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Friday, January 18, 2013

Sure as shooting

There are two reasons not to talk about gun control in the immediate aftermath of the Newtown atrocity, and opposition by the National Rifle Association and its adherents is neither of them.

The first is that addressing gun control right after innocents are shot might in some way seem exploitative. The second is that no imaginable degree of stringent gun control could fully exclude the possibility of an unhinged adult shooting a kindergartener.

But both of these objections are as porous as the sands of our shores battered by Hurricane Sandy. And a consideration of those shores readily reveals why.

With regard to exploitation, there was no thought of it as post-Sandy ruminations turned to how we might best prevent or at least mitigate the next such catastrophe. It was not exploitative to look around the world at strategies used to interrupt storm surges, divert floodwaters, or defend infrastructure. Those reflections continue.

Similarly, it's not exploitative when my clinical colleagues and I speak to our patients in the aftermath of a heart attack or stroke about what it will take to prevent another one. In fact, these exchanges have a well-established designation in preventive medicine: the teachable moment.

It is opportunistic, but in a positive way: There is an opportunity to do what needs to be done. Admittedly, it's better to talk about preventing heart disease, or the drowning of Staten Island, or of New Orleans, or the shooting of children, before ever these things happen. But the trouble tends to be: Nobody is listening then.

We are constitutionally better at crisis response than crisis prevention. We'll get back to the Constitution shortly.

It's not exploitative to talk about what matters when you have people's attention as opposed to when you don't; it's strategic opportunism, pragmatism, and good sense. It is, of course, a damn shame that we only seem to focus our attention on disaster prevention in the immediate aftermath of disasters, public or personal. But if that is our nature, those wanting to get anything done are well advised to proceed accordingly.

As for the second argument: It's true, no degree of gun control short of eliminating guns from the planet could guarantee that a lunatic will never again shoot an unarmed innocent. But that no more obviates discussion of sensible gun control than the fact that no degree of shoreline protection can guarantee we will never again suffer any damage from a monster storm. In defending ourselves, and our children, from monster storms or monstrous people, we are foolish to make an unattainable perfect the enemy of the good we can do.

And there is, clearly, good we can do.

Other than in the hands of military and law enforcement personnel, semi-automatic and assault weapons, and the gear that goes along with them, as in the Aurora, Colo. shooting, serve the purposes of carnage and devastation almost exclusively. Access to them should be regulated accordingly.

As for the Constitution: This really has nothing whatsoever to do with the Second Amendment, and certainly doesn't infringe on it. The Second Amendment doesn't say anything about what kind of "arms." We are left, as a modern society with weapons unimagined in the days of our Founding Fathers, to figure that out for ourselves.

I will leave other Second Amendment arguments, including specific reference to a "well regulated militia," to the Constitutional scholars; I do not pretend to be one. Sensible arguments for gun control sidestep Constitutional concerns entirely.

However we interpret the right for private citizens (having nothing to do with a well regulated militia, for what it's worth) to bear arms, we are left to decide: What arms? We seem to agree that private citizens should not bear nuclear arms. I suspect most of us agree they should not bear chemical or biological weapons capable of destroying entire populations, either. Private citizens don't get to bear the launch codes for missile silos.

It would be surprising news to me if even the most ardent defenders of the Second Amendment felt that private citizens should be able to have a personal nuclear arsenal. And, assuming not, then we all agree: We have to draw a line somewhere. What arms?

We might far more constructively address the question of where to draw the line once we acknowledge that, but for the truly radical and deranged, we all agree there is a line somewhere. Once we've done so, my contribution to the debate would simply be my own standby: Epidemiology should trump ideology.

In other words, things matter because of their effects. If everyone had an Uzi, but no one ever got shot, who would care? The reason for us to care about who has what guns is how they wind up being used.

I have written about gun control before. And, predictably, I have received a deluge of rather uncomplimentary correspondence each time. I expect a bumper crop this time, too. I have taken advantage of such exchanges to ask the more gregarious among my verbal assailants to tell me about any situation in which a semi-automatic weapon was used for self-defense. Most don't seem to know of any, although of course anybody can track down evidence for anything somewhere in cyberspace.

The premise underlying ever-more-potent weapons for personal defense is, of course, fundamentally flawed; it is subject to the arms race principle. If more potent guns are in circulation, then both sides get them. Yes, the good guys can get them, but so can the bad guys. That might invite the good guys to argue for more potent "arms" still, but then, of course, the bad guys get those, too. The more potent the arms, the greater the collateral damage.

The first question for us all, NRA members and die-hard pacifists alike, is: Why do we care? Anyone who wants guns for all just because they like guns, and the consequences be damned, is a damn fool, and doesn't deserve our attention. But frankly, neither does the pacifist who just hates guns, and doesn't care if they are truly useful for self-defense. Let's agree about what matters: consequences.

If we can manage that, then the second question is: What is the interpretation of "arms" in our right to bear arms that best protects us all, including children in kindergarten classes? If we don't have the data, then an analysis should be commissioned to get them. And we should all then embrace the best answer an unbiased analysis can generate. If we do have the data, and yes, I think we do, then we should all pay attention to them.

If we and our children truly are safer for having semi-automatic weapons in everybody's hands, then we should all get our hands on them. But if not, then we shouldn't. We would still have the right to bear arms, of course, just not the ones used preferentially to take an entire classroom of kindergarteners out of the loving arms of their parents, forever.

Something bad could have happened in Newtown without semi-automatic firepower. But it would have been much less bad.

Even if we were less inclined to climate change denial, we would still have to acknowledge that there have always been hurricanes, they've always been potentially destructive, and we can't prevent them. But we can examine the defenses at our disposal, and determine how to use them to produce the best possible outcomes.

We should look to guns as we look to our shores. In both cases, if what we truly care about is protecting the innocent, then sure as shooting, there are lines to be drawn in the sand.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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