Renee Butkus, BA; Robert Doherty, BA; Sue S. Bornstein, MD; for the Health and Public Policy Committee of the American College of Physicians *
Financial Support: Financial support for the development of this position paper came exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-1530.
Corresponding Author: Renee Butkus, BA, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Current Author Addresses: Ms. Butkus and Mr. Doherty: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Dr. Bornstein: Texas Medical Home Initiative, 3111 Beverly Drive, Dallas, TX 75205.
Author Contributions: Conception and design: R. Butkus, R. Doherty, J.D. Lenchus, J. Quinton.
Analysis and interpretation of the data: R. Butkus, R. Doherty, J.K. Carney, T.L. Henry.
Drafting of the article: R. Butkus, R. Doherty, J. Quinton.
Critical revision of the article for important intellectual content: R. Butkus, R. Doherty, S.S. Bornstein, J.K. Carney, T. Cooney, L. Engel, H.E. Gantzer, T.L. Henry, J.D. Lenchus, B.M. McCandless, J. Quinton, M. Southworth, M.A. Wallace.
Final approval of the article: R. Butkus, R. Doherty, S.S. Bornstein, J.K. Carney, T. Cooney, L. Engel, H.E. Gantzer, T.L. Henry, J.D. Lenchus, B.M. McCandless, J. Quinton, M. Southworth, A. Valdrighi, M.A. Wallace.
Collection and assembly of data: R. Butkus, T.L. Henry.
For more than 20 years, the American College of Physicians (ACP) has advocated for the need to address firearm-related injuries and deaths in the United States. Yet, firearm violence continues to be a public health crisis that requires the nation's immediate attention. The policy recommendations in this paper build on, strengthen, and expand current ACP policies approved by the Board of Regents in April 2014, based on analysis of approaches that the evidence suggests will be effective in reducing deaths and injuries from firearm-related violence.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Paul Franke MD
November 1, 2018
While I strongly support the process of developing policy positions by the ACP, I am very disappointed that the current recommendation on firearm safety does not advocate for the use of “smart gun” technologies. As physicians, we do have the ability to reduce the number of accidental firearm related morbidity and mortality through policy recommendations and in our actual clinical practice. How could we not embrace technology that prevents accidental discharge of a firearm by family members, especially children?These commercially available technologies do not infringe on second amendment rights, and obviates the consistent failures of firearm owners to secure firearms. We need bold solutions to this horrific problem, not more “thoughts and prayers”. Please reconsider adding this recommendation to our policy statement.
Eric J Buenz
Nelson Marlborough Institute of Technology
November 18, 2018
The United States can learn from New Zealand’s proactive gun ownership model
I emigrated from the United States to New Zealand. As my family eats only self-harvested meat and my medical research involves shooting animals (1, 2), I have owned firearms in both countries. The suggestions by Butkus et al (3) to reduce gun violence are welcome, however developing specific policies could be challenging. Perhaps there is a more straightforward route to achieve the same goals through emulating the New Zealand firearms ownership system (4).Obtaining a firearms license in New Zealand requires passing a firearm safety test, a police interview of the applicant, a police interview of a close relative in a location separate from the applicant, a police interview of a self-nominated non-related individual, and inspection of two separate secure storage locations for firearms and bolts/ammunition. Once issued a license an individual can purchase firearms, ammunition and even sound suppressors—gun paraphernalia restricted in the US.After passing my New Zealand firearms test, I saw my instructor and asked about another participant in the course who could not grasp the essential elements of firearm safety, such as remembering to treat every gun as loaded. The instructor told me the other participant would never receive his firearms license in New Zealand because of the checks in place. I thought, “In the United States that individual could have simply walked into a gunshow and walked out armed.” 1. Buenz EJ, Parry GJ. Chronic Lead Intoxication From Eating Wild-Harvested Game. The American journal of medicine. 2018;131(5):e181-e4.2. Buenz EJ. Lead exposure through eating wild game. The American journal of medicine. 2016;129(5):457-8.3. Butkus R, Doherty R, Bornstein SS, Health, Public Policy Committee of the American College of P. Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians. Ann Intern Med. 2018.4. Government NZ. Arms Act 1983. In: Government NZ, ed. 1983 No 44. Auckland; 2017.
