Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt
In this edition’s tidbits, the nation is once again dealing with an epidemic of shootings. Now a hospital joins schools, grocery stores and places of worship on the the recent list. I was struck by how much of the health care story was wrapped up in the tragic shooting where a patient took the life of Dr. Preston Phillips, Dr. Stephanie Husen, receptionist Amanda Glenn, 40; and patient William Love at Saint Francis Health System in Tulsa.
First and most obvious, gun control. The shooter bought an AR-15 less than 3 hours before he committed the murders then killed himself. Like the two teens in Buffalo and Uvalde, if there was a delay or real background checks, then these shootings would likely have not happened.
But there’s more. Hospital safety has not improved in a decade or so. Michael Millenson, THCB Gang regular, has made that plain. And that includes harm from surgery. We know that back surgery often doesn’t work and we know that Dr Phillips operated on the shooter just three weeks before and had seen him for a follow up the day before. Yes, there is safety from physical harm and intruders–even though the police got there within 5 minutes of shots being heard, they were too late. But there is also the issue of harm caused by medical interventions. Since “To Err is Human” the issue has faded from public view.
Then there is pain management. Since the opiate crisis, it’s become harder for patients to get access to pain meds. Was the shooter seeking opiates? Was he denied them? We will never know the details of the shooter’s case, but we know that we have a nationwide problem in excessive back surgery, and that is matched by an ongoing problem in untreated pain.
And then there are the two dead doctors. Dr. Husen, was a sports and internal medicine specialist. Obviously there are more female physicians than there used to be even if sexism is still rampant in medicine. But Dr. Phillips was an outlier. He was black and a Harvard grad. Stat reported last year that fewer than 2% of orthopedists are Black, just 2.2% are Hispanic, and 0.4% are Native American. The field remains 85% white and overwhelmingly male. So the chances of the patient & shooter, who was black and may have sought out a doctor who looked like him, having a black surgeon were very low in the first place. Now for other patients they are even lower.
The shooting thus brings up so many issues. Gun control; workplace safety; unnecessary surgery; pain management; mental health; and race in medicine. We have so much to work on, and this one tragedy reveals all those issues and more.
Forced absence from gun violence has created a literal and metaphorical void in schools across our country that may impact students and staff for decades to come. The students are referred to as “Parkland kids,” “Sandy Hook students,” or “Columbine survivors.” These labels are sadly reflective of a new reality for American schools, as students, teachers, and staff no longer feel safe. America’s students feel vulnerable as the facade of schools as a safe place is no longer true. The Center for American Progress recent report revealed that 57% of teenagers now fear a school shooting.
Often, perpetrators of gun violence leave a trail of “red flags” for years, as they are troubled youths. This was the case in the Parkland shooting. Tragically, multiple agencies failed to respond to the signs the troubled young man was leaving, including specifically writing online that he aspired and planned to be a school shooter.
In the aftermath of the Parkland, Florida tragedy, parents and school districts turned to security experts demanding a plan of action. Sadly, the information provided was substandard and lacked evidence to support the strategies as efficacious. Lives weigh in the balance and there is no more tolerance for guessing.
Research is needed to guide the creation of evidence-based frameworks for school communities to address prevention as well as protection. Threat assessment teams are a strategy to assess for potential threats, but more importantly is that an intrinsic safety network is woven into the fabric of the educational system. Exposing the root cause of the contagion of violence impacting our youth is key.
By MATTHEW S. ELLMAN, MD and JULIE R. ROSENBAUM, MD
What if firearm deaths could be reduced by
visits to the doctor? More than 35,000 Americans are killed annually by
gunfire, about 60% of which are from suicide. The remaining deaths are mostly
from accidental injury or homicide. Mass shootings represent only a tiny
fraction of that number.
