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 drgo.us and is reprinted here with permission.