WHAT SHOULD WE TELL OUR PATIENTS ABOUT GUNS?

WHAT SHOULD WE TELL OUR PATIENTS ABOUT GUNS?

What Should We Tell Our Patients About Guns?
A Psychiatric Examination of Medical Decision Making

--William B. Rogers, MD
Doctors for Sensible Gun Laws
http://www.DSGL.org

ABSTRACT
A practicing psychiatrist and former medical director of Community Mental Health and Mental Retardation clinics in East Texas uses the principles of medical decision making learned from his participation in the Texas Medical Algorithm Project (TMAP) to explore and clarify the controversies that have arisen from a star crossed attempt at using a medical/disease model to study the contemporary presence and use of firearms in the United States. The principles of data-driven, medical decision making have failed to resolve serious questions as to whether firearms constitute a public health menace. Epistemology and systems theory are used to examine how physicians do what they do. Has "real science" failed to serve, or have the principles of that discipline been abandoned? How does the physicians' "personal experience" enter into the process? When should a "consensus conference" be used to bring the varying perspectives of the medical community into a respectful dialogue? Are there traditions in the field of medicine for honorable men (and women) to agree to disagree? What role should experts in firearms and firearms injuries play in the dialogue? What would failure to reach a consensus portend for a society that respects the opinions of its physicians?

Introduction to Epistemology
Epistemology is defined in Webster's Dictionary as: "The theory of the ground of knowledge." In the vernacular, epistemology might be thought of as the study of how we know what we know. It is a subject that not many people think about very much after Philosophy 101, but in medicine in general and psychiatry in specific, one cannot not think about it.
Knowledge might be gained by simply taking for granted what one has been told by an authority figure. To inquire how the authority figure got to be one places the student back into the world of epistemology. There is no escape by that route. In fact, the problem is made much worse in that authority is often conferred upon the person or group with the most power. The sequestration and use of power among people is the foundation of politics. It is interesting that an exploration in search of the roots of knowledge turns very quickly into a study of politics. It is perhaps axiomatic that when there is a search for knowledge, the politician is not far away.
Knowledge, though, cannot be synonymous with power or the political process. If it were, then facts, the repeatedly observable quanta of knowledge, would forever be shifting as the sources and demands of power shifted. In Western culture, proper knowledge is thought to be above such arbitrary shifts in power. Facts should remain factual regardless of who is running the show. *

The Scientific Method
In the mid to late 18th century, a methodology of investigation came to be established which is now known as "the scientific method." This methodology has suffered many brutal attacks as it has matured over hundreds of years. Seekers of political power have repeatedly attempted to co-opt the method to the support of their own power bases. Still, the scientific method, or Science, has endured, and today it is a worldwide (if not universal) method of organizing observable facts into useful information. We practitioners of modern medicine take pride in declaring that our knowledge is validated by the scientific method. Lest we become complacent and forgetful of the component parts of this epistemological jewel, a periodic review of the scientific method is always appropriate.
First, the method calls for an observation of a phenomenon. That sounds rather simple, but no less an icon of modern medicine than Sir William Osler has said,
"There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language." [1]
An observation, or more often, a series of observations are studied until a hypothesis can be formed. Turning again to Webster's Dictionary, we find that a hypothesis is "a supposition; something not proved, but assumed for the purpose of argument; a theory imagined or assumed to account for what is not understood." A hypothesis is based on a functional understanding of what the observations may be used to predict.
Thirdly, the scientific method calls for a series of experiments to determine the validity of the hypothesis. An experiment is an exercise in which a series of events (reproducing the previously observed phenomena) are allowed to systematically unfold until a predicted outcome is reliably and repeatedly achieved. Once the experimenters, or scientists, are satisfied that the unfolding events reliably and repeatedly produce the predicted outcome regardless of who sets it up and runs it, the actual experiment can begin. The experiment will consist of systematically removing or altering a step in the unfolding events to determine the role that particular event plays in the reproduction of the now established outcome. Each event in the process will be found to play an important or negligible role in producing the outcome. The validity of that event to the actual outcome is established. The experimental process can also be used to determine how a particular outcome can be changed by varying the events that produce it. Again, the innate value of the experiment is in discovering how outcomes are produced, and how a controlled and predictable change of an outcome can be made to occur by intentionally altering the phenomena that bring it about.
This review of the scientific method illustrates its inherent value to the politician. Being able to accurately predict the outcome of social processes is critical to the establishment and maintenance of power. Even more important to political power is the ability to make a change in the outcome of a social process by altering the events that bring it about and to do so with purpose and impunity. **