Jose S. Pulido
November 10, 2018
I think that the ACP was very valiant in its actions. We as physicians have a duty to keep people safe and healthy yet we have stayed quiet and cowering in the sidelines too long while people are maimed physically and/ or psychologically or they die. I find it similar to the history of physicians fighting cigarette smoking and the ravages of that. History proved us right then and I think that history will prove you right again. Thank you
James Webster MD, MS, MACP
Gertz Professor of Medicine Emeritus Feinberg School of Medicine of Northwestern University
December 7, 2018
Reducing Firearm Death and Injuries in the US
As a longtime advocate for the reduction of gun violence (GV), in Chicago and now in New Mexico, I was pleased to read the enhanced ACP position paper (1) on the topic. In view of the recent exacerbation of GV and the increasing public interest in reducing its toll, I would make several suggestions for ACP leadership and the Public Policy Committee to consider adding to ACP strategies. First: it is time to recommend mandatory registration of; a) handguns, which are involved in virtually all homicides and suicides and; b) semiautomatic rifles, the weapon of choice for mass shootings. Although this would be vigorously resisted by the NRA and some gun owners it is not inconsistent with the SCOTUS 2008 ruling on the 2nd amendment in which Justice Scalia’s majority opinion stated, “The right to bear arms is not unlimited”. The Trauma’s firearm strategy Committee of the American College of Surgeons has recommended an electronic data base registry for all guns (2), ACP should join them! Such an initiative would: Track gun ownership preventing illegal sales such as currently occurs via gun shows and private transfers. Further the legal consequences of not registering a weapon would undoubtedly reduce the number of guns in the US and as per the Australian experience (3), by itself resulting in a reduction in gun deaths and injuries. Particularly since research has repeatedly shown that states with more guns have significantly more gun related incidents of all types (4). It would also be of great help to law enforcement as they prosecute crimes and enforce extreme risk (red flag) protection orders. Finally it would be another way to make guns less socially acceptable, as has occurred with cigarette smoking. Second: with due respect to ACP’s varied political objectives, I believe that the ACP/ PAC should immediately stop contributing to any politician who has NRA backing. To continue do so raises major cognitive dissonance, clearly inconsistent with the values of ACP. If the growing epidemic of GV is to be reversed all strategies must be utilized and all health professionals must be involved (5). Bibliography1. Butkus R, Doherty R, Bornstein SS, et. al. Reducing firearm injuries and deaths in the United States: A position paper of the American College of Physicians. Ann Intern Med. 2018;169:704-707.2. Recommendation from the American College of Surgeons Committee on Trauma’s Firearm Strategy Team (FAST). Accessed 12/3/18. DOI:https//doi.org/10.1016/j.jamcollsurg2018.110023. Chapman S, Alpers P. Gun related deaths: How Australia stepped off “The American Path” Ann Intern Med. 2013;158:770-14. Banglore S, Messerli FH. Gun Ownership and firearm related-deaths. Amer J Med. 2013;126:873-6.5. Wintemute GJ. What you can do to stop firearm violence. Ann Intern Med. 2017;167:886-7. email@example.com
Ethan B. Ludmir MD, M. Ali Elahi, B. Ashleigh Guadagnolo MD, MPH
The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Washington University in Saint Louis, St. Louis, MO, USA
December 6, 2018
A Call for Better Representation: Physicians in Congress and Gun Reform
Three days following the Pittsburgh synagogue shooting, the American College of Physicians published a position paper with updated recommendations to counter gun-related violence (1). In response, the Twitter account of the National Rifle Association of America (NRA) posted a disparaging reply, advocating that physicians should “stay in their lane” and abstain from opining on gun control (2). Hours later, twelve people were shot to death at a bar in Thousand Oaks, California. Days after that, another shooting occurred at Mercy Hospital in Chicago.In these harrowing times, we look to our leadership, both in government and in our professional communities, for guidance. Physicians in Congress are among the most influential members of the medical community, uniquely positioned in the public discourse to speak out on public health crises – including the gun violence epidemic (3-5). We therefore identified the members of the current (115th) United States Congress with medical doctorates, and examined their positions as regards gun control. Nineteen physician-legislators elected to the 115th Congress were identified. All are male, seventeen are Republican, and only two are non-white. All 17 Republican physicians in the 115th Congress have received A-level grades by the NRA; similarly, 16 of 17 Republican physicians received campaign funding from the NRA. Multiple efforts in the past year sought to repeal the 1996 Dickey Amendment, which limits gun violence research conducted by the Centers for Disease Control and Prevention. None of the Republican physicians in Congress sponsored any of these bills, or any other gun reform legislation. This partisanship is consistent with the historical behavior of Congressional physicians. Examining the voting records of physicians in Congress on