Shannon Frattaroli, PhD, MPH; Daniel W. Webster, ScD, MPH; Garen J. Wintemute, MD, MPH
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0283.
Requests for Single Reprints: Shannon Frattaroli, PhD, MPH, Associate Professor, The Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205; e-mail, email@example.com.
Current Author Addresses: Drs. Frattaroli and Webster: The Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205.
Dr. Wintemute: UC Davis Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817.
Author Contributions: Conception and design: S. Frattaroli, G.J. Wintemute.
Drafting of the article: S. Frattaroli, D.W. Webster.
Critical revision of the article for important intellectual content: G.J. Wintemute.
Final approval of the article: S. Frattaroli, D.W. Webster, G.J. Wintemute.
Administrative, technical, or logistic support: S. Frattaroli.
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James R. Gould, MD, FACP
Oncology Associates of W. Kentucky
May 7, 2013
Gun Violence Prevention: A Pathetic Proposition
Who put you up to this? As a physician of nearly 40 years experience, I have no role in gun violence prevention. First, I don’t get paid for my current tasks. Second, the kind words I offer to the obese, underactive, and medically uncontrolled already fall on deaf ears. Advice to pathologic psyches? Third, the system of mental health support collapsed decades ago. Don’t shift the burden of ‘prevention’ to those who can’t get their primary jobs done. Fourth, the criminal justice system is not allowed to do its job: Punish and restrict the freedoms of the convicted. We have known for decades that the cost of rehabilitation is wasted. [My high school debate focus in 1969...] If I am obligated to become part of the gun violence debate (how about PQRI), I WILL throw in the towel. I will abdicate the responsibility I have for so many medical problems over the issue of violence. I will burn my license on the steps of the U. S. Capitol with as much fanfare as I can create. Your manuscript is a specious and shameful effort to involve ‘healthcare’ in the debate over gun violence. Take it home. Focus your attention on mental health funding, mental health homes, background checks, sales prevention, and criminal justice. Encourage those who are tasked with the problem to complete their tasks. Let the docs be physicians and healers, one poor soul at a time.
John P. May, MD, FACP
Armor Correctional Health Services
May 17, 2013
Physician Counseling about Gun Injury
Physician engagement and a public health approach to gun violence as outlined by Frattaroli, Webster and Wintemute (1) and sought by the editors of the Annals (2) includes preventive counseling about guns during routine clinical encounters. We interviewed 53 African American men aged 18-34, the group for whom firearm injury is the leading cause of death (3), following an ambulatory care encounter unrelated to violence. During the visit, the physician briefly counseled the patient about six preventive health issues: alcohol, smoking, drugs, safe sex, guns, and seat belt use. In a post-encounter interview, the discussion of firearms was the issue most commonly recalled by the patients. Eighty-one (81) percent believed that it is important for a doctor to talk with them about guns. (4) The discussion can be within the context of a routine health exam wherein the physician alerts the patient to situations that increase risk. A mnemonic device developed by the Chicago Medical Society uses the word GUNS (5) to prompt questions for patients pertaining to risks: (6)
G – Is there a Gun in your home?
U – Are you are around Users of alcohol and other drugs?
N – Do you feel a Need to protect yourself?
S – Do any of these Situations apply to you:
- Seen or been involved in acts of violence?
- School-aged children at home?
Physicians ought not ignore or hold reservations about assessing and counseling their patients’ risk of gun injury or death.
Department of Medical Education, Paul L. Foster School of Medicine, El Paso
June 10, 2013
Frattaroli et al note the role that fear plays in decisions about gun ownership and gun policy. They also call for more physician leadership. It would be instructive for medical school leadership to determine how many faculty and students possess guns, even in households with small children. While many of them will clearly state that fear is a motivation in their decisions, far fewer will give a direct answer to the question, Who or what are you afraid of? Further internal exploration of this issue may be necessary if more effective physician leadership is to be developed.
Shannon Frattaroli, PhD, MPH, Daniel W.Webster, ScD, MPH, Garen J. Wintemute, MD, MPH
Johns Hopkins School of Public Health
June 21, 2013
We appreciate the diversity of responses to our article. Dr. May’s empirical work provides a patient perspective on the physician’s role in gun violence prevention and is an important complement to the five strategies we discuss. As other readers of this Journal consider whether and how to incorporate more gun violence prevention strategies into their professional practice, the relative importance of such an approach is heightened by Congress’ recent decision not to expand background checks to include all Internet and gun show sales. In a political climate where lawmakers fail to legislate the systemic reforms that a majority of the population supports, education to raise awareness and influence behaviors is one of the few tools that remain.That said we do recognize the limited time available for such outreach, the challenges of promoting safe behavior, and the different perspectives about the role of clinicians in gun violence prevention efforts. As we continue our collective efforts to realize a less violent society, we are encouraged by the willingness to discuss and debate the best course forward. And we remain optimistic that physician engagement in gun violence prevention will lead to fewer firearm-related deaths and injuries. With regard to Dr. Gould’s letter, we are saddened by his response, and thank him for his decades of service.
Frattaroli S, Webster DW, Wintemute GJ. Implementing a Public Health Approach to Gun Violence Prevention: The Importance of Physician Engagement. Ann Intern Med. 2013;158:697–698. doi: 10.7326/0003-4819-158-9-201305070-00597
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Published: Ann Intern Med. 2013;158(9):697-698.
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