‘Firearms are part of a health problem.’ UC Davis ER doctor on role of physicians in gun discussion
The group’s Nov. 7 tweet, telling “self-important anti-gun doctors to stay in their lane,” shocked, coalesced and galvanized not only a giant wave of doctors but also many other medical professionals to get involved in and actively advocate for evidence-based approaches to preventing shooting injuries and deaths.
“The NRA kicked a hornets’ nest, and there’s just been a tremendous spike in interest,” said Wintemute, who practices at UC Davis Medical Center. “What the NRA has done is get tens of thousands of people to make public declarations that they are willing to do something about this. I’m sure they (the NRA) didn’t do it on purpose but they’ve done us a big favor.”
In the days after the NRA tweet, doctors around the nation and even some around the world began posting sometimes-graphic, sometimes-poignant messages that shined a light on just how gun violence spills into their practices and why they are invested in seeing it prevented. Their rebuke to the NRA coalesced into trending themes #ThisIsOurLane and #ThisIsMyLane, prompting hundreds of thousands of retweets and more than 500,000 likes.
As their so-called hashtag activism found resonance, medical professionals began to look for other ways they could help. That’s when many happened upon links to an article Wintemute published Oct. 17, 2017, in the Annals of Internal Medicine, a little more than two weeks after the mass shooting in Las Vegas. In it, he asked doctors to make a public commitment to discuss firearm safety with their patients.
To help those conversations, UC Davis created a “What You Can Do” web page with clinical information, statistics, ways to offer patient counseling, and more. Before the #ThisIsOurLane campaign, 1,330 physicians had made the public commitment to counsel patients.
‘This is what we see every day.’
Since the NRA tweet, Wintemute said, an additional 1,120 doctors have signed that commitment and more than 40,000 medical professionals have since signed an open letter to the NRA, declaring that researching ways to prevent gun-related deaths and disabilities is well within their lane.
Gun violence has a very powerful effect on physicians, said Dr. Sarah Medeiros, who works with Wintemute in UC Davis Medical Center’s emergency department. She also co-hosts a UCD Health podcast called EM Pulse that delves into current topics in emergency medicine, and she’s preparing a segment on gun violence that opened her eyes to the many startling details doctors recall about shooting victims whose lives they tried to save.
In a Nov. 10 #ThisIsMyLane tweet, Medeiros shared her vivid memory of a whole family shot up by a disgruntled neighbor: “The preschooler was herniating brain matter. The big sister had a hole in her lung. Big brother luckily just grazed. Mom shot in three places. Dad, who shielded them all, DOA. I still see their faces.”
Most people think about gun violence when there’s a mass shooting, Medeiros said, but health care workers in urban hospital emergency rooms see homicides, suicides or life-altering injuries almost every day that remind them of the toll that firearms can take. These aren’t memories that doctors typically discuss, Medeiros said, but the NRA tweet unleashed a torrent of them.
“We share these stories to try to make it real,” she said. “This is what we see every day.”
The NRA tweet promoted an editorial written by its lobbying arm, the Institute for Legislative Action, in which it bashed doctors for rehashing the same tired gun-control policies and accused them of citing studies that wouldn’t qualify as evidence in any other debate. NRA’s lobbyists aimed their editorial at a recent position paper from the American College of Physicians published in a widely respected journal for medical internists, Annals of Internal Medicine.
The NRA tweet, in its entirety, stated: “Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.”
In the NRA editorial, lobbyists ridiculed studies of one county in Iowa and another on 106 outpatients at a single clinic, but they did not mention the paper’s plethora of data-driven evidence from U.S. and international government agencies.
Policy without politics
Medeiros said she found out about the NRA tweet, as many other doctors did, when she began to see #ThisIsMyLane responses pop into her Twitter feed. The NRA’s original tweet was often appended. After reading it, Medeiros said, she felt like the NRA was out of touch with the role that doctors have in studying and devising solutions to public health issues.
Medeiros’ colleague, Dr. Aimee Moulin, said that she thought the NRA post was meant to be politically inflammatory and divisive but that doctors can take steps to save lives without getting into politics.
Doctors ask patients about alcohol and tobacco consumption, bike helmets, car seats, drug use and sexual practices, said Moulin, an emergency-room doctor, so why not talk to them about prevention of firearm injuries? If there are children in the home, for instance, are guns locked away and have children been told what to do when they see a gun? Could a patient with dementia access or stumble across a firearm?
The point is to prevent a crisis, Moulin said, adding that urban hospitals see so many gunshot wound cases that the military sends its physicians to train at UCD Medical Center and other hospitals around the state.
“Think about military physicians training in our emergency departments because that is how they get combat training,” Moulin said.
The NRA editorial chastised the “anti-gunner” public health community for not emphasizing better methods of identifying, policing, prosecuting, and incarcerating of suspects as a key aspect of prevention of gun violence.
Wintemute is the antithesis of anti-gun. He has enjoyed target shooting as a child and adult, and as a college student, he even taught target-shooting. He was drawn to studying gun violence after he became an emergency-room physician and learned of the incredible number of people who succumbed to gunshot wounds before an ambulance could even transport them to the hospital.
“I don’t have a problem with the tool,” Wintemute said. “I have a problem with how it’s used and how it’s misused. This is a tool associated with tens of thousands of deaths in the United States. I’m not anti-gun anymore than I’m anti-car. One can work to prevent motor vehicle deaths and injuries without being anti-car, and the same thing is true here.”
How California ranks
Public policies in California already are ensuring that Golden State residents are less likely to be victims of gun violence, Wintemute said, but perhaps the most important thing working in residents’ favor is the low level of gun ownership. Globally, he said, one of the best established facts is that the higher the prevalence of firearm ownership in a population, the higher the rate of firearm violence.