Evidence-Based Medicine
Evidence-based medicine might be thought of as the emergence of scientifically validated algorithms (decision trees) to replace the "intuitive guess" of the "artist" as a standard for the contemporary medical decision making process. The gradual introduction of EBM has been resisted by many practicing physicians as being "cookbook medicine" that is thought to be too highly controllable by third party payers. The first "practice guidelines" were indeed introduced by third party payers who based their algorithms on financial bottom lines to the insurance companies. This was done because there were few if any "clinical outcomes" studies upon which to validate the steps of a treatment process. Contemporary medicine slipped into captivity for the lack of knowledge. It is perhaps only now emerging from that captivity as EBM - based on clinical outcomes - takes hold.
EBM requires somewhat of a paradigm shift in medical decision making. In psychiatry we are finding the shift to be from a system of reflexive decision making (often euphemistically referred to as "the art of medicine") to one requiring adherence to standardized definitions, universally recognized diagnostic criteria, and agreed upon treatment methodologies. In short, EBM is more labor intensive for the practicing psychiatrist. The recent introduction of invaluably helpful decision-making tools such as data-driven and well-tested algorithms and automated manipulation of large databases are beginning to make the endeavor less burdensome.
Most importantly, the arrival of carefully obtained outcomes data is beginning to demonstrate that EBM is very beneficial to our patients, their families, and to the efficient management of clinics where resources are constantly in short supply. [2]

Beyond EBM: Four Sources of Data [3]
It was my great privilege to spend two years in helping (in an admittedly small way) to design and run the Texas Medical Algorithm Project. We called it "TMAP-The Mother of All Projects." By the time we were through, patients and professionals from community mental health centers, state psychiatric hospitals, and state prison facilities all over Texas had created, tested, redesigned, re-tested, and finally finished developing evidence-based, clinical outcome oriented treatment algorithms for the Schizophrenias, the Bipolar Disorders, and the Major Depressive Disorders. As part of the designing of the initial algorithms, consensus conferences were held. A process emerged in which working groups of psychiatric professionals from all over the United States first reviewed the available literature on one of the selected pathologies. Many of us were frankly amazed at how very little "good science" existed to support what we had thought was the best way to treat particular illnesses.
In an article in Psychiatric News, Tim Peterson, Ph.D., a clinical instructor in psychology at Harvard Medical School and a researcher at the Depression Clinical and Research Program at Massachusetts General Hospital, described four sources of data used by prescribing physicians in deciding which psychotropic medication to prescribe for which patient and which illness. Dr. Peterson and his colleagues found that physicians rely on:
1. accepted scientific knowledge
2. patient context
3. situational context
4. own personal experience. [4]

