Thursday, December 20, 2012

Dear hospital CEOs: Commit.

An open letter to the 5754 hospital CEOs in America,

You have been granted a public trust.  It's time to commit, publicly.

President Obama has decided that a form of gun control will be on his agenda for the coming year: "The president signaled his support for new limits on high-capacity clips and assault weapons, as well as a desire to close regulatory loopholes affecting gun shows.... [The] opposition shows little signs of fading away."

All I am asking is that you publicly identify yourself with a position on this issue, for or against.

I know that many of you have a tendency to be quiet of matters of legislation when there appears not to be a connection with hospitals.  But this is a public health issue. The CDC reports 11,492 homicides from firearms (out of 16,799 total) in a year in its most recent figures (2009), a rate of 3.7 per thousand population. (The total rate of deaths by firearms is about three times this, with suicide being the largest category.)

We need your judgment and thoughtful consideration.  We need your convening authority to create opportunities for discussion and debate in your institutions and your communities, to help inform your position. We need you to make your views known to your senators and representatives in Congress.

As Hillel said:  "If I am not for myself, who is for me? If I am only for myself, what am I? If not now, when?"  Please reach deep and think about how you will feel if this issue is decided without your engagement.  You've spent years getting to your current position.  For what purpose if not to participate in one of the major issues facing our society?

Here are some excerpts of articles that might help you decide:

A doctor who lists his name as J. Stefan Walker recently posted this comment about limiting the availability of assault weapons on another website:

The Second Amendment settled the issue, but even before that it has been one of the fundamental rights and responsibilities of our free society to live with firearms. America would likely have been conquered by external invaders or internal fascists long ago had it not been for the reality that common citizens have ready access and skill in handling even advanced weaponry; similarly, the right to keep and bear arms insures that citizens will not be mere prey when criminals or others of malevolent or misguided intentions bear arms against the innocent. I do not question the motives of those who feel the answer to tragic gun violence is to restrict guns or types of guns; but I do question the logic, and the legality. The real issues involved in gun-related tragedies center around more responsible handling / ownership of firearms – and in better mental health resources for the public. Free people must accept the harsh realities of violence in the world – and accept the concomitant responsibility to bear arms of at least equal potency at the ready to protect those within our charge. This does not just mean the police and the formal military: simple math proves that approach will never guarantee adequate safety. There is just no way around these realities.

Here is a contrasting view by Leah Hagler Cohen on WBUR's Cognoscenti:

To feel is good.

It is a kind of intelligence. It’s a first response which may spur us — if we don’t hasten to deaden it — to further response: to action.

If the reason this latest event stands out from the rest has less to do with its uniqueness and more to do with the tender age of the majority of those killed, how shall we make use of our emotional response? How shall we let it — our grief — inform us? 

I am no policy maker. I have no expertise in violence or gun laws or mental illness or video games or the Second Amendment. I am only a mother. Even that is irrelevant. Would I feel any less if I had no children of my own? We are all in this together.

Here’s what we can do. We can tell our stories and listen to one another. We can educate ourselves about the issues and about who has the power to implement change. We can find creative ways to partake of that power and responsibility. We may even choose to reckon with ourselves — privately and collectively — about the role each of us played in the most recent tragedy, if only through silence and inaction. Others will have more practically useful ideas. I know only this: we start by being willing to feel.

Former hospital CEO Nick Jacobs adds:
Back in the eighties, much of the inpatient mental health system all but vanished in this country, and today behavioral health challenges continue to carry a stigma that is not only tenuous but also very detrimental to the well being of not only those challenged individuals but for all of us.  So, yes, behavioral health issues have clearly been a part of each of these attacks. And is that an easy fix?  I think not.  I believe the stigma associated with mental illness is a huge problem, and even if we seek help, it is many times not available.

Let’s discuss the third rail.  As a kid I grew up with guns and target shooting was one of my favorite family pastimes.   I can tell you that we never had a problem due to the fact that we owned those guns.  They were locked up; they were handled appropriately, and they were used for what they were intended.

However, when you see facts like:  There have been 62 gun-related mass murder attacks across this country since 1982, or that approximately 50 million people own about 250,000,000 guns in the U.S., you have to wonder about connectivity to this issue.

The chief medical examiner has said the ammunition was the type designed to  break up inside a victim’s body and inflict the maximum amount of damage,  tearing apart bone and tissue.  So what about gun control?   Do I believe that semiautomatic weapons, armor piercing bullets, extended clips, et al., contribute to the ease of access for these mass murderers? Yes, I do.  I would love to see controls regarding the above mentioned killing devices, but I do not believe this is the only solution.  Should people be permitted to own guns?  Yes.