gun control legislation since 1993, we found that physicians were significantly less likely to ‘buck’ their party on gun reform bills than non-physicians in Congress. Physicians broke with their party positions only 12.7% of the time on key gun-related legislation over the past 25 years, compared with 22.2% for non-physicians (p=0.03). Looking toward the immediate future, this landscape is unlikely to change; in the 2018 midterm elections, four physicians were elected as new members of the House of Representatives. Three of these Representatives-elect received the endorsement of the NRA, including one Democrat. The gun violence epidemic represents a clear and present danger to the well-being of the country. We urge physicians in Congress to advocate for common-sense gun reform, or else stand down and make room for those who will.Ethan B. Ludmir, M.D. The University of Texas MD Anderson Cancer Center, Houston, TX, USAM. Ali Elahi Washington University in Saint Louis, St. Louis, MO, USAB. Ashleigh Guadagnolo, M.D., M.P.H. The University of Texas MD Anderson Cancer Center, Houston, TX, USAReferences1. Butkus R, Doherty R, Bornstein SS, Health and Public Policy Committee of the American College of Physicians. Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians. Ann Intern Med. 2018;169:704-707. doi:10.7326/M18-15302. NRA Account at Twitter.com, Nov. 7, 2018; URL - https://twitter.com/nra/status/1060256567914909702, Accessed: 11/14/2018.3. Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162(7):513-6. doi: 10.7326/M15-03374. Koop CE, Lundberg GB. Violence in America: a public health emergency: time to bite the bullet back. JAMA. 1992;267:3075-3076.5. Grinshteyn E, Hemenway D. Violent death rates: the US compared with other high-income OECD countries, 2010. Am J Med. 2016;129:266-273.
Michael S. Victoroff, MD
University of Colorado School of Medicine
December 18, 2018
Refining the ACP Position on Firearms
It is appropriate for medical organizations to advocate for reducing firearm injuries. This is the intent of the American College of Physicians’ (ACP) recently updated position paper on that topic. The ACP’s ideas are largely in harmony with several other medical organizations, including the American Medical Association, the American Academy of Family Physicians and the American Academy of Pediatrics, as well as a joint statement of principles published in 2015 by eight medical specialty organizations and the American Bar Association. The general agreement across these organizations is about a platform for social action; it reflects a common pool of concerns as well as some shared misconceptions and blind spots.These policies take the form of advocacy briefs. They only employ supporting arguments; they cite only supporting references; they rely on the seriousness of the problem to engage readers in their convictions. These manifestos are not balanced investigations; they don’t present counterpoint, argument or contradictory evidence; they offer little exploration of uncertainties, barriers or foreseeable shortcomings. To be fair, that’s not what policy statements do.The ACP’s recommendations are sometimes accompanied by statistics, but they are not evidence-based in the way clinical guidelines seek to be. A formally evidence-based approach to firearms misconduct could not possibly deliver turn-key solutions for the gamut of problems that need attention. In any case, evidence is only partially informative for social issues that intersect health care, which are typically governed by value judgments, cultural beliefs and perceptions of risk and benefit. (For example, decisions about the end-of-life, contraception, diet, sports and occupational risk, child rearing.)It should also be noted that policy making is different from offering advice in a clinical setting. Firearms misuse, where the relationship between law and behavior is complicated, requires different approaches in the meeting room and the examining room. Troublingly, the medical profession suffers from a relative lack of knowledge, experience and credibility on firearms matters. This can change. One of the most important functions of a medical organization is promoting education.The following commentary is a response from a physician knowledgeable about firearms. It is not a treatise on ethics or a systematic review of the ACP’s references or the wider literature on firearms risk. It addresses the major points of the ACP paper in order, but not in every respect. For brevity, the full text is not quoted for every item. (Readers may find it helpful to read the papers in parallel.)1. The American College of Physicians recommends a public health approach to firearms-related violence.There is an emerging bias in medical literature that a “public health approach” to firearms injury is the “correct” one. While a population health view of firearms misconduct is helpful and overdue, it is not any kind of panacea. It is having a hammer and seeing nails.