Two Opposing Theories
Members of the medical profession are appropriately interested in what they can do to help reduce injuries caused by the illegal or accidental discharge of a firearm. Every physician educated in the United States has served time in the emergency room of an urban hospital. There is not a physician practicing in the entire country that has not seen only too vividly the kind of damage caused when a bullet bursts through human flesh.
A review of the medical literature produces peer reviewed journal articles by Kellerman and Reay in the NEJM in 1986 [5] (with a reprisal by Kellerman, Rivara, and Rushforth in the NEJM in 1993 [6] ) and Koop and Lundberg in JAMA in 1992 [7] offering data and analyses in support of an idea which was eventually seized upon by the Centers for Disease Control in an effort to define firearms violence as a public health problem and the presence of firearms in the United States as a vector for the problem.
This model is a very familiar one to physicians. A problem is remedied by removing the vector. Want to stop the plague? Get rid of the rats. Want to stop gun violence? Get rid of the guns.
In the spirit of K-I-S-S (keep it simple, stupid), organized medicine has announced loudly and publicly that the uncontrolled, private ownership of firearms must be curtailed if the "epidemic" of firearms related violence is to be contained.
But, there is a problem in this politically active paradise. Not all physicians agree with the proposal for a solution, and they certainly don't agree with the science (or what is purported to be science) in the early and subsequent research published in many of the mainstream medical journals. These concerned physicians, who also worked in those inner-city emergency rooms and who would also like to help curtail the morbidity and mortality of gunshot wounds just as much as their brothers in the "guns as public health menace" camp, have produced a body of literature with a plethora of data taken mostly from the disciplines of sociology and criminology. As this "counter movement" gained momentum, highly credentialed researchers among the criminologists and sociologists joined forces with the physicians in a scientific endeavor to examine the role of the presence of firearms as a "cause" for firearms injuries. The research wasn't politically correct, and it got very little mainstream media attention or funding, but it did proceed, and gradually the body of literature has grown and been published in books, law reviews, sociological journals, and selected medical journals. Several highly respected scientists from the non-medical fields started the work with admissions of personal biases against the uncontrolled presence of firearms in our society. These men were strong enough in their pursuits of pure science to change their views as the research continued and the literature matured and the data proved their initial biases to be incorrect and non-defendable. [8] These physicians and criminologists and sociologists are now not only convinced that firearms in and of themselves are not harmful, but that the presence of firearms may well produce a stabilizing effect on many of the communities they have studied. [9]
When two diametrically opposite theories emerge with respect to a single vibrant issue, a spirit of competition will arise. Not only would we expect each "side" to produce and defend its literature, but we would also expect each side to attempt to seek out and demonstrate flaws in the methodologies of the other. [10] We would, in fact, be disappointed if such a contest did not arise. Certainly we would want the two sides to be professional, to be as courteous as possible, and to focus their attacks on the issues and not the persons or motivations of their opponents. In the spirit of the scientific method, we would expect both sides to formulate reasonable hypotheses based on their observations, and we would expect them both to do experiments to validate their hypotheses, and to ultimately help us make useful information out of their mountains of data.
We might want all of this, but to date, we would be sorely disappointed.

Two Opposing Theories: Point-Counterpoint
For the purposes of comparison and contrast, we might divide the two opposing theories into "Guns Take Lives" and "Guns Save Lives." The following are personal observations made by the author over the past 10 years and are not the result formal, empirically validated study.


GUNS TAKE LIVES
This group bases its arguments on selected medical data that have been vigorously, and to the satisfaction of many of the opposing party, successfully attacked and refuted. The lack of this group's ability or willingness to defend their position (accept for much unwarranted and non-professional ad hominem retorts) has been disheartening, and serves well to attract increasing and positive attention to their opponents. This group is characterized by urban dwellers who have no training in the use of firearms and who are prone to admit that they are "afraid of guns and wouldn't want to be anywhere near one." Their position is quite politically correct. They get considerable time and attention from the mainstream media. They tend to congregate with the political Left and to be members of the Democratic Party.
The members of this group believe that ready access to firearms "causes" an increase in violent crime. They are convinced that the presence of a firearm in a home places the occupants of that home at higher risk for violence, and they are either unaware of the refutation of the early research that gave rise to that claim or they choose not to believe it and cannot or will not publicly debate the issue without resorting to ad hominem attacks upon their adversaries.


GUNS SAVE LIVES
This group is supported by data and literature from the fields of law, criminology, and sociology. The opposition rarely acknowledges their work.
To find their literature, the reader must search outside the mainstream medical literature. The view supported by this group is more prevalent in suburban and rural locations than in the cities. These people tend to own firearms and know how to use them in sporting, competitive, and trained combat situations. The growing numbers of licensed concealed handgun carriers are virtually all members of this group. Their views are considered quite politically incorrect. They rarely get mentioned in the mainstream media, and despite the fact that they have good data demonstrating millions of successful uses of firearms annually to prevent violent crimes, it is nearly impossible to find the reporting of such phenomena on network television news or in the urban-based newspapers. These people tend to congregate with the political Right and to be members of the Republican or Libertarian Parties.
The members of this group have massive amounts of data demonstrating a decrease in violent crimes in communities where "shall issue" concealed carry law has been passed. They point to examples in England, Australia and Washington DC to demonstrate a statistically significant increase in violent crime when severe gun control or gun confiscation is adopted. They are convinced by their data that privately owned firearms are used to deter or prevent millions of potentially violent crimes annually (and that in over 80% of such situations the firearm needs only to be brandished and not actually fired).

