This is Everyone's Lane
Monday, December 3, 2018
By Stephanie Bonne
On a busy day in the ICU, I was back and forth between meetings, notes and patients, when my phone buzzed a couple times with Twitter notifications. Something seemed to be up. I stepped out of the elevator as the page loaded and found myself in the hallway of the hospital staring in disbelief.
"Someone should tell self-important anti-gun doctors to stay in their lane. Half of all the articles in the Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves…" A tweet from the NRA.
Seriously? Content aside, the tone is divisive, condescending, disenfranchising, and makes malicious claims about the quality of peer review, which is the foundation of evidence based medicine. I'm a trauma surgeon at a busy urban center. At this point, I've been up for 2 days, I'm a week behind on my charts, I'm burning through a grant to study gun violence, running from meeting to meeting to ensure patient quality and manage our hospital's violence intervention program. Gun violence isn't just my lane, it's my highway – all day, every day. How dare they say I don't belong here?
In the moments and hours after, I went with my gut and unabashedly tweeted my reaction with a hashtag gaining traction: #Thisismylane: a bloody floor, a chair in the waiting room. And the stories: A son, a mother-to-be, a child, a husband, a father.
The stories go on and on, as they do for all of us. The hashtag became a rallying cry and pretty soon I was getting calls – can you be on our show, our podcast, can you comment, can we use your photos? In the flurry of the media attention that followed, it was easy to get swept up in the excitement of all of it. But just like the rush of the trauma bay or the tension of the operating room during an ex lap (an exploratory operation, which is often required for victims of a gunshot wound), I stayed grounded in one thought.
Our patients. Our patients need to be at the center of this, the way they are at the center of our trauma bays, the center of our ORs, and the center of our care, and were at the center of my day on the day the NRA decided to tweet. That means that doctors need to be serious about a public health approach for mitigating gun violence because that is what will save our patients, and we really need to spend some time thinking about what that means.
Public health is about primary prevention (stop someone from getting shot), secondary prevention (stop someone from getting shot again), and tertiary prevention (mitigating the effects of being shot). It involves 4 steps: surveillance, identifying risk factors, developing and testing program, and implementation. So, let's look at each, and talk about the solutions, which arise from both messaging and policy.
Surveillance: We know how many people die. We don't have accurate data on how many nonfatal injuries there are. Without a uniform data collection system and reporting system for firearm injury, we guess it's somewhere between 80,000 and 200,000 per year. Maybe we could prevent gun violence if we could talk to the survivors. But we have no real way to meaningfully identify them. Funding for more robust surveillance has been poor, largely of the lack of congressional funding to the CDC as a result of the Dickey Amendment. Messaging has been pretty effective at creating some philanthropic funds, but policy hasn't really budged. We can do better here.
Identifying risk factors: Again, we are pretty good here. We know that depression and suicidality with a firearm in the home is a risk factor. Children, the elderly, those in poverty, and victims of domestic abuse are at higher risk. We could do better at understanding risk if we had better surveillance. Without data, our messaging has been clear: lethal means matter. Restricting accidental access by children and those who may be suicidal is important, as is the restriction of access by domestic abusers. Carefully designed policies can be enacted to change all of the above; some states already have, and these have started to see decreased deaths. But messaging can only go so far and policy solutions have been hit or miss. We can do better here.
Developing and testing programs: Without good data and a good sense of risk factors, it's hard to create programming. Despite this, surgeons have been leaders in developing hospital- and community-based violence prevention interventions. These types of programs have shown success, but are woefully underfunded and highly variable in their approach. We can do better here.
Implementation: Here is where we really get held back on the policy front. We can try our best to implement child access prevention programs, gun lock distribution, buybacks, domestic abuse restraining orders, emergency protection orders, or other policy and messaging solutions that have been shown to decrease injury and death. But until politicians are willing to act, implementation will continue to be problematic. We can do better here.
We are facing an uphill batting in the work to decrease firearm injury in the United States. However, doctors have the attention of the public. This social media campaign will come and go and the 24 hour news cycle will distract us with something else soon. What will remain, however, is a new public understanding of why doctors feel so passionately about this issue and why the solutions to our problems lie squarely in the field of public health. As long as we keep that message alive, surgeons, and all doctors, can be real leaders in the fight against firearm injury and death. This is our lane, all of us, we will stay in it, and maybe we can turn it into a runway from which we can take off and fly.
More information on "#ThisisOurLane" can be found at: