The Quiet Room
Robert Glatter, MD: The United States has the highest rate of firearms-related deaths in the developed world. More than 80% of all firearm deaths in developed countries occur on our soil.[1,2] School shootings continue throughout the country, most recently with the shooting on May 18 in Santa Fe, Texas, taking 10 young lives; and two injured students in the May 25 shooting in Noblesville, Indiana. The epidemic of gun violence continues to plague our communities.
Joining us to discuss this epidemic are Dr Peter Masiakos, director of pediatric trauma surgery at Massachusetts General Hospital in Boston, and Dr Chana Sacks, an internal medicine physician who is also at Massachusetts General Hospital. Welcome to both of you.
Glatter: Dr Masiakos, you and Dr Cornelia Griggs published an eloquent essay titled, "The Quiet Room" in late December 2017 in the New England Journal of Medicine. Your essay highlights the emotional toll of the indescribable tragedies that surgeons experience when they inform parents about the deaths of their children in the context of gun violence. Can you describe the key take-home messages from your essay and how your messaging can help the public better understand how we physicians see this crisis?
Peter T. Masiakos, MD: Cornelia and I had planned to write something after the Las Vegas shooting, on the heels of the multiple incidents that have happened during the past 2 or 3 years. We wanted to contextualize the role of the physician and what we experience by taking the patient out of the statistics category and putting them into a human category. What we see is far more than what is reported.
We felt that it was an obligation on our part. In fact, we have been hearing this from other colleagues, that the patients we take care of are not just a statistic, so we wanted to humanize the patient in that paper. It was a perspective that both of us felt strongly about.
Glatter: This is certainly something we rehearse in our minds; what you talk about in this essay rings true. It is that eerie silence and then those shrieks of pain. It is incredibly disturbing. The families are going through immense pain, but healthcare providers experience that pain too. You brought this point home.
Masiakos: It is the hardest part of our job, as you know, to tell a mother or father that their child has died a preventable death. The perspective piece was meant to help the public understand that we are not automatons who deal with a number. Unfortunately, that is what we wait to hear about after each of these events—how many have died, how many have been injured, how many were brought to the emergency departments, how many were worked on by doctors and surgeons, and how many went home.
What the public needs to see is the exact toll that this takes, not only on the families and the victims, but also on the healthcare providers, the first responders, the nurses, and the fellow students, their teachers, and the community.
Where Gun Owners and Non-Gun Owners Agree
Glatter: In a recent paper published in the AMA Journal of Ethics , the authors discuss what role, if any, physicians should play in the response to gun violence, a question not only of professionalism, but also of law, culture, and ethics. They argue that physicians have important roles to play in the larger landscape of advocacy, public opinion, and reduction of gun violence, but that it is not ethically or legally appropriate for doctors to serve as gatekeepers of gun privileges by assessing competency. Do you have specific thoughts about this?
Chana A. Sacks, MD: When I read this article, I had a lot of thoughts. Your question points out one possible area of disagreement or controversy. What struck me were how many areas we all agree on. Of their many points, the first several were points of obvious consensus. Another article came out recently in the American Journal of Public Health, from the gun violence research group at Johns Hopkins, reporting on surveys of gun owners and non-gun owners, and showing that 88% of gun owners and non-gun owners believe that background checks need to be tougher; and 85% of both groups believe that there should be some competency requirement for people to get a concealed carry license.
It is easy to discuss this issue as divisive, but when you look at those statistics, when you look at how much agreement there is, you could spin this in an entirely different way. What other issue in this country unites Americans so completely as this? If we start to think about it that way and stop accepting this premise that this issue is so divisive that there can't possibly be common ground, I believe that we could make real progress. When we start to consider the vast areas where gun owners, non-gun owners, physicians, and people across this country do agree, there are many areas we could move forward.
Masiakos: I don't believe that this is limited to any specific specialties. At the American College of Surgeons (ACS), there was a similar concern about divisions. Several surveys have now been completed among the membership of the Committee on Trauma and the board of governors of the ACS, and I will echo Chana's points that the areas of consensus far outweigh the areas of division. Of the 15 questions that were asked of the members of the Committee on Trauma, 14 of the 15 points were areas with 70% or greater consensus, and those included access to firearms that are meant for military use restrictions.
