Monday, December 17, 2012

The Horrific Newtown Shooting and the Inconvenient Facts About Gun Control, Mental Illness and How the Physician Community Should Respond

Like millions of other Americans, the Disease Management Care Blog was transfixed by Mr. Obama's comments at last night's Newtown vigil.  The President passionately spoke for and to the nation in a time of heartbreaking grief.  Well done, sir.

Then reality set in. 

Unfortunately, there are a number of inconvenient truths that are more than a match for President's considerable intelligence and persuasive rhetoric. 

To wit:

1) First some perspective: Schools are extraordinarily safe with a suicide/homicide rate of one death per 2.5 million (see page 6). All in all, a child is still far more likely to be injured on the way to school or in their home pool than on our nation's school grounds.

2) Been there, done that: according to this classic MMWR report, the evidence that restricting access firearms improves community-based outcomes is inconsistent.

3) Soft target: And then there is the disturbing possibility that armed killers, with little to fear from metal detectors or sign-in policies, purposely choose gun-free zones like schools. 

In the meantime, the DMB's physician colleagues are renewing calls for firearm ownership screening and education at the point of care.  To their credit there is good evidence that it helps....


1) While there are two sides to every story, law abiding and constitutionally protected gun-owning parents may feel they are being unfairly bullied by a well-meaning physician.

2) When pediatricians are confronted by adults who are unwilling to consent to their child's immunization recommendations, the "difference in philosophy" may lead to a termination of the doctor-patient relationship. The same happened to this patient because of her weight. Are gun owners next?  And after them?

3) What happens if firearm-screening bubbles up into a 6th vital sign (the 5th one didn't work out so well) or physician pay-for-performance (with gaming could alienate the very patients it's designed to help?).

4) No corner of health care delivery is immune from the mischief of electronic health records (EHRs) and gun control is no exception.  Should gun owners be concerned that a) millions of unintended data breaches or b) government "background checks" of health information exchanges could increase their vulnerability?

And then there is the thorny issue of mental illness.

1. The majority of patients are still concerned about the release of any of their medical information.  Behavioral medicine providers are too.

2. We can not only use computer based algorithms to assess the quality of life for persons with mental illness, but predict a likelihood of community violence. Should either be made available to law enforcement?

3. Last but not least, us docs can issue and reissue impotent position statements all we like. but the mental health system is failing: we are all Adam Lanza's mother.

DMCB take-aways:

The DMCB has seen the President confidently direct his considerable rhetorical skills at topics like global warming and war in the Middle East.  While Mr. Obama is well-meaning, guns may similarly be beyond his political skills, especially because he's a 2nd termer with limited political capital. 

While Newtown has shocked the conscience of a nation, the DMCB is not holding its breath.

That doesn't mean America's docs can't be of assistance.  In addition to dusting off, recycling and renewing their current policies, physicians need to keep things in perspective and

a) lead the discussion on the use of predictive modeling to identify potentially violent patients. How do we reconcile the privacy rights of persons with mental illness with a constitutionally broad right to bear firearms?  If we remain silent on this, the lawyers will decide and it won't be pretty.

b) confront the possibility that the EHR is a threat to gunowners.  If not, explain why it wouldn't be cross-referenced with firearm licensing, pharmacy records or used to perform background checks?

c) advocate for fixing the mental health system so that parents who are struggling with a deeply disturbed child can get the help they need.

Image from Wikipedia


Jeff said...

I can certainly see the knee-jerk reaction by many to this horrific tragedy by calling for "gun control". As a responsible gun owner, I cringe to think of how the politicians will abide by their adage of "never let a good crisis go to waste".

You have rationally presented this in practical terms (unlike the physician blogger this weekend who called all gun owners sociopaths).

As the Sandy Hook shootings are still sinking in, perspective is not easy for many to obtain. As solutions are sought, they must be crafted from a practical, and not emotional perspective.

We see that "drug-free" school zones provide those with authority a false sense of security, and politicians a means of making it appear that they have done something to address the drug problem. Yet drug availability is MUCH higher in schools these days than when I went to school in the 70's. The same goes for gun free zones. The 2 only provide PENALTIES to those who violate these zones, and do nothing to prevent gun and drug crimes.

With the possibility of a single-payer (government) health care system in the future (and thus government access to medical records), documenting firearms in the chart would not sit well with many gun owners. I wonder how many would answer the question of gun ownership truthfully? (just as I wonder how many now answer the question of tobacco use truthfully). Having worked in Peds for many years, I think it's reasonable to mention gun safety to ALL parents as anticipatory guidance.

I am of the belief that Sandy Hook is a Black Swan event-random and unpredictable. Unfortunately, this is difficult to stop, although we can put measures in place to minimize the effects of such incident.

Andrew Jackson said...

The whole thing is a tragedy, but gun control is not the answer. I have two school aged children, and I have never owned a gun before. I was kind of against it, but seeing the faces of those children has made me change my mind. I'm looking at getting a gun. They now make a handgun that will not fire unless the owner is holding the gun. Which eliminates the fear of my kids accidentally using the weapon on themselves, as well as if an intruder gets the gun it cant be used on me or my family.