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CHICAGO -- Physicians can be part of the solution when it comes to preventing gun violence, doctors and researchers said here at a conference on violence as a public health issue.

"There are a few critical things we can do to help change trajectory of firearm injury in this country," said emergency physician Megan Ranney, MD, of Brown University in Providence, Rhode Island. At the meeting sponsored by the Association of Health Care Journalists, she listed three ways emergency physicians could get involved:

• Participate in violence intervention programs after someone ends up in the emergency department (ED), in order to reduce the risk of recurring injury
• Participate in gun violence research
• Advocate for environmental, cultural, and normative change

"We as emergency physicians can and must screen for those risk factors for all types of firearm injury: community violence, domestic violence, suicide, unintentional injury, and yes, mass shootings as well," she added.

"I've personally identified and intervened with patients who are at risk of all of those, and so far as I know, I've made a difference," she said. "As emergency physicians, we have that teachable moment with patients; we also have a teachable moment in the larger community ... to try to change the structural drivers that have people end up in our ED in the first place."

A Change in Perspective

Ranney said her attitude on gun violence changed in 2008 or 2009, after a young man arrived into her ED with a gunshot wound.

"Being July, we had a new set of physicians and medical students, for many of them it was going to be the first gunshot wound they'd seen. There was this buzz in the room as we assembled the social worker, the radiology tech, and my trauma surgery colleague; we're all ready for what we think is coming in. And then the patient rolls through the doors and it was not what we had expected."

The room grew quiet as the staff learned that "instead of it being a victim of community violence, it was actually a young man who had shot himself in the head, and he'd used his father's firearm," said Ranney. "He know where it was and how to access it and in a moment of impulsivity, took his own life. We managed to keep him alive just long enough for his father to come in and say goodbye to him."

"That moment shifted my approach to firearm injury," she said. "I'd thought about it in terms of treating people after they'd come through my doors. It was the first time I'd seen someone take their own life with a gun ... One of the things that incident led me to thinking about and questioning was why it is that although two-thirds of firearm deaths in this country are suicides, we never talk about firearm suicide as part of our firearm injury epidemic?"

Ranney said that she has been an emergency physician for almost 20 years and has only seen about five people die; of those, three were firearm suicides. "I started questioning, what is it about access to a firearm that changes that trajectory, and how could we shift that? How could we put time and space between a person who wants to hurt themselves and access to a firearm?"

She said the incident led her to start talking about how physicians have a role in stopping the epidemic of preventable firearm deaths.

Two Kinds of Trauma

Two kinds of trauma are most important in understanding the drivers of gun violence, said Bradley Stolbach, PhD, associate professor of psychiatry and behavioral neuroscience at the University of Chicago.

"The first is unaddressed internal psychological trauma," he told the audience. "People are carrying all kinds of trauma within them from adverse childhood experiences ... Many of them have lost people to violent death. There is no support provided to them to support their recovery around any of the trauma they've experienced."

"The other driver I've come to understand is much more important is structural violence -- the way our systems are harming people or taking care of people is at the root of many of our problems," Stolbach continued. "What we can do is work to change the systems but that's centuries-long work; they've been this way for centuries. For us here [in Chicago] the historical trauma that underlies all this structural violence is the enslavement of African people and the dehumanization of Black people and commodification of their bodies, which continues to this day."

"We can work to address those systemic issues and at the same time we have to work to take care of people who are hurt," he added. "We can't stop doing one to focus on the other. We have to do both all the time. But there's not a lot of support for either one."

Abdullah Pratt, MD, an emergency medicine physician at the University of Chicago, founded a group called Trauma Recovery & Prevention of Violence (TRAP Violence) to teach inner-city youth conflict management skills to help prevent violence, among other strategies.

Contrary to the common belief that urban violence is mainly about gangs and drug wars, most of the violence comes from an inability to resolve interpersonal conflicts, Pratt said. "It's not gang violence, as much as we want to think that ... It's interpersonal, not to be able to conflict-resolve. I've lost at least six or seven close friends due to that -- 'You bumped into me at a bar; neither one of us could back down.' It's all about not taking another loss to your pride because your whole life you've never had a win."

He said his work in this area is motivated by "the pain and suffering I went thru as a youth, witnessing gun violence every day on the South Side of Chicago," including the loss of his only brother to gun violence, as well as the loss of ten other people close to him in a single summer for the same reason.

Role for Government

State and local governments also need to get involved, said Richard Miskimins, MD, associate trauma medical director at University of New Mexico Health in Albuquerque, who was part of a successful effort to get the state to open an Office of Firearm Injury Prevention in its Department of Public Health.

The new office will help coordinate prevention efforts between state agencies, localities, tribes, and non-governmental organizations to address gun violence comprehensively, Miskimins said, noting that solutions will be different in different localities. "Things that are going to work in Chicago aren't going to work in New Mexico."

"One of the reasons we wanted it in the Department of Public Health is so people viewed it as a public health issue," he noted. "We wanted this to focus on what firearm injury prevention strategies should and shouldn't be."

"We really wanted it not to be based on feelings," he added. "I live in a state that has a high rate of firearm ownership. I go out and I shoot guns with my friends, and I also go and hunt things, but we want to make sure everyone is well educated" on gun safety.

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