Physicians Are Steering the Conversation About Gun Violence


The NRA’s response in November to the American College of Physicians’ newly published position paper on reducing firearm injuries and deaths—tweeted just hours before a gunman killed 12 people at a California country music bar—was blunt:

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“Someone should tell self-important anti-gun doctors to stay in their lane.”

That tweet galvanized the medical community. The hashtags #ThisIsMyLane and #ThisIsOurLane began to trend on Twitter. And less than a month after the Twitter feed @ThisIsOurLane was created, it had more than 27 000 followers.

Megan Ranney, MD, MPH, is one of the leading voices in the “This Is Our Lane” movement, whose supporters emphasize the need for scientists, physicians, and other health care professionals to tackle gun violence the way they would any other deadly epidemic: with well-funded, thoughtful research to assess its magnitude, identify risk factors, and improve prevention and treatment.

Dr Ranney, an emergency physician and researcher at Brown University, is the chief research officer for AFFIRM, the American Foundation for Firearm Injury Reduction in Medicine, a new nonprofit supported by a number of medical professional organizations, including the American Medical Association.

She spoke with JAMA about why firearm violence is a public health problem and how physicians can be a part of the solution. The following is an edited version of that conversation.

JAMA:Gun violence, including some highly publicized mass shootings, has been a problem in the United States for decades, but that NRA tweet November 7 seems to have galvanized the medical community. Why?

Dr Ranney:Gun violence is an American epidemic, and it’s been an issue that many of us have been working on behind the scenes for years. I think what we saw after the NRA tweet was partly a response to the outrageousness of the assertion, but it also reflected the hard work that a lot of folks have been doing over the years to try to develop a coherent public health approach to this issue.

JAMA:How much has the current political climate been a factor in galvanizing physicians?

Dr Ranney:One of the things that strikes me most about the physician response to this topic is how nonpolitical it is. For most physicians and other health care professionals, gun violence is not an issue of politics. It’s an issue of human lives. What I’ve seen in the response in our community is an insistence that this needs to come back to the patients’ stories.

JAMA:How has gun violence affected your work as an emergency medicine physician?

Dr Ranney:I think for every emergency physician across the country, unfortunately, treating victims of gun violence is something that is part of our—for lack of a better word—bread-and-butter. It is an integral part of every residency program, and almost every hospital across the country sees victims of gun violence. It is something that affects us, both in terms of the number of resources that are needed to respond to a trauma and in terms of the emotional aftermath. Many of us carry the kind of long-term memories and sadness about patients we took care of that we wish we could’ve saved.

JAMA:You’ve noted that gun violence victims are the hardest patients to save. How has that motivated you?

Dr Ranney:I think there are 2 things. One is that the mortality rate from gunshots is so much higher than that of other injuries. There was a great research letter in JAMA looking at the fatality rate of trauma cases in Denver, and the fatality rate from gunshot wounds is increasing. It’s well over 35%, and that’s for folks who make it to the hospital. We know that 90% of suicide attempts with a gun die, and most of them never make it through the doors of the emergency department. When you compare it to the mortality rate from car crashes or falls or even stabbings, the difference is staggering.

We, as researchers and health care professionals, are used to not just treating victims of epidemics but also preventing those injuries and illnesses from happening. Look at our response to HIV or opioid overdoses or Ebola: We identified a problem, and we did something about it.

JAMA:An editorial accompanying the ACP’s position paper suggested that the document missed the mark because it ignored the importance of policing gun violence as a preventive measure. What is your take on that?

Dr Ranney:We all know that laws are useless if they’re not followed, and we do need enforcement. However, a true prevention strategy for gun violence, just like the prevention strategy for car crash deaths, is more than just about the criminal justice space. It’s about changing the upstream factors that lead to gun violence in the first place. When I say violence, I’m talking about mass shootings, but I’m also talking about homicide and about suicide, which is two-thirds of the gun deaths in this country, as well as unintentional injuries, a small but particularly tragic subset of gun deaths.

JAMA:The NRA has questioned the quality of the evidence that the ACP used to support its recommendations. Some physicians blame a lack of federal funding for the shortage of strong evidence. Do you agree?

Dr Ranney:I agree with the NRA tweet that the strength of the evidence is low. The state of the research on firearm injury, or gun violence prevention, is more or less where it was back in 1996, when the Dickey Amendment was passed. Imagine if we were still doing the same thing for sepsis or cancer that we were doing in 1996.

I also agree that a large reason for that deficit in research quality is the lack of funding. A paper that was published in JAMA in January 2017 looked at the amount of funding for various injury and disease conditions compared to the mortality burden. Firearm injury has approximately the same mortality rate, around 10 or 11 per 100 000, as sepsis. And yet, it receives less than 0.8% of the funding that sepsis research does.

Does the funding need to be federal? I think that’s ideal, but we can make a lot of progress with nonfederal funding. You look at what the Gates Foundation is doing for malaria. You look at what the American Cancer Society did back in the 1940s to fund the very first trials on chemo, before the National Cancer Institute was created at the NIH.