Last February, the news staff at 24/7 Wall St. reviewed the most recent annual data on gun violence: total number of deaths in 2016, the death rates by population size in 2016 and violent crime rates in 2016. Coming in at No. 43, California ranked among states with the least gun violence.
No. 1 was Alaska; No. 50, Massachusetts. Five of the 10 states with the worst gun violence were in the South: Alabama, 2; Louisiana, 3; Mississippi, 4; Arkansas, 9; and South Carolina, 10. In addition to Massachusetts, five other northeastern states had some of the lowest levels of gun violence: Maine, 42; New Jersey, 45; Connecticut, 46; New York, 48; Rhode Island, 49.
Wintemute said he’s seen media reports noting that California has had more mass shootings than any other state – 187 since 2014, according to data from gunviolencearchive.com – but what those reports fail to note is that the next state in line, Illinois with 164, has less than a third of California’s population.
The UC Davis researcher has extensively studied laws to determine whether they actually help stem the number of gun-related injuries and deaths, and he said California has several pieces of legislation that have worked in concert with federal laws to deter injuries, homicides and suicides.
There are laws aimed at identifying individuals likely to commit crimes with guns. When a retailer sells a firearm, a notification gets sent to the state Department of Justice, which performs a background check on the purchaser. Federal laws do not allow felons to buy guns, Wintemute said, but California has taken that one step further: It prohibits gun sales to individuals with violent misdemeanors on their records and prevents anyone served with a temporary domestic violence restraining order from buying a firearm while the order is in effect.
If someone has any of those flags on their record, he said, it just pops up and they don’t get to buy a gun.
“All of this happens, if you will, administratively,” Wintemute said. “There are problems. Sometimes a restraining order is served or a psychiatric hospitalization occurs, and it’s not reported, so DOJ doesn’t know about it. It’s not in the data, and that’s a problem.”
State leaders have taken a number of other measures that have helped. Among them: Buyers must wait 10 days after the purchase before a gun is released to them. Sales of military-style weapons capable of firing multiple rounds have been outlawed. Private sales of firearms must go through a licensed dealer, meaning a background check must be done and there’s a paper trail. That measure closed what has come to be known as “the gun show loophole.”
Gun violence restraining orders
“People don’t follow the law all the time,” Wintemute said. “We’ve learned that maybe as many as 20 percent of firearm purchases in California where background checks would be required actually don’t have background checks. We know that from asking people about the guns that they have bought. We just got that information a couple weeks ago.”
What Wintemute likes about California’s leaders is that they are always willing to experiment with how to deter violent gun crimes. Recently, he said, California instituted gun violence restraining orders allowing law enforcement and family members to go to a judge and ask that a high-risk individual be prohibited from buying or possessing weapons.
“It’s a new policy in California,” Wintemute said, “and we’ve actually done, in my judgment, a very poor job of making law enforcement and others aware that it even exists.”
He said he’s wondered since the Tehama County and Thousand Oaks shootings whether law enforcement or family members even knew this measure exists. In both cases, individuals identified as the shooters had been reported to law enforcement. On the other hand, Wintemute said, his research has uncovered two other mass shootings that were planned in California but didn’t occur because gun violence restraining orders were issued.
There will always be discretion in when measures like this are taken, Wintemute said, so he feels it is his job as a public health policy researcher to help all the parties understand whether policy interventions actually save lives and, if so, the best practices for implementation.
That’s what researchers at the American College of Physicians were trying to do when they published the position paper, detailing 10 measures that have been shown to work, Wintemute said. That’s the paper that drew the ire of the NRA and prompted its Nov. 7 tweet.
This work is not about politics, said Dr. Jaymin Patel, who also works in the emergency department at UCD Medical Center. Rather, he said, it is about getting physicians out of the business of treating patients with gunshot wounds.
Patel tweeted several times in the #ThisIsOurLane campaign after ER Dr. Tamara O’Neal lost her life in a Nov. 19 mass shooting at a Chicago hospital. In one post, he said: “So before you think that we have a political agenda or we should ‘stay in our lane,’ consider the fact that maybe simply all we want to do is to stop having to treat human beings with PREVENTABLE GSWs. Our activism is a product of our empathy, not our judgment.”
On the front lines
Patel said his most painful memory of the impact of gun violence came when he was a first- or second-year medical student shadowing an ER doctor for a night. Multiple victims came in with gunshot wounds, or GSW’s, that night, he said, and one very young patient didn’t make it.
About 30 or 45 minutes after the patient died, the doctor was talking with a resident about another patient when all of a sudden, a blood-curdling scream from across the ER cut off their consultation.
The patient’s mom had come “into the ER, saw her child’s body, saw he was dead, and she started screaming uncontrollably,” Patel said. “For me, as a first- or second-year, it was completely unexpected. I remember feeling nauseous. My knees got weak. I had to excuse myself and walk outside the ER. I remember walking outside the ambulance bay and finding a wall and putting my back on the wall and crouching down. I almost passed out.”
Moments like these inspire the kind of research that Wintemute and others do, Patel said. Firearm-related deaths are a public health crisis, wrote editors of the Annals of Internal Medicine in response to the NRA editorial. In 2016, the latest year for which federal officials have data, 38,658 U.S. residents died as a result of gun injuries. Five years earlier, that death toll was about 20 percent lower.
Doctors are aware of these types of statistics, Wintemute said, but before the #ThisIsMyLane campaign, gun-violence prevention efforts weren’t a front-burner priority for a broad swath of the medical community. Now, he said, he’s in discussions with major medical associations who want to form a coalition that will promote prevention efforts.