Four Sources of Data Considered
Recall that there are four sources of data available for the clinician in deciding which therapeutic modality to use (accepted scientific knowledge, patient context, situational context, and personal experience). In psychiatry a psychosocial intervention is considered to be part of the clinician's therapeutic armamentarium. We will now investigate issues related to the clinician's four sources of data as he or she attempts to discuss firearms with a patient.

Accepted Scientific Knowledge
It should now be apparent that "science" does not have very much to offer the clinician. There are two opposing theoretical positions, both with mountains of data and literature. There have been no adequately conducted "consensus conferences" (see below) and a mutually beneficial, adversarial struggle has not been joined. Physicians enthusiastic about the theoretical position of one group or the other tend not to be aware of the arguments posed by the opposition, and the mainstream media does not give equal and balanced information from both schools. Thus most physicians are ill informed of the complexities and nuances of the issues related to firearms. Recommendations offered to the memberships of various medical societies and organizations in the name of science are spurious and one sided. They must continue to be seen as such until the organizations and societies take the two theoretical viewpoints seriously and encourage consensus conferences and respectful debates between the groups.
Sir William Osler said,
"The [Medical] societies should be a school in which the scholars teach each other." [11]
At the American Society of Criminology's meeting in 1994, University of Illinois sociologist David Bordua and epidemiologist David Cowan called the public health literature on firearms "advocacy based on political beliefs rather than scientific fact." [12]
Medical societies including the American Psychiatric Association, the American Medical Association, the American College of Emergency Physicians, and the American Academy of Pediatrics have done a great disservice to their members and to their patients by failing to encourage an open, dispassionate, respectful dialogue among colleagues with differing viewpoints.
Consider further the wisdom of Sir William Osler who said:
"Let not your ear hear the sound of your voice raised in unkind criticism or ridicule or condemnation of a brother physician." [13]

"The greater the IGNORANCE, the greater the DOGMATISM." [14]

"Never let your tongue say a slighting word of a colleague." [15]

"Remember how much you do not know. Do not pour strange medicines into your patients." [16]

"Full knowledge, which alone disperses the mists of ignorance, can only be obtained by travel or by a thorough acquaintance with the literature of the different countries." [17]

Patient and Situational Context
Consider two cases both of whom are patients in your practice:
The first is a woman being stalked by an ex-lover who has vowed to kill her if she won't reconcile with him. She is terrified of him. He has beaten her before. She is personally firearms "naïve." She has never owned a gun and finds herself frightened of them. She is afraid to have one in her home because she read in a magazine that doing so will put her and her child at higher risk of being a victim of violence their own home.

The second is a woman being stalked by an ex-lover who has vowed to kill her if she won't reconcile with him. She is appropriately concerned and takes his threats seriously. She knows he can be quite violent and cannot be reasoned with when he gets that way. The police have advised that she get a restraining order, but she knows that will not deter her ex for one moment. She grew up in the rural Southern United States. Her father and her brothers were all hunters and handled firearms from their early teenaged years. They taught her to shoot a .22 rifle when she was 11 y/o. One of her brothers is a career Gunnery Sgt in the USMC. She owns a nine mm semi-automatic pistol. She is a graduate of 3 police sponsored combat-defensive pistol courses, AND she has a concealed handgun license in her current home state of Texas. She placed second in the NRA city-wide competition for pistol shooting in her hometown last year.
Both of your patients have asked you the same question:
Doctor, do you think under the circumstances that I will be safer with a gun in my home or without a gun in my home?

Considering your assessment of the patient context and the social context, how would you answer your patients' questions?
1. Are you confident in your ability to assess the mental status of your patient?
2. Have you been trained to assess the patient's potential for suicide under the obvious pressure that she finds herself?
3. Have you been trained to assess her potential for becoming psychotic under this stress?
4. Are you prepared to do a complete social assessment to determine what kind of neighborhood she lives in, whether she has helpful neighbors, whether she has active telephone service with cell phone backup, what her work schedule is (walking across dark parking lots late at night)?
5. Do you know anything about the kind of experience and training she has or doesn't have with respect to self-defense and the use of a firearm?
6. Do you know anything about the kind of firearm she owns or is planning to purchase?
7. What has your medical specialty society advised you to say to your patients about having firearms in the home?

