American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, December 16, 2014

Public health as political prisoner

If a foreign government took the U.S. Surgeon General hostage, I'm confident we'd be pretty upset. I think we would be working on reprisals, and maybe even prepping a SEAL team.

I don't know if it's better or worse that we need no help from a foreign power to take our surgeon general hostage. Our own political system manages all on its own.

Admittedly, it's not quite the surgeon general who is hostage to our political system; it is the president's nominee, Dr. Vivek Murthy. Dr. Murthy's nomination is in limbo, because Congress won't take up his confirmation. We'll get to why in just a moment.

Before that, however, it's worth noting that everybody who is anybody in public health and medicine supports Dr. Murthy as a highly-qualified candidate. I am pleased to be counted among them, and from a uniquely personal vantage point. Dr. Murthy was a medical student of mine at Yale quite some years ago, and I got to know him well during those formative years. We have remained close, and collaborated, ever since.

He is both an excellent candidate for the job, and a really good person.

But, as noted, his candidacy is, in essence, a prisoner of our political system, or at least, of political discord.

Why? In some reports, Dr. Murthy is cited as having spoken in favor of various gun control measures long before he was a candidate for surgeon general. Naturally, we are talking about truly radical stuff here, like, for instance: background checks so we don't routinely arm deranged sociopaths. Or, perhaps, not everyone being entitled to semi-automatic weapons with high-capacity magazines. Truly outrageous assaults on the second amendment, clearly.

But we needn't go nearly that far. The official reason for opposition to Dr. Murthy is a tweet dated 10/16/12 that states: “Guns are a health care issue.”

If we reasonably take the full expanse of “health care” to encompass both patient care, and public health, I think the only possible reaction to this statement is a yawn, and: Duh!

What can possibly be controversial about this statement? For gun control advocates, there is clearly no cause for dissent. Those contending that guns foment murders and massacres certainly agree that a public health issue is in play.

But there can be no cause for dissent from the most ardent gun enthusiasts either. After all, the rationale for guns-for-all is so that we can defend ourselves, presumably against the harms to which we might succumb if unarmed. Self-defense against harm is, pretty self-evidently, an issue of both public justice, and public health.

And, of course, anything with the potential to involve emergency surgery and blood transfusions is pretty much, by definition, a health care issue.

And then there is the, forgive the pun, real smoking gun of the “guns are a health care issue” issue: suicide. I don't think anyone wants to refute the notion that suicide attempts are a health care issue. After all, we health care professionals are the first responders to them. This one, too, should be among those truths we hold to be self-evident.

So here's the thing: Guns are used far more often for suicide than for either homicide or self-defense. We don't have all the research we would like on the topic, mostly because the NRA spends pretty lavishly to ensure it won't get done, but what we have is rather compelling. A peer-reviewed paper from 1998 suggests that the ratio of gun use for suicide to use for self-defense is 11 to 1. CDC data from 2010 indicate that 60% of firearm deaths are suicides, and more than half of all suicides are by gunshot.

That second statistic is more compelling than it may seem. After all, most people who contemplate, and then attempt suicide, don't have guns. So what it means that more than half of all suicides are gun related is this: Most people who attempt suicide do NOT use guns, but those who use guns succeed much more often.

Guns don't kill, people kill, even themselves. But guns make them a whole lot better at it.

And that's tragic, because suicide may result from uncompensated depression, or a moment of despondency that could be assuaged. A suicide attempt is an opportunity to identify the source of such anguish, and restore the chance to live. A completed suicide is: game over. Guns are strongly associated with the latter.

The simple, if sad, fact is that we are indeed all subject to the slings and arrows of outrageous fortune. Maybe at one time or another most of us think at least fleetingly about taking arms against that sea of troubles, and by opposing, ending them. For most of us, it is just a fleeting thought. For some, it evolves into a plan, a gesture, or an attempt. For those with a gun handy, it results far more often in the need for a hearse rather than an ambulance. This is not ideology; it's just epidemiologic fact.

Suicide is a health care issue. If guns figure in it, as they irrefutably do, then guns are a health care issue, too. QED.

The surgeon general, whatever his or her views on gun control, has no political authority, and will do absolutely nothing about gun control in office. Even if the position did allow for that, why would that unsettle anybody? Even the president of the United States, openly in support of gun control legislation also supported by a decisive majority of us Americans, can't get much of anything done about it. Is the NRA really all that concerned about the profound ramifications of a public health physician's personal opinion? I'm impressed if so, because it must mean I have all kinds of power to which I am oblivious.

Far more likely, nobody actually is all that concerned about Dr. Murthy's totally predictable, completely uncontroversial position on this topic. It is all just political theater.

But it is bad theater. A public health physician stated, before ever he was under consideration for surgeon general, that guns are a public health issue. We may ignore the fact that he was exercising his first amendment rights at the time, and posed then, as he poses now, no threat to the second amendment rights of anyone else.

More importantly, he was speaking a truth, universally recognized as such. There should be no political agenda directed against universally recognized truths.

Cheer or lament it, public health is no threat to gun rights. But threats to public health that result from ideology over epidemiology, and resistance to statements of fact, are potentially ominous for us all.

However we may differ over guns, I suspect all of us like to live in a society where stating a fact does not bring reprisals. On that basis alone, please tell your members of Congress you would like Dr. Murthy freed from his political prison, and confirmed as U.S. Surgeon General. Ideally, no SEALS will get involved.

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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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.

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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.

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 Iowa City, IA, 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.

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.

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.

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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.

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

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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.

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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).

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.

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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.

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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.

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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.

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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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