There’s a lot physicians can do to reduce
these numbers. Typically, medical organizations such as the AMA recommend
counseling patients on firearm safety. But there is another way to use
medical expertise to help reduce harm from firearms: physicians should evaluate
patients interested in purchasing firearms. The idea would be to reduce the
number of guns that get into the hands of people who might be a danger to
themselves or others due to medical or psychiatric conditions. This
proposal has precedents: physicians currently perform comparable standardized
evaluations for licensing when personal or public safety may be at risk, for
example, for commercial truck drivers, airplane pilots, and adults planning to
adopt a child. Similar to these models, a subset of physicians would be
certified to conduct standardized evaluations as a prerequisite for gun
As a primary care physicians with decades
of practice experience, we have seen the ravages of gun violence in our
patients too many times. A 50-year-old man shot in the spinal cord 30 years ago
who is paraplegic and wheelchair-dependent. A 42-year-old woman who sends her
teenage son to school every day by Uber because another son was shot to death
walking in their neighborhood. A teacher from Sandy Hook who struggles to cope
with post-traumatic stress disorder.
Physicians can contribute their expertise toward determining objective medical impairments impacting safe gun ownership. These include undiagnosed or unstable psychiatric conditions such as suicidal or homicidal states, memory or cognitive impairments, or problems such as very poor vision, all of which may render an individual incapable of safely storing and firing a gun. In this model, the clinical role would be limited in scope. The physician would complete a standardized evaluation and offer recommendations to an appropriate regulatory body; the physician would not be the final decisionmaker regarding licensing. An appeal process would be assured for those individuals who disagree with the assessment.
At least two-thirds of the perpetrators and victims of gun violence are males under the age of 30. What else do they have in common? They live in neighborhoods with high crime rates and low family incomes, they knew each other before the violence broke out, they usually aren’t employed.
But there’s another commonality these young people share which isn’t often mentioned in discussions about gun violence and crime.
It turns out that the part of the brain that controls processing of information about impulse, desire, goals, self-interest, rules and risk develops latest and probably isn’t fully formed until the mid-20s or later. And while adolescents and young men understand the concepts of ‘good’ versus ‘bad’ as well as older adults, they tend to let peer pressures rather than expected outcomes guide their behavior when choosing between risks and rewards.
Take this neurological-behavioral profile of males between ages 15 to 30 and stick a gun in their hands. The brain research clearly demonstrates that kids and young adults walking around with guns understand the risks involved. Whether it’s the NSSF’s new Project ChildSafe, the NRA’s Eddie Eagle or the grassroots gun safety programs that have expanded since Sandy Hook, nobody’s telling the kids something they don’t already know.
So what can we do to mitigate what President Obama calls this ‘epidemic’ of gun violence when the population most at risk consciously chooses to ignore the risk? I suggest that we look at what communities have done to protect themselves from other kinds of epidemics that threatened public health in the past.
And the most effective method has been to quarantine, or isolate, the area or population where the threat is most extreme. It worked in 14th-century Italy, according to Boccaccio in The Decameron. Why wouldn’t it work now?
Last month the city of Springfield, Mass., recorded its 12th gun homicide. If the killing rate continues, the city might hit 15 shooting fatalities this year, a number it actually surpassed in 2010. This gives the city a homicide rate of 10.2 per 100,000 residents, nearly three times the national rate. Virtually all the violence takes place in two specific neighborhoods bounded by Interstate 291 and State Route 83, and all the victims are between 15 and 30 years old.
Reducing gun violence by increasing access to mental health services may cost billions of taxpayer dollars and give drugmakers that help treat mental illness a revenue windfall. But will it reduce gun violence? The answer is uncertain.
In the wake of the tragic shooting at Sandy Hook Elementary School, there have been repeated calls to increase access to mental health services as a way to reduce gun violence in the U.S., even though the evidence is weak at best that those services actually reduce gun violence.
Absent from these calls to action is any sense of how much that policy would cost. Many argue that any cost is worthwhile if it prevents just one needless death due to gun violence. But we live in austere fiscal times and knowing the price tag before taking action makes sense (click on the image above to enlarge).
A just-published Bloomberg Government Study estimates that the potential impact on the federal deficit due to increased spending on mental health services could exceed $260 billion from 2014 to 2021.