We also reflect the fabric of the country. As physicians, we are as diverse as the public. We have our opinions, but insofar as what we do for a living and taking care of patients who are injured and dying, we have been able to rally and pull together in many areas where consensus exceeds the majority.
The Basic Fundamental Facts on Firearm Morbidity and Mortality
Glatter: Getting back to this public health article, I wanted to hit on one point about domestic violence and mental health, and that was an area of agreement, from what I understand. Gun owners and non-gun owners alike agreed that those were two key areas where we need regulation and tightening of restrictions. Is that your understanding from the paper, Chana?
Sacks: Absolutely. At a certain point, whether there is agreement or disagreement, we are talking about basic, provable, fundamental facts. The risk of death for someone who is experiencing intimate partner or domestic violence increases by many times if there is access to a gun in the home. That is based on strong data. There is widespread agreement about our need to do more in that space. That is one example of an area we can move forward on that is not that controversial.
Masiakos: Legislators around the country are talking about this too. A bill is going through the Massachusetts State House now; it has been approved by the House and now is on the Senate side. The bill focuses on removing the gun from the home of a person who either threatens or is threatening. I believe that this is a low-hanging fruit. I don't believe that anyone can dispute the need to do something like that if we can demonstrate that a weapon is more likely to go off in the hands of someone who is willing to or threatening to use it.
Sacks: No one wants to pass laws for the sake of passing laws that don't have a chance of working in reducing morbidity and mortality from gun violence. We want to move forward on a path that will work. Our ability to analyze the data around what works and what doesn't, which educational interventions work for clinicians and which don't, what is effective and what isn't—that absolutely has to be our guiding principle as we move forward.
Glatter: The National Violent Death Reporting System (NVDRS) has been around for a while. It is in 40 states and apparently will be expanding to all 50 states. Do you see that as something that's positive on this end? Certainly, we get useful data from the NVDRS.
Sacks: A good source of data here is absolutely critical, as you said, and the NVDRS expanding to all 50 states. Having better, more complete data is critical, and the numbers are clear on a national level. As you said at the beginning, this is an American problem. After a few years of relative stability, we have seen an increase in firearm-related deaths over the past 2 years.[8,9] But it's not only the 38,000 deaths a year; twice as many people are injured by firearms, and we know those numbers are solidly based on those data that you're mentioning.
Accidental and Nonaccidental Firearm Injury Prevention Measures
Glatter: Certain measures can be taken in the home, such as gun lockers, trigger locks, and using biometrics and fingerprint identification to open or unlock a gun. Do you see these as helping in this crisis?
Masiakos: I don't think they can hurt. We just had an event in Virginia where a 4-year-old got hold of a gun in the home and shot and killed his [brother]. Having a gun that can be mistaken for a toy is not something you can justify. If you think about responsible gun ownership, you have to start talking about how you can store the gun safely. And it is not just teaching gun owners how to do that; it is also teaching physicians how to instruct, how to approach the subject, how to ask the question about safe gun storage at home. We should be allowed to do that. We have been endorsing that, as physicians and traumatologists.
Sacks: This is a very important point. What is the clinician's role in taking action, to move forward in the space that does not require a single law to be passed? Those areas are a big focus of our gun violence prevention coalition here at Mass General.
Much of our effort involves educating clinicians and others about how to have this conversation. Everyone agrees that patients at high risk for impulsivity are at high risk for potential violence. We should be having this conversation about their access to firearms. That's a no-brainer. Yet, we know those conversations don't happen, in large part because people are not well trained to do that. That is a solvable problem and one of the pieces we're working to solve.
The Massachusetts Medical Society, the Boston police department, and others are developing basic information and guidance to help clinicians have this conversation—basic information such as where to get gun locks and how much they cost. We are putting the information that has the potential to lead to safer gun storage and to potentially save lives in the hands of clinicians and patients. That is a problem we can solve.