There is a role for federal funding, there is a role for state funding, and there is a huge role for private foundation funding. That’s where organizations like AFFIRM are poised to step in. Rather than continuing to wait on politicians and government to act, we felt that it was time to do something ourselves. We know that we need better answers. We need more funding to create those answers, but the source of the funding is not as important, and the rigor of selection and conduct of studies is critical.

JAMA:The editorial author also argues that regardless of the research budget, there are inherent statistical challenges that would preclude scientific certainty with respect to many policies related to firearm violence. What are those challenges?

Dr Ranney:The first and foremost challenge is that we don’t have accurate measurements of the number of injuries and deaths across categories. Obviously, deaths are easy to measure in general, but we don’t have standard methods for medical examiners across the country to decide whether a gun violence death should be categorized as unintentional, vs suicide, vs homicide.

Worse is the measurement of injuries. For that we depend largely on hospital billing codes, with some supplementary data sources like the National Trauma Data Bank, but those are not designed for accurate surveillance. One of the big roles that we [as physicians] can play is trying to get that first data to measure outcomes. When you look at some of the critiques of the early research around guns, a limitation is how accurate do we think we are in measuring whether there’s a gun in the home? There’s a lot of stuff that we could do better by collaborating with gun owners in making this truly a nonpartisan issue. We’re all interested in increasing safety.

JAMA:Is the hope that “This Is Our Lane” will lead to increased funding? Or is the goal mainly to raise awareness of firearm violence as a public health problem?

Dr Ranney:One of the neatest things about “This Is Our Lane” is that it is this beautiful, organic movement that grew from the work many of us had been doing for years. I think we will figure out in the weeks and months to come what the next steps are, but I think our biggest goal is to save lives and prevent injuries.

For some people, it’s about continuing to keep this public health issue in the public eye. For some, it is about federal funding or nonfederal funding, with private-sector funding being a really critical part of the solution. Certainly, right now, and possibly forever, it’s going to be about education of physicians and patients. It’s going to be about improving care for survivors.

We don’t need to approach gun violence as a political problem, and with the other folks involved with “This Is Our Lane,” as well as various collaborators across the country, ranging from AFFIRM to folks at the University of Michigan involved with the FACTS group, to folks at University of California Davis with the “What You Can Do” initiative, to a group of med students called SAFE, there are a lot of us working together to try to move the needle and make some real progress in reversing this epidemic.

JAMA:You mentioned FACTS, the Firearm Safety Among Children and Teens Consortium. The Eunice Kennedy Shriver National Institute of Child Health and Human Development recently awarded a $5 million, 5-year grant for FACTS. Could you talk about the consortium’s goals and your role in it?

Dr Ranney:The big goal of FACTS is to really restart the science of pediatric firearm injury prevention. To achieve that, they’ve assembled a terrific collective of researchers from across the country. We’ve done literature reviews and we’ll be starting some pilot projects. I am leading the work group on secondary prevention and longitudinal consequences, looking at what happens to kids and their communities after a firearm injury, whether it be a suicide attempt or a mass shooting. What can we do to prevent those consequences and to prevent future injury? There’s a lot in the news about PTSD [posttraumatic stress disorder] and anxiety after mass shootings. We think it’s important to not just talk about that, but also to do something.

JAMA:Do you think “This Is Our Lane” will encourage more people to study firearm violence prevention?

Dr Ranney:That’s really the goal behind AFFIRM. We just released our first grant opportunity for young researchers. When I first started doing this—I’ve been a violence prevention researcher for over a decade now—I was explicitly told not to research or talk about gun violence because it would be impossible to create a career with that focus. I’m seeing a lot of folks across the country pop up and say, “This is important to me, and I want to be able to research it in a really thoughtful manner so that the quality of evidence can be better.” For that to happen, there needs to be funding. That’s a large part of the purpose behind AFFIRM. I think groups like FACTS, which are pairing senior researchers with junior researchers, will be critical. We’re starting to see a grassroots network of collaboration and funding that will help to grow the field so that folks who are coming out of residency and PhD programs and fellowships today don’t get the same advice that I got 10 years ago.

JAMA:Why didn’t that advice discourage you?

Dr Ranney:Initially, it did. I didn’t explicitly look at this issue for the first few years. Two things changed my approach. One was a series of clinical experiences with patients that were absolutely tragic, preventable deaths. One patient I took care of had shot himself in the head and did not survive. It really highlighted for me how firearm injury is different: If that person had attempted suicide by taking a handful of pills, I would have saved him.

The other thing was Sandy Hook. For many of us, the images of seeing those kindergartners walk out of that school, and then the images of the parents whose kids never made it out, will remain in our brains forever. I know that there are ways that we can stop this epidemic without infringing on folks’ rights. Our country can solve thorny issues, and I know we can solve this one, too.

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