Rand Paul Blocks Surgeon General Nomination For Calling Guns A Health Threat

Rand Paul has placed a hold on Dr. Vivek Murthy, Obama’s nominee for Surgeon General, because of calling guns a significant public health threat. Paul stated, “As a physician, I am deeply concerned that he has advocated that doctors use their position of trust to ask patients, including minors, details about gun ownership in the home.”

As I have discussed before, this position is based upon recommendations of medical organizations which are justifiably concerned about the health risks of gun violence in this country. Following the Newton shootings fifty-two medical organizations including the American Medical Association, American Psychiatric Association, American College of Physicians, American College of Surgeons, American Academy of Family Physicians and American Academy of Pediatrics sent a letter to President Obama requesting such intervention.

The text of the letter (pdf here) follows (emphasis mine):

The undersigned medical organizations, together representing the vast majority of practicing physicians and medical students in the United States, share the nation’s grief and sadness over the recent tragic school shootings in Connecticut. As physicians, we see first-hand the devastating consequences of gun violence to victims and their families. We offer our experience and expertise in finding workable, common sense solutions to reduce the epidemic of gun violence—indeed the overall culture of violence—in America. We also urge the nation to strengthen its commitment and resources to comprehensive access to mental health services, including screening, prevention, and treatment.

The investigation into the Connecticut shootings is still continuing, and the issues surrounding such violence are often complex and can vary significantly from case to case. Strategies for preventing gun-related tragedies must also be complex and carefully considered. The relatively easy access to the increased firepower of assault weapons, semi-automatic firearms, high-capacity magazines, and high-velocity ammunition heightens the risk of multiple gunshot wounds and severe penetrating trauma, resulting in more critical injuries and deaths. Even for those who manage to survive gun violence involving these weapons, the severity and lasting impact of their wounds, disabilities and treatment leads to devastating consequences for families affected and society, and contributes to high medical costs for treatment and recovery. Renewing and strengthening the assault weapons ban, including banning high-capacity magazines, would be a step in the right direction.

Many of the deaths and injuries resulting from firearms are preventable. More resources are needed for safety education programs that promote more responsible use and storage of firearms. Physicians need to be able to have frank discussions with their patients and parents of patients about firearm safety issues and risks to help them safeguard their families from accidents. While the overwhelming majority of patients with mental illness are not violent, physicians and other health professionals must be trained to respond to those who have a mental illness that might make them more prone to commit violence. Funding needs to be available for increased research on violence prevention in general, and on the epidemiology of gun-related injuries and deaths in particular, as well as to implement available evidence-based interventions. Of equal importance is providing sufficient access to mental health services. While we strongly supported the passage of the Mental Health Parity Act of 2008, unfortunately, the promise of better access top psychiatric treatment will not be a reality absent requisite federal and state funding. This effort should be combined with an education campaign that reduces the stigma of seeking mental health services.

Newtown, Connecticut has now been added to the sad litany of recent mass shootings, including Columbine, Virginia Tech, Fort Hood, Arizona, and Aurora. As we come together as a nation to mourn the most recent victims of senseless gun violence, we must make a real and lasting commitment to work together on meaningful solutions to prevent future tragedies. We stand ready to work with Congress and the Administration to make progress in protecting our communities, especially our children, from this epidemic of violence.

We would expect that a nominee for Surgeon General would support the recommendations of these medical organizations. Discussing the presence of guns in the home does not mean these medical organizations are advocating banning guns. Medical organizations recommend that physicians ask about a wide variety of potential risks. When we ask patients about use of seat belts we are not seeking to ban automobiles. When we ask elderly patients about electrical cords which could present a risk for falls we are not seeking to ban electric lights. When we discuss keeping medications safe and out of the hands of children we are not seeking to ban medications.

Think Progress has more on how Rand Paul’s view is out of step with that of the medical profession:

The idea that gun violence is a danger to public health is utterly uncontroversial among doctors’ groups, academic institutions that focus on public health, and children’s safety advocates. Although Paul criticizes Murthy’s position that physicians and pediatricians should ask patients about the presence of guns in their households, the American Medical Association (AMA) adopted a resolution in 2011 officially opposing any law that bars doctors from having open conversations about gun safety and the risks of having firearms in a household with their patients.

In fact, just yesterday, the American Academy of Pediatrics (AAP) issued new guidelines recommending that households with children who are diagnosed with depression should remove guns and ammunition from their homes entirely.

Not only would Obama’s nominee for Surgeon General be making recommendations in the mainstream of medicine today, Murthy’s views are consistent with those of Reagan-appointee for Surgeon General C. Everett Koop who has written about the dangers of gun violence.

