Panelists pointed out that a patient may present as a victim once yet might be the perpetrator in another case.  In such circumstances it is critical to avoid a judgmental attitude that would complicate intervention to prevent future incidents.  For example, constructive guidance can be formulated about non-retaliation, impulse control, and conflict resolution more helpfully than advice regarding the choice of a weapon.

Screening and interventions can be applied to members of an at-risk population, not just rationed to injury victims.  These methods can be applied while patients are waiting in the Emergency Department for x-rays or blood-tests.  Kids are eager to talk about violence in their lives even when presenting with routine complaints.  Programs have asked kids: “In the past 6 months did you get into a serious physical fight, have a friend carrying a weapon, or heard gunshots?”  Affirmative answers correlate to a probability of presenting with a firearm injury in next few years.

No doubt, gun-control advocates would be more than happy to support such efforts billed under the masthead of “gun safety” or “gun violence prevention”.  If so, partnership with gun-control partisans will ensure resistance from gun-rights advocates.  Conversely, partnership with gun-rights advocates will tar healthcare systems research efforts as giving in to the gun lobby.  Either outcome would be destructive.

Panelists offered encouraging evidence that data mining EHR databases to guide psychosocial services provided by healthcare systems can be cost effective in reducing the probability of subsequent expense in both the emergency room and lifelong healthcare.  This promise will be realized only with the support of all interested parties.

One panelist held: “We need to leave our politics outside the exam room.  We must hear the voices of all stakeholders, not just the ones we want to hear.”  If healthcare practitioners are to maintain a legitimate claim to objectivity, they are best advised to confine their interventions to the sphere of biopsychosocial behavior, steering clear of advocating for item-specific point-of-sale regulations, safe storage laws or similar measures.

Requirements for approving gun sales are not part of health care. Best practices in safe storage of hazardous materials are best left to the FDA for drugs, the Consumer Product Safety Commission for cleaning supplies, and the NRA for gun safety.

EHR’s are great tools for tracking patient behavior and risks. Otherwise, let’s look to the real experts.


’MarkPA’ is trained in economics, a life-long gun owner, NRA Instructor and Massad Ayoob graduate. He is inspired by our inalienable rights to “life, liberty and the pursuit of happiness” and holds that having the means to defend oneself and one’s community is vital to securing them.

This article originally appeared at and is reprinted here with permission. 

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  1. At what point in history did doctors confuse simplistic machines/tools like firearms with complex, self-replicating, autonomous, microscopic entities like bacteria, viruses and prions?

    • How long has it been since doctors were called leaches because they routinely used them to let out the “bad” blood. Part of the problem is doctors know so much that isn’t true, much of this can be attributed to poor science and bad statistical evidence gathering. More modern examples can be found in how they decided butter, eggs, and coffee were bad for you, and margarine was good.

      Most of the doctors that have signed on to the silliness of the guns are evil crowd have done so simply because they fell for the lies passed off on them as real statistical data. That said, if your doctor asks if you have guns in the home, tell him no and find another doctor.

      • Most doctors will do whatever it takes to repay their loans, and maintain their careers. Very few will rock the boat for the truth.

      • Don’t you dare forget shrimp! That was my bailout point. For around half my life I had rewarded myself for what I considered exceptional accomplishments with a steak dinner and a shrimp cocktail (I know I’m simple, get over it!). Then our medical establishment discovered that the absolute WORST thing you could eat was shrimp. For those who weren’t around, the screechers had not convinced me to give up 2 packs of cigarettes a day, but were so incredibly shrill that they actually managed to convince me to drop shrimp. Around 10 years later, in one report, with no intermediate steps, shrimp went from the worst thing you could eat directly to the best thing you could eat. And I went directly to “fuck you, I am never listening again.” While I was dining on a steak with a shrimp cocktail.

        • Kinda funny how that works.

          I remember in the late 90s and early 00s when there was a skin cancer hysteria going on. “There is no guaranteed-safe amount of sun exposure!” people screamed on the radio, in news articles, on morning TV shows. Everyone was told to use SPF BlockOutTheSun because YOU’RE GOING TO GET CANCER AND DIE.

