The Gun Lane We Need Doctors In, and Government Out

How to "stay in your lane" properly as a medical practitioner.

This article originally appeared November 16 2018 on Medium. It carries some relevance now, in the wake of Cuomo declaring a “gun violence emergency” in his state, despite the homicide rate in NYC and outlying areas being near a historic low.

Much has been said recently of the NRA’s hyperbolic statement that doctors need to “stay in their lane.”

The freakoutery over this is thick, and palpable, and almost entirely misses the most important point on both sides, which is that we do in fact need doctors in the most important lane of gun deaths, those being suicides. To unravel it all, let’s first look at the article the NRA tweeted, then some of the backlash, then let’s look at the actual problem, where doctors can in fact actually help, and where our state governments are doing some of us a terrible disservice.

The Article

The tweet that triggered the left links to an article by the NRA’s Institute for Legislative Action. While I’m sometimes not a fan of the NRA, the opening passage of the article is pretty much on point, and in my estimation, a solid and legitimate criticism.

Everyone has hobbies. Some doctors’ collective hobby is opining on firearms policy. Half of the articles in the “Latest from Annals” email from the Annals of Internal Medicine journal are related to firearms.

The most prominent of these articles is a position paper written by the American College of Physicians (ACP) that expands upon their 2014 paper and reflects every anti-gunner’s public policy wish list, save for the outsized role given to doctors. The ACP’s policy recommendations include a ban on semiautomatic firearms and “high” (read: standard) capacity magazines, licensing and permitting requirements, improved reporting to NICS, restrictions on concealed carry, and so on. None of the ACP’s policy recommendations focus on law enforcement or the importance of identifying, prosecuting, and incarcerating criminals. As Philip J. Cook notes in his commentary, “It is unfortunate that the public health community has not recognized the importance of policing gun violence as a key aspect of prevention.”

Language matters, and the ACP “favors enactment of legislation to ban the manufacture, sale, transfer, and subsequent ownership for civilian use of semiautomatic firearms…” They refer to the targeted firearms as “assault weapons” only in parentheses, and the word “rifle” only appears once in the entire document: in the appendix, specifically in a section about 3-d printing a rifle receiver. Does the ACP support a handgun ban?

Put simply, “yes,” they do support a handgun ban, and goes back to a tremendous misunderstanding within the non-gun-owning public (including apparently a lot of doctors) about firearms themselves. “Semi-automatic” simply means the gun chambers another round after you shoot a round, and readies itself to fire another. It is a simple, straight forward, common feature. And this feature is tremendously popular, given that around 60% of firearm purchases are for stated “self-defense” reasons. A qualified analysis by Keith Shannon, which matches numbers I’ve drawn up myself, shows that approximately half of all firearm sales are semi-automatic, and around a third of all guns in private possession in the United States are semi-automatic. The lion’s share of these weapons are pistols, the kind you see every police officer in the country carry, and which have been available for purchase in one format or another for over 100 years. And there is no possible way, mathematically speaking, to magically evaporate these things. They’re here to stay.

(Read Back: The Magic Gun Evaporation Fairy on HWFO)

Further, the dreaded AR-15 rifle, which draws so much ire from the public, is basically nothing more than a longer range, bulkier version of these pistols, with which it’s actually more difficult to murder someone due to its lack of concealability. This is why we see handguns used 19 times more often than rifles in US crimes. The AR-15 and similar rifles are far superior weapons in a medium range running gunfight against other armed opponents, but their distinguishing features don’t help you murder kids, or mug someone, or rob someone’s house, or even in fact defend your kids from a robber or a mugger. The folks buying them are preparing themselves for the rare but statistically realistic chance they may be stuck in one of those “medium range gunfights against other armed opponents” by no choice of their own.

Or they’re shooting hogs.

Much of the NRA piece’s remaining criticism is legitimate, although there are some things the NRA piece very improperly snows over:

The ACP wants to require gun purchasers to undergo an “educational program” before they can obtain a firearm and they support universal background checks, which would necessitate a licensing and permitting system as well as a registry of firearms and owners. This ignores the RAND Corporation’s finding that evidence on the impact of licensing and permitting regimes on firearm homicides and total homicides as well as total suicides and firearms suicides is inconclusive. The ACP is apparently only interested in pseudo-science “evidence” that supports their preferred anti-gun policies.

While the fears the NRA proffers about firearms registries may be legitimate for other reasons, the ACP’s recommendation of an “educational program” is solid, particularly when it comes to suicide, and if properly implemented could be divorced from the sorts of gun tracking that the NRA opposes for ideological reasons. We covered that here.

The NRA also missed a golden opportunity here, to remind the public of their own efforts to improve education related to suicide, which are recounted below. Nobody ever accused them of having good PR, I suppose.

The Response

The response from doctors has been tremendous, and highlighted everywhere, but this NY Times piece is pretty typical fare for the topic, and leans heavily on tropes we’ve previously identified in our gun series. Here’s a quick example. By my count, the Times piece drops six anecdotes about gun homicide victims on its way to this:

“Annals of Internal Medicine is not anti-gun; we are anti-bullet holes in people,” Dr. Laine said in a statement to The New York Times. “And if we are biased, the bias is toward counseling our patients to reduce their risk of firearm injury and toward evidence-based solutions to the public health crisis that firearm injury has become.”