There is no easy solution.  I would hate to see our schools and colleges become modified prisons.  I would hate to see our lives become self-imposed solitary confinement chambers, but clearly excessive access to kill-type weapons, inadequate access to behavioral health treatment, lack of understanding of drug interactions, and excessive exposure to violence seem to have created the perfect storm.


Anonymous said...

I would encourage everyone to let data drive their position. Think of gun control as a treatment for a condition. When considering treatments, we do pilot studies and evaluate whether or not the treatment achieved the desired goals. It isn't as simple as looking at the number of gun deaths and saying we must therefore ban guns. You would never let such a simple rationale guide treatment decisions without evidence that the treatment actually brought about the desired effect. Thankfully in the US, we have 50 states that have very different gun laws. We can look at what happened in those states when their versions of the proposed laws were passed. Look at meaningful endpoints. An assault weapons ban may decrease the number of crimes committed with assault weapons, but did it decrease crime or lower murder rates? Were lives saved? What is the number of gun owners that need to be treated with a ban in order to see an effect? Do the costs to those gun owners justify the intervention? What does the data say about concealed carry? Does allowing citizens to carry guns have an impact on crime? Are their documented side effects? Or just predictions of doom? This is the kind of information we should be seeking, but it seems to be missing from the debate.

I would love to be able to tell you that such an honest investigation has led me to the conclusion that gun control measures like those being proposed have the desired impact, but I can't. Maybe you'll be able to. Regardless of position, let’s try to maintain the same standards for drawing conclusions from data that we do for all other treatments we propose for our patients.

Anonymous said...

I have been contemplating a more extensive general comment for later, but first would like to reply to anon 1:12. I agree theoretically about data, but unfortunately during the election we learned that not even 'facts' are safe from interpretation.
Another criterion that might be used is the risk/benefit ratio, or the harm/no harm decision. That is, is the risk of harm to someone from banning assault weapons greater than the risk of harm to someone from not banning them? I think that one's easy - tell me of someone who will be irreparably harmed in a real way by not having access to such a weapon.

Another option is to forget about the guns and regulate or tax the dickens out of the bullets, using the tax revenue for mental health, gun licensing programs, or other related issues.

The bottom line is, there ARE solutions to this problem. We do not have to accept the status quo. Indeed, we cannot accept the status quo any longer - we now have 26 reasons why, if we didn't have thousands before that.

nonlocal MD

Anonymous said...

Your risk/harm analysis assumes that there will be a reduction in risk by banning assault weapons, and I don't believe that has been established. Evidence from such bans (including a CDC analysis) doesn't back that notion up. Based on what I've read of the incident, I have no reason to believe that there are fewer people dead in CT right now if all the shooter had was handguns with magazines that hold no more than 10 rounds. The burden of proof is on those wishing to ban the weapons to show that the ban would actually accomplish something, and that burden hasn't been met.

Same with the tax proposal. What evidence is there that this would accomplish the desired goal?

Anonymous said...

No, I don't agree with your premise that the burden of proof is to 'show that the ban would actually accomplish something'. Your burden of proof is to show that putting in the ban would irreparably harm someone, and that's a hard sell indeed. And if you mention the 2nd amendment in your next reply, then all will be clear.


Mitch said...

Good for you on hospital CEO's and guns. Add insurer CEO's, medical device's....maybe even politicians?

Anonymous said...

If hospital CEO's are not moved by their moral duty, they may be so by the very real risk to their own institutions. This is a known problem in ER's, and a Johns Hopkins doctor was shot on the inpatient ward by a distraught relative. A near-miss occurred in my own hospital lab when a terminated employee showed up in the lab with a rifle looking for the director. Authorities found an arsenal in his home.
Unfortunately hospitals are very logical targets, and not just in the inner city.

nonlocal MD

PaulH said...

The UK has very low gun ownership and some very restrictive laws on it. The UK has a very low level of gun related murders. Seems to me that these 2 are linked! We've managed not to be invaded (for a very long time)nor had to resort to guns to protect against major civil unrest. Is the USA really that different?

Lynn Nicholas said...

Paul, I could not agree with you more. As healthcare executives we should absolutely be leading the charge on many aspects of the business of health, not just those that affect hospitals directly. Furthermore, we should be doing everything we can to keep people out of our hospitals. This matter is no doubt very complex; as you say, it’s a societal issue and a public health issue as well.

I hope to engage the Massachusetts Hospital Association (MHA) Board of Trustees on this topic, particularly as Massachusetts considers its own options. But we shouldn’t wait for a “convening discussion.” I hope all leaders in the hospital arena will do what they can both publicly and privately to help advance this issue in a way that safeguards the communities we serve to a better degree.