          Now they’re pushing Vitamin D supplements on everyone because unless you live in a lower latitude and/or spend 8-12 hours outside every day, you’re not getting enough sunlight to synthesize an adequate amount, and Vitamin D (among other benefits) helps prevent cancer.

          It’s a good thing we have all these experts to tell us we were doing it wrong when we did what they told us to.

  2. So they find that 60% of deaths are suicides…mental health issue…NOT gun violence issue.
    Then they find a lot of shootings and deaths are by young minority men…they will be called racists, of course.
    Yes…gun owners need to properly store/secure their guns to prevent theft and accidents.
    People also need to secure their swimming pools…drugs…cars…etc etc etc
    And…we need to prosecute criminals using guns…with laws already on the books…before adding any more laws. Harsh penalties…no early releases. Oh wait…that would be racist as well.

  3. So again, we’re supposed to care what the profession that is officially the 3rd leading cause of death in the USA(very likely #1 cause if all cases reported) thinks about the 2nd Amendment?

    • For some people “party” comes second, or even third.

      – Here’s what’s good (or sucks less.)

      – Here’s what the govt could do, or not, to help that (for realz.)

      – Those are the people who do that.

      Sometimes one does form a rule of thumb for convenience, to save digging through all the smoke n misdirection. “Partisan” by approximation.

      The party that was all about banning folding things that go up, who’s Presidents crowed about the vague n ineffective “AWB”, who’s congress-critters n state candidates can’t stop talking about how hard they’re gonna ban all the things, who’s ATF false-flagged gun running to get people all wee-wee’d up so they could advance their preferred policy (their own spokesthings said as much), who…

      Gotta stop. We’d be here past the election.

      Sometimes “not one of those guys” is a convenient approximation. Not because of their party, but because their party keeps getting an important issue (or three) wrong.

    • The biggest problem in the United States is that the Bill of Rights is now treated as a “partisan view”. If that continues, there is going to be a huge number of deaths and not all will be from firearms.

    • Everyone is free to have their own partisan opinions in life. Not everyone is free to act on their partisan biases at all times.

      Do you want your doctor medicating you based on the Republican party platform or even performing surgery based on white privilege? Or would you maybe rather see a doctor who makes diagnoses based on scientifically sound medical evidence?

  4. “Doctors without Partisans.” – that’s good.

    The article’s whole premise is a lovely idea with two problems.

    Much like “gun violence”, and “gun safety”, “improving health care” is a fig leaf for reaching out to broader policies. When they say “system”
    and talk costs, they mean “No hang-gliding for you!” because they think it’s dumb (or icky.) Now that your health care (cost) is everybody’s business, they have another way in.

    They’re there for the frission of righteous imposition on the proles. Be a jerk, advance processionally, and feel good about yrself for doing it. Irresistable.

    It sounds like some folks at the conference were trying to approach things effectively, but that’s not why most people go after guns. They enjoy calling people not like them “dregs”, n look to manufacture more chances to do that.

  5. I attended a “mental health intervention” something or other a while back that was for first responders and healthcare personnel. What I learned over that weekend of games, role playing, interviews and whatnot was that these public health instruction types all operate from the perspective that they are savior and you are the worst case scenario. In was nearly asked to leave after asking why we treat obvious cases of need and cases where no need is indicated the same way. The answer in not so many words was that we’re all helpless pieces of shit and can’t wipe our own asses without professional intervention.

  6. Medicine will regain some credibility when they shake off their faith in medieval practices and actually improve lives instead of destroying them, especially with children.

  7. So when will healthcare providers show the same level of concern about HAI’s, iatrogenic deaths due to medicines administered in hospitals, or patient abandonment?


    And before we invest too much credence into the mental health industry, let us remember that the man who was president of the APA, and who received a lifetime achievement award, was the man behind the now thoroughly discredited “Stanford Prison Experiment.” Pshrinks have much to answer for, and the fact that many of their peer-reviewed papers’ results cannot be replicated, and an increasing number of papers are withdrawn entirely… well, it doesn’t put the mental health industry on a firm ground to criticize anyone else.

  8. Im sorry to pile on the medicos gone wild theme but…

    Anybody else see last week the “Maybe reducing the hypertension threshold by10 points was nonsense?”

    The first tell this was maybe not entirely empirical was they knocked both #s down by exactly 10. Measures seldom track that well.