“Public health approach” originally began as a useful heuristic. Indeed, population statistics have produced some helpful insights. But, it is not clear how much firearms injuries are amenable to typical public health intervention strategies. For one thing, a goal of zero incidence makes sense for smallpox, but not for gunshots. The metaphor is not perfect. One conclusion that seems to be emerging from study of shootings in the U.S. is the importance of socioeconomic and cultural determinants in assault and suicide rates. This would argue—contrary to most published positions—against regulations aimed at hardware in favor of approaches that address human conditions.A telling bias is embedded in the very term "firearm violence." The connotation is that use of a gun against a person is always wrongful. This prejudice pervades medical literature as well as popular journalism. It is widespread in the paper’s references. From the perspective of firearms educators and users, it forecloses authentic discussion about firearms for military, law enforcement and personal defense. A burlesque analogy would be policy denouncing "cutting into the abdomen."This creates dissonance for those who believe lethal force is sometimes justified. If the ACP concedes this, then some of its recommendations are not well reasoned. Evading realistic perspectives on firearms use opens gaps where evidence and opinion are at odds with some of the ACP’s positions.In particular, neglecting bona fide self-defense is a form of cultural inattentiveness that distorts some of the ACP’s otherwise thoughtful suggestions. In the author’s experience as a firearms instructor, a personal defense fantasy is somewhere in the mind of everyone who purchases a gun or presents for training. The numerical likelihood of a self-defense event is not calculable for any individual, nor is this the chief factor in anyone’ risk assessment. For the vast majority of Americans, some degree of magical thinking—positive or negative—viscerally determines attitudes toward firearms. Negative coloration is detectable in parts of the ACP’s policy.2. The medical profession has a special responsibility to speak out on prevention of firearm-related injuries.This unobjectionable statement hides a vector for bias that immediately follows:Physicians should counsel patients on the risk of having firearms in the home, particularly when children, adolescents, people with dementia, people with mental illnesses, people with substance use disorders, or others who are at increased risk of harming themselves or others are present.This portrays firearms in the home exclusively as a risk, with no allowance for any positive value. It is reminiscent of abstinence-only sex education, which is demonstrably counterproductive and not taken seriously from a public health perspective. It puts firearms owners on the defensive and invites confrontation. Also, it wrongly assumes that physicians are automatically competent to have these conversations.The ACP deserves credit for encouraging “firearm violence prevention” in medical curricula. The problem with this, like physician sex education, is that the curriculum matters. Few medical schools have reached out to resources who can deliver firearms education expertly. No sane policy opposes violence prevention. But, indoctrination from a position of monocular negativity guarantees alienating an audience that is important to reach. Consider this in light of physician sexuality education since the 1970s.Portions of the ACP policy expose gaps in understanding of firearms culture. Lack of cultural competence has been a source of embarrassment for doctors across a spectrum of issues. A better informed perspective among healthcare professionals (particularly in the behavioral sciences) along with relevant factual information on firearms mechanics and operation, could reduce phobias and misinformation while increasing provider credibility. This approach impossible from a curriculum with anti-gun mindset as a core value.The ACP makes a valid case for physicians to discuss firearms risks in a variety of settings. Research is needed to build better scripts and strategies. Suicide, dementia, a spectrum of developmental, cognitive and characterological conditions—and substance use disorders—provide many opportunities to intervene on behalf of patient safety. But, the ACP characterizes this as a free speech issue, which it is not. It is simply a sound practice guideline.3. The ACP supports appropriate regulation of the purchase of legal firearms.This tautology and much that follows presumes current laws are effective. The ACP misses an opportunity here to propose needed reforms. “Background checks” (as currently done) are imperfect and problematic, yet are advocated sometimes with uninformed and unrealistic expectations.a. Sales of firearms should be subject to satisfactory completion of a criminal background check and proof of satisfactory completion of an appropriate educational program on firearms safety.This point comprises two separate, densely packed recommendations that need independent appraisal.Criminal Background Checks at time of sale. The ACP might have examined the National Instant Criminal Background Check System (NICS) more critically. A criminal background check (CBC) is far from an evaluation of fitness for firearms possession. The ACP seems content with the existing elements of BATFE form 4473 (the paperwork that, since 1998, initiates a CBC). But, these are founded on premises that are not entirely sound. Even the fundamental assumption behind a CBC begs the question, “How does criminal conviction figure into firearms risk?” It would be nonsense to say it is irrelevant. But, at the level where the law operates, it is hard to determine how much this factor contributes to objective risk, and how much is social bias.The ACP should have expanded its discussion to transfers, in addition to sales. It could have urged sounder methods for appraising fitness for firearms possession. It might have discriminated more thoughtfully between weapons and use cases that