The eyes have it: The intersection point of physicians and gun violence

WALTHAM, MA April 5, 2016 As an audience participant at the Firearm Violence: Policy, Prevention, and Public Health – described as the 12th Annual Public Health Leadership Forum that features state Attorney General Maura Healey who discussed reducing gun violence in the Commonwealth of Massachusetts. I was interested in what AG Healey might suggest as the linchpins for reducing gun violence.  As the highest ranking law enforcement officer in the Commonwealth, Healey is an advocate for people in Massachusetts in all health-related domains.

Major public health issue in Massachusetts according to Dennis Dimitri, M.D. president of the Massachusetts Medical Society.  85 people are killed by firearms on a daily basis across the country. “Physicians must discuss gun safety and have the continued right to do so that is an issue physicians feel quite strongly about” according to Dimitri.  Physicians need to ask about access to guns because the likelihood of death by firearm in the homes where domestic violence and suicidal depression exists may occur if a gun is present.  Physicians have been seen as “the trusted source of information for patients and their families” according to Steve Ringer, M.D. suggesting a need for education and leadership.

George Benjamin, M.D., “If it hurts people or kills people it is ours” referring to the responsibility of physicians to take an open and direct approach to reduce gun violence, injury and death due to firearms.  Public health responsibility to overcome the fear of gun violence yet a paradox exists in that society normalizes violence in society.  Game systems today have celebrated gun-related violence that has become part of the culture.  The protective safety of guns is overstated.  Arguably, the view that a gun protects us against violence but far too often a toll is taken in increased the presence of a gun suicide, homicide, and accidental death due to the presence of a gun. Intimate partner violence takes the lives of 51 partners a month. More days with mass shooting than days without.  “A persistent drumbeat of gun violence approximately 91 daily – 33,000 annually” according to Benjamin.  What are we doing about suicide?  “It is an impulsive action that one cannot re-think when a firearm is used.”  Gun ownership is declining and fewer people are owning guns in 2016 although there are more guns than people in America.

  • Make guns safer – using technology, i.e. password or fingerprint
  • Make people safer with their guns, annual firearms safety class
  • Make people safer in an environment with guns in it, gun storage, background checks, create youth safety education, sensible gun laws

Maura Healey became AG in 2015 – formerly an assistant D.A. in Middlesex County has been dealing with heroine crisis and improving criminal justice system.  “We in law enforcement deal with this on a daily basis here in Massachusetts” according to Healy.  We aren’t able to prosecute away all of these individual incidents there are too many. It is not about the right to bear arms it is about future generations of people and the health of people across the Commonwealth. This is a crisis that requires renewed focus and a persistent approach as a public health and civil rights issue that needs to be addressed from a broad underpinning of disciplines including physicians. Gun dealers need to follow the rules when it comes to gun sales.  “Trauma may beget trauma and violence may beget violence” according to Healey. Empowering young girls to be aware of their rights against being victimized. Healey cited the violence intervention program at BMC that has intervened with families for 10 years.  Healey is committed to increasing access to mental health services for those most at risk. Opportunity to conduct research to deliver and make a difference in the crisis of gun violence. Healey talked about intersection points where frontline personnel interact with those at most risk of death. Physicians are at a precious spot to intervene.  Healey’s mother is a school nurse and her father is a teacher and coach – also at the intersection point for youth safety and support.

Rep David Linsky and gun legislation.

In the state of Florida it is not allowed for physicians to ask their patients about gun ownership – a case currently being challenged in the state’s court system.

National violent death reporting system identify unintentional deaths are greater than what is reported in death reports.  Children are killed by someone else – usually a friend showing the gun.  Suicide prevention without changing laws. Focus should be on how suicide takes place rather than why a suicide takes place.  The acute phase of a suicidal urge is often short lived.  Keep highly lethal means away from those who are suicidal – for those who cut themselves or use poison to kill themselves the lethality is reduced greatly.  Rates of suicide are explained by the presence of a gun in the home. Suicide prevention plan includes getting gun out of the house for a period of time.  Friends need to help get guns out of the house during periods of crisis.  Gun sales need to be aware of those who might buy a gun in order to kill themselves.  3 suicide deaths in one week from a NH gun store.

Guns have not fundamentally changed in the way they have been designed since 1916.  Stephen Teret, Ph.D. talked about changing the vehicle or vector of gun violence as a method of harm reduction.  He cited the science of changing the mosquito to reduce the incidence of the Zika virus or yellow fever by genetic alteration and likened this to changing guns in the manufacture of a “smart” gun that will recognize its owner.

Reverend Jeffrey Brown, a Boston area Baptist minister cited a Community-based collaborative for crime reduction in cities. Violence changed the city.  Conducted over 1000 funerals at his church and in the greater Boston area before coming to the conclusion that “something needed to be done and he was the one to do it”.  He and  colleague members of clergy walked the streets in Dorchester in an effort to understand the life after 9:00 PM in the neighborhoods.  The effort did not go unnoticed by members of the police department.  This cast the seeds of the 10-point plan in collaboration with the Boston police department by brokering a community-police collaborative.

David Rosmarin, M.D. at McLean Hospital – Rampage violence or spree violence is rare but always sensational- “violence is the currency of what we do” so MDs need to become comfortable with the conversation of violent intensions. The serious mentally ill account for only 3-5 % of all US violence – substance abuse a big factor in violence according to Rosmarin.  Violent intention is frequently communicated in advance.  “There were signs along the way that were ignored” according to Rosmarin.

What does our system have for those who are making threats of violence?  This is a question especially when police and first responders are called at times of crisis.

Divorce, loss of employment, substance abuse. Nihilism – fatalism.

Preparation in advance – no single typology.  In NY, MH professionals, RN’s, MDs are mandated reporters to Division of Criminal Justice patients “if they are likely to engage in conduct that would result in serious harm to self or other.”

Risk Assessment – Structured Professional Judgment – dynamic factors, static factors

  • Magnitude: verbal, shove, strike, shoot
  • Likelihood: low, medium, high
  • Imminence: immediate, short-term, chronic
  • Frequency: one-time, repeated
  • For each and overall: low, medium or high

Be humble, tolerate uncertainty, and try to articulate the valence given each factor. • Someone may be low imminence, moderate likelihood, chronic risk, and high potential magnitude—high magnitude always the case with guns

Slide presented by Dr. Rosmarin 2016

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