Personal Experience
When physicians attempt to give advice or do counseling in an area in which they are not thoroughly trained and if they give advice or do counseling without having ever done so while actively under the supervision of a senior teaching physician who could work with them on the content and the technique of their advice and counseling, they are quite likely to have their behavior driven by counter transference. (Counter transference is a psychological mechanism that induces behavior based on one's own unexplored and unresolved areas of personal, psychological conflict. It eliminates the ability of an individual to be objective, dispassionate and even handed in the forming of an opinion or the performance of a task.)
It would seem intuitively obvious that the more trained a physician is in the safe and effective use of firearms, the more likely he or she would be able to assess firearms issues with a patient. (This would make a great research project. Where are the graduate students when we need them?)

What Physician Shooting Enthusiasts Want From the AMA…
Timothy Wheeler, MD is an internist who has worked with the Claremont Institute to establish an organization called "Doctors for Responsible Gun Ownership." In a letter to the AMA published in the April 8, 2002 AMNews, Dr. Wheeler lists the following things that he thinks "gun owners" (including many physicians) want from the AMA. [18] Dr. Wheeler's list and commentary follow:
What can our AMA leaders do to improve relations with gun owners?

1. Accept that we gun owners are not a public health hazard. Those who misuse firearms are a tiny minority. Visit any organized shooting sport activity and you will see a dedication to safety that any physician would comfortable with.
2. Start taking seriously the opinions of experts on firearms injuries - the criminologists. There are 25 years of research data that confirm the safety and social good of the average American gun owner. But medical journals have ignored it, instead jumping on the gun control bandwagon.
3. Call up the National Rifle Association's Safety and Training Division. Ask its experts to work with you in reducing gun injuries. The NRA has been teaching gun safety for 130 years. Can our AMA afford NOT to partner with such a useful resource?
4. Give up the quest to identify a class of bad guns. When we lend our scientific authority to buzzwords like assault weapon, pocket rocket, and junk gun, we damage our own credibility. Any category of guns we demonize will include high-quality firearms used by civilians and police for decades.
5. Lighten up on the rhetoric. Yes, there are still too many gun deaths and injuries. But it's hard to argue that we have an epidemic. Fatal gun accidents have been steadily decreasing for 70 years, according to the National Safety Council. The Centers for Disease Control and Prevention tells us all gun deaths dropped by more than 25% during the 1990s. Gun ownership has been a part of American life since colonial times, and it's not likely to disappear anytime soon. so let's welcome gun owners as knowledgeable allies in our effort to reduce gun injuries.
The Consensus Conference
When the leadership among our colleagues on both sides of the issue (Guns Take Lives vs. Guns Save Lives) come to their senses and decide to again become physicians attempting to practice evidence-based medicine, we will most likely see the emergence of some exciting and productive consensus conferences hosted by medical societies and universities.
A consensus conference is appropriate when:
1. acceptable scientific knowledge cannot establish a data-driven algorithm for medical decision making.
2. patient and social contextual data are not clearly defined, or are being obtained by individuals who are not trained in the gathering or use of the required information.
3. personal experience is excessively variable and when there is no knowledge of what the appropriate level and content of personal experience should be to allow for safe assessment and the giving of advice.
4. further rational and prospective studies are being planned.
A properly conducted consensus conference will invite ALL STAKEHOLDERS to the table. For firearms issues, this should include:
1. people who like guns and people who do not like guns.
2. The Academy, the Playing field, and the Street. That is, university professors of the various stakeholding disciplines, sports enthusiasts, and people with practical knowledge will sit down with their opposite numbers to explore issues, try to agree on what the relevant questions are that need to be asked, and try to agree on methods that will be used to obtain the answers to those questions.
3. The political Left and the political Right, if - and only if - they can suspend their quest for political power and participate in an honest, open, dispassionate dialogue while maintaining a sense of respect for colleagues who hold differing opinions.
American Medical Association President, Richard F. Corlin, MD, has written about having an initial consensus conference for planning the AMA position on firearms issues, research and policy. Dr. Colin has demonstrated great wisdom, and the refreshing attitude of a physician seeking the solution to a difficult problem while faced with oppositional theories that he doesn't personally know enough to evaluate.
Dr. Corlin's letter in the December 17, 2001, AMNews should be read carefully by physicians in both of the opposing camps. Who knows? With this kind of attitudinal shift, we may someday see more than just 1/3 of USA physicians enrolled in the AMA. As for now, it seems that the doctors are staying away in droves!
In Summary: What Should We Tell Our Patients About Guns?
First, we should be honest and tell our patients that legitimate medical science cannot currently help us. On the other hand, the disciplines of criminology and sociology seem to have good data and interesting and perhaps helpful literature.
Secondly, we need to realize that patient and social contextual data can be helpful, if the individual physician is trained in gathering the information and making sense out of it. Most physicians are not trained in this, and they would be engaging in malpractice if they attempted to represent themselves as trained and able to do it.
Ultimately, with the current abysmal state of our scientifically valid knowledge, most physicians will find themselves relying on their own personal experiences with people and with firearms. Physicians detest those three awful words:
"I Don't Know."
And yet, that is what a lot of us are going to have to say when our patients ask us about firearms issues.