reasonably require little oversight and those that deserve a lot. While the roots of CBC in the justice system are historically understandable, it is disputable that law enforcement auditors are the right experts to evaluate mental status.The ACP’s uncritical endorsements of criminal conviction and “mentally defective” (not a medical term) as lifelong disqualifications fall short as evidence-based conclusions.Proof of Firearms Education. The relationship between education and behavior is complicated. “Firearms education” needs better standardization. Just as firearms curricula are needed for healthcare, there are opportunities for medical experts to contribute to public firearms training. Experience with medical errors and patient safety has refined our understanding of “education” to reflect aspects of cognition, attention, perception, memory, habit, practice and the effects of stress and other impairments. Education is fundamental but not sufficient to create a culture of safety. The ACP might have suggested discussion about standards for instructors, especially for use cases focused on personal defense.Training should be a top priority for everyone who interacts with guns or gun users—or render opinions about gun safety. Effective firearms education not only cultivates knowledge and skill but tends to have a halo effect on judgement. Shooting enthusiasts and armed professionals also know (as physicians do) that skills are perishable; they require refreshment. The ACP could have considered making demonstration of proficiency a part of the qualification for some classes or uses of weapons.Opportunities should be more available for health professionals to become competent to engage in constructive discussions about gun handling, storage and safety. This will not make doctors gun experts or give them standing to craft laws or policies. But, it would be valuable in clinical care.Substance use. The ACP recommends making “substance use records” available to the CBC process. This opens a world of privacy issues that could have counterproductive effects. Past substance use is difficult to extrapolate. Present substance use is logical to consider for firearms qualification, but only as a screening factor. Actual intoxication—particularly with alcohol—is probably a bigger factor in firearms misconduct. The ACP misses an opportunity to recommend how information about alcohol and other substance use should be balanced against other considerations in the evaluation of firearm fitness. While illegal substance use is certainly a marker for potential misconduct, ethical drugs prescribed for psychiatric conditions may be stronger indicators of risk. Does the ACP mean to entrust the evaluation of psychopharmaceutic history to NICS staff?Domestic violence. Conduct labeled “domestic violence” can be associated with serious risk to household members, intimate partners, probably co-workers and perhaps the general public. Among the “red flags” that should provoke investigation into firearms access, this would be one of the brightest. Here again, the ACP seems to consider this a permanent and incurable condition—which may go farther than medical evidence allows.Intervening when firearms are available to people with violent dispositions should be a high priority. But, the point of sale is only one logical time to trigger it. CBC looks at a historical snapshot of risk; this is another of its weakness. Better tools are needed to address dangers that are clear and present. (Extreme Risk Protection Orders are discussed in Section 10.)Waiting periods. Requiring an interval between CBC and taking possession of a new gun is anecdotally supportable for first-time buyers. This could be lifesaving in a small number of cases where a non-gun owner has an impulsive suicidal inspiration. But, makes no sense for buyers who already have firearms available. Evaluating mental status should also be incorporated into settings where guns can be borrowed or rented, where CBC is not done, and waiting periods are infeasible.Legal concealed carry (CC). The ACP raises the important point that more study needs to be made of the effects of armed civilians in public. But, it presents this problem in a simplistically negative light, which does not seriously address the high support for, and prevalence of civilians carrying firearms (concealed and openly) in the U.S. Nor does the ACP call out potential implications for training, certification and demonstration of proficiency. This is an area where CBC has minor utility compared with other assessments that deserve robust discussion.The ACP opposes CC reciprocity among states. This is a negative way of saying what could be framed positively. Many thoughtful gun owners and law enforcement officers favor a national standard for concealed carry licensure with full reciprocity—just not with the current patchwork of standards. The analogy to drivers’ licenses is largely valid, although not entirely. The goal should be uniform standards for fitness and competency. The ACP seems unaware that most states that certify CC licensure do impose training requirements. The problem is how seriously they take them. The ACP could helpfully argue for uniform national credentialing based on meaningful education and training along with appropriate psychological screening and demonstration of proficiency at different skill levels, under the oversight of certified instructors.4. The ACP recommends that guns be subject to consumer product regulations regarding access, safety, and