Cross posted at The Moderate Voice

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4 Comments

  1. 1
    Randy says:

    Hi Ron,
    I’m a solo family practice doc in a small town in the Midwest.  I’ll start by saying I don’t agree with Rand Paul blocking the nomination and am glad Obama’s candidate was confirmed.  With very rare exception, Obama has the right as president to have the nominee of his choosing confirmed.
    Where I disagree is with the implication that there is wide agreement among doctors on whether we should be asking patients, especially children, about guns in the house.  If I have a reason to ask then I will (generally in the case where there is someone violent in the home) but not in the context of routine physicals or well child checks.  If I understand Dr. Murthy’s position he believes we should be asking these questions routinely.  I also don’t agree with the characterization of guns as a health problem in the same sense as a disease.  They are a hazard in the same way electrical cords and cars are.
    I understand many medical organizations support the practice, but as I’m sure you know there is something of a disconnect between these organizations and docs “in the field”.  They tend to be dominated by academics and in my opinion don’t have a very good understanding of what private docs do all day.  It looks like you are self-employed so maybe you know what I mean.  If you go to a website like Sermo, or even the discussion board for the EMR I use, you will find a great deal of disdain for and disagreement with these organizations.    Many of them seem to exist to line their own pockets.
    Anyway thanks for the soapbox.  I see from your other website you specialize in diabetes, something I always wish I was better at controlling.

  2. 2
    Ron Chusid says:

    Disagreeing with a practice recommendation is one thing, but to block a nomination for Surgeon General for backing the recommendations of multiple medical organizations is a different thing. I see that you also disagree with blocking the nomination, which is the main point here.

    Like it or not, I think that many forces are pushing us to follow practice guidelines. On the one hand they can be a pain and there could be valid arguments as to why they don’t apply in actual practice. On the other hand, beyond hopefully being of value, reimbursement is increasingly being tied to quality measures based upon following practice recommendations. If nothing else, I find all the extra money I’m now paid for various forms of quality-based bonuses helps make it more tolerable to go along. While I don’t treat kids and this specific example doesn’t apply to my practice, there are analogous examples. For example, I have added questions such as loose rugs or electrical cords being exposed in the home to my standard geriatric H&P and Wellness Exams based upon practice guidelines regarding fall assessment.

    In addition, following practice guidelines should provide some protection if ever hit with a related malpractice suit, and create risks if ignored. Would you really put it past a lawyer to go after a doctor if a child was killed by a gun in the home and the doctor never asked about it? (This raises the question of who would file the suit as the parent who owned the gun would not be in a good position to sue, but what if the parents are divorced and a wife sues an ex-husband and the doctor when her child is killed).

  3. 3
    Randy says:

    If you’re making much from quality bonuses I believe you’re in the minority.  I’ve been working on PQRS and Meaningful Use mainly to avoid the Medicare pay cuts in 2015.  The small bonuses from them do not equal the time and expense necessary to qualify for them, and will be phased out in a couple of years anyway.  I do agree that “pay for performance” is the way of the future for better or worse.
     
    Fear of litigation is kind of a far-fetched reason to ask kids about guns in well-child visits.  Although it may be recommended by some professional organizations, in my view there is not a widespread consensus among practicing physicians.  I believe I’m like most physicians in that I take guidelines with a grain of salt and combine them with my best judgment for the individual patient.

  4. 4
    Ron Chusid says:

    I don’t know how I compare to others, but I’m receiving a fairly substantial amount of money from various types of incentive bonuses based upon quality measures from both Medicare and Blue Cross. The Medicare ones are being phased out but not the ones from Blue Cross. As Medicare is trying to change to payment based more upon quality, it is likely that the same types of measures will continue to influence pay even when the current programs are phased out.

    Often the bonuses come down to controlling diabetics, having  a high percentage of female patients have mammograms, etc. (For the moment I’ll ignore the recent questions regarding mammograms). I have also spent a lot of time on paperwork regarding Medical Home bonuses, but in the end the payments made it worthwhile. (I’m also not surprised by the studies questioning the value of Medical Homes–basically I do what I always did clinically but now do more paperwork to get the bonuses).

    I don’t think that documentation of following practice guidelines is a bad idea at all  from the point of view of defense should there ever be a malpractice suit. Obviously the situation has to be considered. In some cases where guidelines involve medications to be used there are legitimate reasons not to follow a guideline, such as patient response to the medication or the presence of other medical conditions. (One reason guidelines cannot be followed blindly is that most patients do not have a single problem which guidelines often address.)

    When we are dealing with questions to ask, there is far less of a downside risk to following guidelines as opposed to prescribing a medication which might be contraindicated for certain patients. However I don’t deal with children so I can’t say whether this particular guideline is followed widely.

    Besides the Medicare and Blue Cross incentive bonuses which are the largest, it seems like every managed care plan is also paying bonuses these days, and hopefully those aren’t going away. It takes a bit of time to make sure they have up to date quality data, but in the end it is worth the time.

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