Glatter: The American Medical Association (AMA) has been pushing this for decades now, trying to advocate to reverse these horrible trends. They certainly have been backing universal background checks, banning assault weapons, safe storage of firearms. The AMA [held] meetings in Chicago, and I believe this is another area where physicians are seeing an opportunity to try to push the agenda little bit.
Masiakos: I can't speak for the AMA, but it is something the AMA has been trying to address for two decades. It is not something new. It has become more sensationalized because of the divisions in our country, but the policy and the position of the AMA has been the same for the past 20 years. I believe that it is important to talk about these things.
It comes to that 70/30 split we see again and again and again, when you ask, "What can we do to fix this?" Physicians should be on the front lines and we should be talking about this. The AMA will do exactly that, just as the ACS did last month at the Advocacy and Leadership Conference in Washington, DC, and the ACS will be doing at its Clinical Congress in October.
I believe that we have come to a point where we're motivated. I return to our essay and say that this is the hardest part of my job and what motivates me. I am motivated to put myself out of business as a traumatologist. That's what I want.
When Gun Violence Leads to Personal Loss and Pain
Glatter: That is well said, and it brings me to another point. Chana's second cousin was murdered in the shooting in Newtown, Connecticut [and she also wrote an essay for the New England Journal of Medicine]. My heart and all of our hearts go out to you for this painful loss, but I can see how this has motivated you and pushed you toward what you are doing now with this coalition.
Sacks: My cousin Mark Barden, who lost his son, is dedicating his life to making sure that no other parents have to experience what he has gone through. In many ways, I am following his lead. What became so clear to me, over the past few years, is how much there is to do. Those policy elements that you talked about are important—of course they are—but even more than that, I would push every academic medical center and others to look inward, and ask, "What can we do? Where can we step up if there will not be federal funding for research in this area?" How can academic medical centers fill that void, because there is a path forward here.
Masiakos: On that day in 2012, my day stopped. If Mark can pick himself up and do what he is doing for his son, and Chana can do what she is doing for her cousin, then we are all obligated as human beings to do as much as we can to fix this. My role as a physician is superseded by my role as a father, a spouse, and a citizen. If we cannot talk about fixing this problem, then we are in big trouble. Not to emotionalize it, but you cannot talk about this without emotion.
Glatter: These are our families and our friends who have suffered immensely. This is such an important discussion to have. We're not going to have funds to push this research forward federally. In fact, Megan Ranney, an emergency physician in Rhode Island, has started AFFIRM to raise funds outside those typical gates. I applaud her on her work so far. Obviously, there is more to be done, but it's definitely heartening.
Masiakos: Our colleagues are now talking about it, and not in a back room; this is out in the open, and people are saying, here are five things we can do now that have been shown to work. Research pending, let us think about doing these now and going with the data when the data come. The last thing you want is to do something that has an unintended consequence, but we have been in the business long enough that we understand those things. We have seen the child who has been shot by a brother or shot accidentally, or who picks up a gun. How do you account for the 380,000 guns that are reported lost or stolen every year that end up in the hands of someone who may commit a crime? This safe storage idea is not an idea that is out of bounds or completely out of whack. This is something we should be thinking about, educating ourselves about, and talking to our patients about.
Sacks: And teaching our trainees to talk about.
Masiakos: And teaching our children about. Along with being a father with a weapon in your house, and having children in the house who can mistake this weapon for a toy, with these things comes awesome responsibility. With anything that you have that has a dangerousness associated with it, there is responsibility. Why can't we use that as a starting point? Responsible gun ownership is fine, but let's do it. There is no reason to have 350,000 guns stolen every year. Secure them. Secure them so the kids, 1700 kids, don't shoot themselves. You can see that I am passionate about this; it is the passion that has been generated over 20 years of seeing these tragedies.
Beyond the school shootings and beyond suicide, beyond the interpersonal violence of suburban America, inner-city violence is also another thing that we have to talk about. Passion comes from experience, and I am glad to see that my colleagues are beginning to bubble up and say, we have seen enough of this and we have to talk about it.
Glatter: Thank you, Peter and Chana. This has been an incredible discussion—very deep, very rich.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Docs Say, Let's Start Where Gun Owners and Non-Gun Owners Agree - Medscape - Jun 28, 2018.