design; it supports tracer elements and identifying markings on ammunition and weapons.These issues are separate. Guns are currently subject to consumer product regulations, so it is not clear what this recommendation is asking to change. Firearms makers, sellers and users all have obvious interests in device safety and quality. These are currently supported by testing and standards development organizations (e.g., SAAMI ) as well as liability law. If the ACP envisions new technologies, they should be reviewed for safety and effectiveness like medical treatments. Currently, there are several bandwagons for mechanical firearms “safety” modifications that are being hyped beyond what they can deliver.Regarding forensic tracing, while a faction among gun owners oppose it on principle, many users find some measures potentially acceptable, if they come without unreasonable costs or burdens. Any solutions need to accommodate or exempt enthusiasts who load their own cartridges.5. Firearm owners should adhere to best practices to reduce the risk of accidental or intentional injuries or deaths from firearms.This phrasing is biased. The purpose of defensive weapons is to create “intentional injuries,” including deaths. A better term might be “misuse.” Ignoring legitimate scenarios for lethal force damages what is otherwise a self-evident proposition. No one is in favor of accidents. The portions of this section that discuss safe storage are nearly self-evident, although storage plans need to be individualized and many physicians are not enough informed to offer safe advice. Firearms experts agree that almost all unintentional injuries result from violating a few basic rules. The question is what role healthcare providers choose to play in promulgating these.6. The College cautions against broadly including those with mental illness in a category of dangerous individuals. Instead, the College recommends that every effort be made to reduce the risk of suicide and violence, through prevention and treatment, by the subset of individuals with mental illness who are at risk of harming themselves or others.The ACP attempts to find reasonable ground without stigmatizing all people with mental illnesses as dangerous, while urging care for the few who may be. This provision is the most problematic in this manifesto, because it reaches into the heart of violence, beyond the limits of current wisdom. Almost everything in this Section is eminently reasonable and extraordinarily difficult. It would be welcome progress for firearms safety to shift from an easy but inadequate focus on hardware, toward the character, temperament, training and fitness of users.7. The College favors enactment of legislation to ban the manufacture, sale, transfer, and subsequent ownership for civilian use of semiautomatic firearms that are designed to increase their rapid killing capacity (often called “assault weapons”) and large-capacity magazines, and retaining the current ban on automatic weapons for civilian use.This item is quoted verbatim, because its language and tone are different from the rest of the Paper. This multifold recommendation is less well reasoned than the preceding; it is argumentative and contains more misconceptions and bias.The ACP seems to understand that the term “assault weapon” is prejudicial. It is undefined and avoided by firearms manufacturers, trainers and knowledgeable owners. Yet, the ACP flouts this term deliberately, despite certainly knowing it is inflammatory and polarizing. While there is a precise definition of “assault rifle” in a military setting, that term refers specifically to a selective fire machine gun (with certain tactical features that have advantages in modern warfare over battle rifles that dominated in WWII). The ACP wrongly states that fully automatic weapons are banned from civilian use (which they are not). In any case, non-automatic (semi-automatic), small caliber rifles with detachable magazines have been best selling long guns in the U.S. since the 1990s. They are weapons of choice among police departments because they balance defensive capability against the risks of collateral damage from other weapons like pistols, shotguns and higher powered rifles. These same reasons recommend them to civilians. It should be acceptable to almost anyone to call them “AR15-style rifles.” The BATF has no way of knowing how many are in circulation or who has them. The NRA estimates 8.5-15 million. This fact in a vacuum does not say anything about the social value of these guns, but it gives a denominator for epidemiological statements about their risks, and a clue to what would be entailed by a national confiscation program.There is no point in trying to calculate the real-world probability of home invasion for any given American. What matters ethically (and legally) is that citizens are allowed to provide for this possibility—whatever it might be—by having firearms in their home that would give them a realistic chance of prevailing in an actual fight. Following the assessments of (and adoption by) police, FBI and military, and other survivors of gunfights, many thoughtful civilians conclude that a lightweight, low caliber, low recoil, controllable, affordable antipersonnel weapon whose ammunition is less likely to over penetrate structures (and targets) than most other firearms, is the best choice. Regarding magazine capacity, tactical experts would advise a defender to plan on having at least as many rounds of ammunition ready at hand as the attackers. The need