  9. I guess they’re not going to explore things like “Police Unions” or “Revolving Door Incarceration” or “Massive recidivism” or even “criminals do criminal things.”

    Because if they studied actually putting criminals in jail in a meaningful way, i.e. “do the crime, do the time” then there wouldn’t be nearly as much gang and criminal violence.

  10. Does anyone note the long-standing conflict of interest in the medical profession? If prevention and intervention lead to reduction in symptoms (whatever it is that causes a person to visit a doctor), the need for doctors declines. After the Salk vaccine, we find that the need for doctors specializing in treatment, and researchers specializing (getting funding) in Polio is not a promising field for new doctors. Like government, if problems are solved, need for solution-providers goes away. No one really wants to self-eliminate their raison d’etere.

    Additionally, any investigation by the healthcare industry cannot help but be grounded by a desire to remove guns from the hands of non-criminals. Anti-gun advocates are afraid of guns, period, end of sentence. Mentally, they believe their stress levels will all but disappear if they don’t have to worry that every stranger they meet is a crazy gun owner who just snaps.

    Since anti-gunners are all “good” people, and they don’t associate with “bad” people, or go where “bad” things happen, removing guns from legal gun owners who might snap just makes all kinds of sense. Such beliefs are manifest evidence that liberalism (anti-gun fanatics) is a mental disorder.

    • Sam,you’re right on the money, except don’t give the vaccine undeserved credit. What we called polio before the vaccine was introduced and what we call polio after the vaccine introduced are 2very different things. Maybe you’ve noticed the news where kids are falling to “polio” like illnesses….these conditions always existed, they were called polio pre vaccine.

      • You might notice that even you refer to that as “news”, since for some reason the disease has been missing for around 65 years. I suppose that was coincidental?

        • Larry, the polio is an enterovirus, usually infects the gut, has been around for a very long time. Suddenly in the 1940-50’s it became a paralytic epidemic? You might want to read up on provocation polio and the the timeline usage of the pesticide DDT and how DDT was capable of causing the very symptoms called polio in the 40’s and 50’s. Or just keep believing the fairy tales you get handed by the drug industry and the government. They always tell the truth….

  11. Before the medical community tries to solve the so-called “gun problem” they should first work to eliminate all the deaths by medical mistakes (which are far greater in number than deaths by firearms).

    • My first wife was killed because of a doctor’s misinformation on what ihe was doing. I plotted vengeance, thankfully he moved to parts unknown before I could carry out what I had planned. I don’t know where he went. He is 5’9 weighed 180 lbs,57 years old now, light complected, blue eyes and has a habit of wearing cowboy boots and portraying himself as an ” ole country doctor. This guy is a quack, do not trust him if he is your doctor. His initials are S. H.

  12. “..EHR’s are great tools for tracking patient behavior and risks. Otherwise, let’s look to the real experts.”

    And they are equally great for anti-gunners to track behavior and risks of the people they don’t like, mainly gun owners.

    Having the data seems like a good idea, and I appreciate the idea that more data can lead to good things. But! I have become a cynic as I have aged and all I see with EHR’s is a great big pile of data that someone is going to figure out how to weaponize against some group or another.

    • I appreciate MarkPA’s information and insight, but all this is mere distraction. The next push for single payer healthcare will include provisions to deny all health care to people who demonstrate unhealthy lifestyle (a list changeable at the whim of bureaucrats). Once the government provides the benefit, you are bound by federal rules; inescapable.

      I once read something about the world future where no one could conduct any business, or commercial interaction without a specific badge of approval from the ruling body. Interesting idea.

      • The current question about firearms ownership and safety is optional if I want to answer. With single-payer, that option will go away and sooner or later, registration will be a prerequisite for getting care.

  13. Don’t lump us all together. Not all doctors are liberal closed minded trolls. I am a member of DRGO and have decades of experience with craniofacial trauma.

    • SoBe, until MD’s come clean about the autism epidemic and the chronic childhood disease epidemic they are complicit in, and come clean about letting themselves being used as drug pushing mules for the pharmaceutical industry, your profession will be increasingly viewed with jaundiced eyes, and deservedly so.

  14. If only we could get Doctors without Partisians to look in malpractice deaths or vehicle deaths.
    Answer – They don’t have an agenda behind them.


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