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Thursday, February 14, 2013

Gun control and numerical nonsense

I have expressed my support for gun control emphatically, here and elsewhere, and in so doing given myself up for human target practice. I expected nothing else.

Once more into the breach, even so.

There are, of course, some valid concerns and challenges raised by those who oppose gun control. I don't mind admitting that. For one thing, nothing worthwhile as having fewer gun-related deaths in the U.S. is worthwhile is ever easy. For another, I acknowledge that a disagreement doesn't require that everyone on one side of the argument be a moron. Perspectives and priorities can differ, even among decent, intelligent people.

And, frankly, a comprehensive plan to reduce gun violence, including bans and restrictions on certain kinds of weapons and ammunition and body armor, enforced regulation of sales and interstate commerce, buy-back and amnesty plans, background checks, better mental health screening and care, stiffer fines and sentences, a massive enforcement initiative, etc., would be challenging to conceive, and harder still to implement. Not impossible, mind you, just hard.

So I concede there are challenges, including the need to keep reasonable arms accessible to reasonable people for reasonable use. We left-leaning public health types love civil liberties, and America, and the genius of our Constitution too, you know.

But there are some truly vapid arguments against gun control. And salient among these is: "The assault-style weapons and high-capacity magazines you want to ban account for only a tiny proportion of gun-related deaths, and a vanishingly tiny proportion of all deaths." This is an all but constant refrain for the anti-gun-control chorus. I've heard it many times, usually in the context of being called names that would make my poor mother pass out.

But as noted, this is utterly vapid, nihilistic nonsense. A non sequitur. And here's why:

Against the backdrop of prevailing epidemiology, not many die in plane crashes. So if our sole concern is the total number of cause-specific deaths, plane crashes are just no big deal. We have no more reason to do anything about them than we do about assault weapons used in massacres.

In fact, if this is a numbers game, strictly, then the next time you are boarding a plane and wondering what was done after the last calamitous plane crash to make it less likely to recur, that answer really ought to be: "Not a damn thing, of course. Have a nice flight."

It doesn't end there. Not many people died on September 11. Not in the grand scheme of death. More than one million people die prematurely in the U.S. every year, and more than 80% of those premature deaths are due to chronic diseases. So September 11 was really miniscule compared to tobacco; or eating badly; or lack of exercise. Or guns. Or car crashes. Or texting while driving.

So why the fuss? If we are not concerned with who dies, or how, or at whose hands, if it's all about how many, then our response to September 11 has been wildly exaggerated. More of our military personnel have died in our response to September 11 than were killed on that day that lives in infamy. If it's about the numbers, we are doing something very wrong.

So, of course, it clearly is not just about the numbers. And here's a numbered list of reasons why:

1) One death is a lot if it's yours, or that of someone you love.

2) What most of us really can't stand is not risk, or vulnerability, we are all going to die, after all, but helplessness. It is human nature, our constitution, if you will, to fear and revile risks we don't control, those imposed on us, like a Kevlar-clad lunatic bursting into my lab, or my kids' school. I feel in charge of my steering wheel, even though my car is far more likely to be the death of me than a gun. That doesn't change our thinking, we don't want dangers imposed on us. That, too, is a libertarian concept.

3) A focus on numbers ignores circumstance, context, and choice. People choose many behaviors that invite some degree of danger. First-graders in their elementary school classroom, or people attending a movie, have done no such thing

4) A numbers game ignores the motivation of mass murderers. The real intent of the Newtown attack and the September 11 attack is not measured in the body counts, appalling as they are. It is measured in the psychological aftermath, it's an assault on our culture and society. The perpetrators of massacres are people who want to, and do, make history. Not so for every hoodlum with a Saturday night special. Assault weapons in the wrong hands are used to assault not just individuals, but our way of life. The very notion of security and liberty, beautifully conjoined, is in their crosshairs.

5) Numbers-based arguments lead toward a slippery slope. They invite us to ignore all causes of death, no matter what we might do about then, that don't climb above some arbitrary statistical threshold. Since my day job is focused on the leading causes of death in modern society, cardiometabolic diseases, I suppose I should welcome this thinking, since it would divert all relevant resources to me and others like me, and the work we do. But I don't welcome it. It's absurd. It would mean no firemen, because after all, how many people die in fires in the grand scheme of things? It would mean no lifeguards. No crossing guards. No child safety caps. No guardrails. No Coast Guard. Maybe no police at all. It's nihilistic, dysfunctional, dystopian nonsense.

What matters about massacres resides in the nature of the menace, not the casualty count in epidemiologic context. I am an epidemiologist, and readily acknowledge that not everything that counts can be counted.

In the current, intensifying debate about gun control, all valid arguments should be heard. A numbers-based argument is not among them. What matters here is what is being assaulted, and that was never just a number.

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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