is to suppress incoming fire for the 8-12 minutes it will take police to arrive, which reasonably falls in the range of 30 rounds. Of course, this scenario is rare and perhaps too detailed for healthcare providers to discuss. But, it is not unrealistic, and the ACP’s policy directly opens this conversation.In taking a categorical stance against AR15-style firearms, the ACP dismisses their history and actual properties and overstates their risks. In contrast to the professional tone of the preceding Sections, the ACP uses here some overexcited rhetoric, “…designed to increase their rapid killing capacity,” that better fits partisan journalism than professional discourse.8. The College supports efforts to improve and modify firearms to make them as safe as possible, including the incorporation of built-in safety devices (such as trigger locks and signals that indicate a gun is loaded). Further research is needed on the development of personalized guns.This section revisits the issues in #4. People unused to firearms often have misconceptions about the usability and effects of mechanical modifications. Some features that promote safety in one scenario can be disastrous in another. Some features that seem theoretically valuable prove unworkable in the field. Familiarity with firearms operation and mechanics helps guide users to weigh appropriate choices.So far, the science fiction notion of personalized weapons remains technologically infeasible. But, there are some scenarios in which many gun owners would welcome devices that make weapons inoperable by unauthorized users. Currently, tactical considerations, serious problems with reliability and concerns about hacking make potential customers wary.9. More research is needed on firearm violence and on intervention and prevention strategies.The ACP rightly pleads for better data on firearm injuries, misconduct and prevention strategies. However, current data from available sources are remarkably poor. It must be repeated that data gazing alone will not directly answer the important questions about how best to reduce adverse events for populations and individuals.10. ACP supports the enactment of extreme risk protection order (ERPO) laws.Legal mechanisms are critically needed to smooth the confiscation of weapons from individuals at risk of harming themselves or others. The input of behavioral experts is needed to ensure due diligence in the adjudication process, as well as police training. One concern is that the proliferation of these laws will foreseeably increase the number of killings by police of people who are in crisis or disabled.ConclusionThe ACP calls for a “multifaceted and comprehensive approach to reducing firearm violence.” This Policy does not quite meet that goal. It contains constructive ideas while perpetuating some misconceptions that need refinement. Its capstone is the rallying cry, “Firearm violence is a public health threat in the United States that must not be allowed to continue.” This is a hyperbolic bumper sticker. If the College understands “firearm violence” to mean “misconduct, misuse and accidents related to firearms,” it would be easy to recruit partners for this mission.References Butkus R, Doherty BA, Bornstein SS. Reducing firearm injuries and deaths in the United States: A position paper from the American College of Physicians. Ann Intern Med. 2018; 169(10):704-707. https://www.ama-assn.org/press-center/press-releases/ama-recommends-new-common-sense-policies-prevent-gun-violence [12/7/18] https://www.aafp.org/about/policies/all/gun-violence.html [12/7/18] https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/Unintentional-Injury-in-State.aspx [12/7/18] Weinberger SE, Hoyt DB, Lawrence HC III, Levin S, Henley DE, Alden ER, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med 2015; 162: 513-6. Dr. Victoroff is a competitive sports shooter and certified NRA instructor in Pistol, Rifle, Shotgun and Personal Protection. In addition to firearms education for the public, he teaches firearms courses for medical and behavioral professionals for suicide reduction and dementia safety. Stanger-Hall KF, Hall DW. Abstinence-only education and teen pregnancy rates: Why we need comprehensive sex education in the U.S. PLoS ONE 6(10): e24658. https://doi.org/10.1371/journal.pone.0024658 Sporting Arms and Ammunition Manufacturers' Institute, https://saami.org/ [12/8/18]/ https://www.mcclatchydc.com/news/nation-world/national/article201882739.html [12/16/18]
The ACP positions agree with several other medical organizations with which they share concerns, as well as some misconceptions and blind spots. Major positive points are appeals for professional education about firearms, for research on ways to mitigate firearms misconduct and accidents, and development of strategies to reduce suicide and firearm-related misconduct. Major shortcomings are disproportionate support for regulations based on hardware rather than human risk factors; acceptance of existing criminal background checks that are deeply flawed and insufficient; bias against bona fide defensive firearm use; cultural insensitivity to concerns of firearms owners; missed opportunities to advocate for improvements in risk assessment, counseling and provider training; and poorly reasoned opposition to some weapon configurations that are widely favored for home defense by firearms experts. The paper’s recommendations could be improved and its credibility enhanced, by refining its understandings and analysis of the issues it addresses.