Many doctors shared a similar message to the N.R.A.: For physicians who treat gunshot victims, the topic of gun policy is absolutely “in their lane.” More than 35,000 people in the United States are killed in firearm-related deaths every year, according to an annual average compiled from C.D.C. data by Everytown for Gun Safety, a gun control group.

This is the classic Everytown bait and switch, regurgitated. Talk a hell of a lot about homicides, and then quote statistics dominated by suicide — a problem for which auto loading firearms is literally irrelevant. In fact, the dominant problem of gun deaths in this country, suicide, is not mentioned once in the Times article, nor is it mentioned almost anywhere else in the sea of angry responses to the NRA.

And of course, nowhere in the dialog do we see anyone, on the red or blue side, mentioning that homicides in the country are basically tied for historic lows.

Suicide is the Lane we Need Doctors In

As we unpacked before, suicides make up two thirds of gun deaths, and seven eighths of those suicides are men.

Having a gun in the home is not statistically correlated with overall female suicide rate, but is statistically correlated with overall male suicide rate. What that means, is that fewer firearms in the home don’t really affect the female numbers (they just find a different way to do the deed) but that men having suicidal thoughts are apparently hastier, and having guns out of the home could save some of their lives.

But as we discussed in the above link, some kind of government mandate to seize guns from suicidal men would make things worse, because it would disincentivize men from gaining treatment for their condition. The only legitimate solution to this issue, which I repeat is two thirds of the problem, is to educate male gun owners about the risks and encourage them to entrust their guns to a buddy when they’re going through a rough patch. That one thing could save six times more people annually than the entire total of domestic violence homicides, and there are only two paths to get there:

1) Overall gun education

2) Doctors must discuss firearm ownership, safety, and storage, with their patients

Many doctors are afraid to have the firearm discussion with their patients, and many of those fears stem from a 2011 Florida law (heavily pushed by the NRA) called the Firearms Privacy Owners Act, or FPOA. There was much wailing and gnashing of teeth over this law, but it didn’t do what many people said it did, and in the end it was thrown out by the 11th Circuit Court anyway. FPOA said doctors shouldn’t ask their patients about guns, and can’t enter their gun ownership status into medical databases, but it had a specific exception that allowed doctors to do both of those things if they believed it was relevant to the medical care or safety of the patient, or to the safety of others. If a patient was depressed, or suffered from anxiety, or PTSD, or any mental condition, or even had children, gun questions were fair game under the law. Doctors aren’t prevented from asking these questions. There was even a report in the Annals of Internal Medicine which clarified this.

And since the law is overturned, and has never existed elsewhere, there is almost literally no reason for doctors to avoid having these discussions with their patients.

The NRA are Doing Good Work Here, if Limited in Scope

I personally find the NRA’s nationwide work in this space to be very lacking, and I think they could do a lot more with outreach to their own membership base to assuage the suicide problem, which by God I’ll say again is two thirds of the problem. But at a state level, they’ve done some very interesting work which could form a basis for nationwide policy changes, or at least state by state reform.

In the state of Washington, 80% of gun deaths are suicides, higher than the national average. In 2016, the NRA supported a state bill called the Suicide Awareness and Prevention Education for Safer Homes Act. From a Washington Times article on the bill:

The bill requires suicide awareness training for gun dealers and owners of shooting ranges. It would add suicide prevention messages to hunter safety courses, promote education about safe firearm storage, and prompt pharmacists to talk to customers about safe storage of prescription drugs.

“We may not agree on gun control, but we all want to prevent suicide,” said Stuber, one of the speakers at the Zero Suicide Inland Northwest conference Friday at Gonzaga University. “One bullet fired, and I became a single parent and a widow.”

The bill was a collaboration between the NRA and anti-gun groups. It passed, with bipartisan support. Suicide rate statistics tend to lag, so the most current information I’ve been able to find for Washington State, or any other state, is for 2016. It will be interesting to track how Washington State fares under this new bill, compared to the relative rise of suicide across the rest of the country.

The Government is Not Helping

Some state governments interfere, or outright prevent, this life saving solution.

In California, you literally can’t give your gun to a buddy if you’re suicidal. Calling a friend and saying “Hey, I’m having a rough patch, can you hold on to my pistol for me?” is literally a crime. The conversation instead must take the following form. “Hey, I’m having a rough patch, can we go down to the local gun store or otherwise licensed federal firearm dealer, have you undergo an extensive background check, and then wait ten days hoping I don’t kill myself in the interim when you can finally hold on to my pistol for me?” And then there’s the issue that if the gun owner having suicidal thoughts seeks inpatient treatment, he or she is prohibited by law from getting their firearm back in perpetuity.

So instead, the gun owner with the suicidal thoughts keeps the gun in the house. Also potentially foregoes seeking treatment from a doctor.

This is terrible law. Somewhere around 1,500 people die per year in California from firearm suicide. That’s more than all domestic violence deaths nationwide. And there are many other states with laws that take a similar form.

If we stuck with a numbers-driven approach to firearm policy, instead of policy based on emotion, it would help us tremendously in the process of actually saving lives.


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