References:
1. Osler W. "On the Educational Value of the Medical Society." p. 278. Taken from Counsels and Ideals from the Writings of William Osler printed privately for members of the Classics of Medicine Library, Birmingham, 1985.
2. Ransack J. "Evidence-Based Medicine Aims to Improve Patient Care." Psychiatric News, June 15, 2001. p. 17.
3. Ransack J. "MDs Go Beyond Data In Choosing Medications." Psychiatric News, February 1, 2002. p.4.
4. An abstract of "A Survey of Prescribing Practices in the Treatment of Depression" is available on the Web through www.sciencedirect.com.
5. Kellerman AL. and Reay DT. "Protection or Peril? An Analysis of Firearms-Related Deaths in the Home." NEJM 1986. 314: 1557-60.
6. Kellerman AL, Rivara FP, Rushforth NB et al. "Gun ownership as a risk factor for homicide in the home." NEJM. 1993; 329(15): 1084-91.
7. Koop CE, Lundberg GD. "Violence in America: A Public Health Emergency." JAMA. 1992; 267: 3075-76.
8. Keck G. Point Blank: Guns and Violence in America. New York: Aldine de Bruited. 1991. (Intro and review of Keck's work is available on the Web at: http://www.guncite.com/gcwhoGK.html )
9. Lott JR. Mustard DB. "Crime, Deterrence, and Right-to-Carry Concealed Handguns," 26 J.LEGAL STUD. 1,4 (1997).
10. Sutter E. "Guns in the medical Literature: A Failure of Peer Review." Journal of the Medical Assn of Georgia, 83 (13). (Also available in its entirety with exhaustive references on the Web at: http://rkba.org/research/suter/med-lit.html?suter#first_hit. )
11. Osler W. "On the Educational Value of the Medical Society." p. 277. Taken from Counsels and Ideals from the Writings of William Osler printed privately for members of the Classics of Medicine Library, Birmingham, 1985.
12. Kats DB, Schaffer HE, Waters WB. "How the CDC Succumbed to the Gun Epidemic." Reason Magazine, April 1997. On the Web at: http://reason.com/9704/fe.cdc.shtml .
13. Osler W. "Osler, the Teacher." p.199. Counsels and Ideals….
14. Osler W. "Chauvinism in Medicine." p. 300. Counsels and Ideals…
15. Osler W. "Osler, the Teacher." p. 199. Counsels and Ideals…
16. Ibid. p. 199.
17. Osler W. "Chauvinism n Medicine." p. 287. Counsels and Ideals…
18. Wheeler T. "What gun owners want from the AMA." AMNews. April 8, 2002. (Doctors for Responsible Gun Ownership is on the Web at: http://www.claremont.org/1_drgo.cfm. )
* Only a psychotic individual (or perhaps a psychopathic scoundrel) would take refuge in an attempt to redefine the meaning of "is." We don't use those particular terms when a group in power makes such an arbitrary shift in such a basic verb. Such a power-based movement would be referred to as a "tyranny."
** In the ancient Hebrew scripture, the prophet Isaiah asks the Lord why the Children of Israel are being carried away into exile by the Babylonians. In the Book of Isaiah Chapter 5, Verse 13, The Lord answers: "...My people are gone into captivity because they have no knowledge."