Renee Butkus, BA; Robert Doherty, BA; Sue S. Bornstein, MD
American College of Physicians
January 24, 2019
With 63 references in this policy update and 142 in the original paper, we respectfully disagree with Dr. Victoroff that our recommendations are not supported by the evidence on the effectiveness of different policies to reduce injuries and deaths from firearms. We acknowledge that the evidence is limited in some cases, due in part to congressional restrictions on, and lack of dedicated funding for, firearm violence research by the Centers for Disease Control and Prevention and other federal agencies. We have urged that Congress allocate such funding, and ACP also has affiliated with AFFIRM, a non-profit organization comprised of healthcare leaders and researchers who seek to end the epidemic of firearm violence through research, innovation and evidence-based practice. Yet the need for additional research should not be used as a rationale for inaction on policy interventions that, based on the best available evidence, are likely to be effective in reducing firearm violence. As you acknowledged, a policy paper and the evidence used to support positions is different from a clinical guideline.We stand by our view that firearm violence—and yes, that is the correct term, when nearly 100,000 persons are killed or injured by firearms each year in the United States, from suicides and attempted suicides, and from intentional and negligent/accidental shootings—is a public health crisis. With regard to the self-defense benefits of firearms, in the 2014 paper, we presented several studies that helped us conclude that access to firearms increase the likelihood of injuries and deaths and outweigh the beneficial effects of defensive gun use, especially when at-risk persons are present (such as children and adolescents, persons with substance use disorders and certain mental health conditions like major depression, and persons with dementia). The evidence cited in our paper shows that women in particular are at greater risk of injury and deaths when firearms are present in a home. While individual adults have a constitutional right to have firearms in their homes for self-defensive purposes, we believe that the potential risks of keeping firearms in the home versus their potential self-defense benefits should be objectively presented and considered, just like any other known health risk factors. Should a person choose to have a firearms and ammunition in the home, as is their right, we assert that they have an obligation to store them safely, securely, and separately, to reduce the risk of deaths and injuries associated with negligent storage, and child protection laws should be enacted to require such safe storage. We believe that the evidence shows such laws and best storage practices, combined with physicians asking and counseling at-risk patients about guns in the home as recommended by the editors of the Annals of Internal Medicine, can save lives. Effective public health interventions usually involve a combination of public education, clinical interventions, research, and public policy responses, as has been the case in the public health responses to reducing the health risks of tobacco use, excessive drinking of alcoholic beverages, the opioids use crisis, and substance-impaired driving. We believe these can be informative in developing a public health response to reduce injuries and deaths from firearms, without violating second amendment rights.Dr. Victoroff, in conclusion, we appreciate that you took the time to write a comprehensive review of our paper, explaining why you take issue with much of our analysis and recommendations, in a respectful and collegial manner. While we are encouraged that you have a genuine interest in wanting to find approaches to reducing “misconduct, misuse and accidents related to firearms” we are puzzled because most of our recommendations are intended to accomplish this, from requiring safe storage of guns and ammunition, to closing loopholes that allow some domestic violence offenders to obtain guns, to requiring background checks for all gun sales and transactions, to enacting extreme risk prevention laws to temporarily remove firearms and ammunition from persons found by a judge to be at immediate risk of using them to harm themselves or others--with due process, to conducting research on ways to make guns safer—all of which is supported by our comprehensive review of the evidence and the dozens of citations cited in the paper. 1. Laine C, Taichman DB. The Health Care Professional's Pledge: Protecting Our Patients From Firearm Injury. Ann Intern Med. ;167:892–893. doi: 10.7326/M17-2714
We thank Dr. Franke for his comment. The College supports efforts to improve and modify firearms to make them as safe as possible. Personalized or “smart gun” technology was included under the rationale for position 8, a position that was reaffirmed from the 2014 paper. At the time we determined that further research was needed on the development of personalized guns though we do support any effort to make firearms as safe as possible. The discussion can be found here http://annals.org/aim/fullarticle/1860325/reducing-firearm-related-injuries-deaths-united-states-executive-summary-policyWe thank Dr. Webster for his comment. We have not taken a position on gun registration but will consider doing so in a future update. With regard to the ACP Services PAC it is important to note that the American College of Physicians and ACP Services, Inc. are two separate organizations. ACP is designated by the IRS as a 501(c)3 entity, while its sister organization, the American College of Physicians Services is designated as a 501(c)6. Because of its c3 tax status as a charitable organization, the American College of Physicians is prohibited by law from operating a Political Action Committee (PAC).No portion of ACP member dues goes to support the ACP Services PAC’s contributions to political candidates. Rather, the ACP Services PAC is supported by voluntary contributions from ACP Services members who choose to support it. Our understanding is that the ACP Services PAC board decides which candidates will get its support, and a variety of issues and criteria are used. More information about ACP Services, Inc, and the ACP Services PAC, can be found on the Services website, https://www.acpservices.org/.
Butkus R, Doherty R, Bornstein SS, for the Health and Public Policy Committee of the American College of Physicians. Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians. Ann Intern Med. [Epub ahead of print 30 October 2018]169:704–707. doi: 10.7326/M18-1530
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Published: Ann Intern Med. 2018;169(10):704-707.
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