Physicians Practice on Evidence. But We’re Kept from Gun Research. Why?

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We treat and counsel injured patients every day. Usually, we use science to guide our practice. Ample evidence supports how we evaluate and resuscitate our injured patients. We know when to transfuse blood, which tests to order, and when a patient should go straight to the operating room.

For most of our patients, we also have guidelines to support our counseling about risk factors. For instance, we know that screening and delivering brief interventions during an ED visit can reduce drinking-related injuries, reduce use of opioids, and address multiple other risk factors; these interventions can reduce later injuries, reduce costs (including for violent injury!), and reduce future ED visits and deaths. As a profession, we have conducted an immense corpus of research to address preventable risk factors for our most common diseases and injury mechanisms.

Unfortunately — despite the fact that, each year, we treat approximately 80,000 ED patients for firearm injuries — we know little about what ED providers can do to help prevent future firearm injury. We know how to treat the physical wound. But we do not have the tools to effectively prevent subsequent injuries or deaths.

Most firearm deaths are sustained by older white men, living in rural areas, who commit suicide. The risk factors for these deaths — and the interventions that are likely to be effective — are very different from those of young women killed by their domestic partner, or of young men killed in an urban community that is being destroyed by violence. But we don’t yet know what type of screening and counseling would save the life of a victim of domestic violence whose partner owns a gun — versus a suicidal teen whose father owns a gun — versus a young man who has just been in his first physical fight and who has friends with guns.

We also lack evidence to help our patients, and our colleagues, in preventing the mental aftermath of trauma. Exposure to firearm injury and death has huge ripple effects, on friends, family, first responders, and the greater community. Rates of depression, anxiety, PTSD, and substance abuse — as well as a contagion of violence — soar after exposure to violence. As physicians, we are used to addressing mental illness and substance use. We just don’t know how to do so after a firearm injury or death.

All of this begs the question: Why don’t we have this evidence we need to guide our practice?

Despite the fact that firearm injury has a similar burden of injury to that of sepsis, research is funded at only ~2% of what would be expected. Federal funding on opioids — which have only a slightly higher mortality burden than firearms — is over 100x higher than that for firearm injury. And this lack of funding is despite specific calls from the National Academy of Medicine (formerly the Institute of Medicine) and from multiple physician organizations (including my own specialty organization, the American College of Emergency Physicians). This lack of federal funding for research persists despite repeated proof that — with adequate federal funding — we can work, as physicians and public health researchers, to reduce the burden of injury.

Even former Representative Jay Dickey — the man who started this ban on federal funding — called for lifting the de facto ban on federal funding.

This lack of federal funding for firearm injury research is important for three reasons.

First, federally funded grants are generally perceived as more impartial and more rigorous than grants funded by (often biased) private groups. Just think about the debate over the ethics of pharmaceutical-company-funded drug research!

Second, the lack of federal funding means that researchers are unable to develop the large, ambitious studies that this field desperately needs. Prevention studies are expensive and time-consuming if they are to be done well. Only the federal government, traditionally, has funded the types of ground-breaking prevention research that this field needs.

Third, the lack of funding has largely dissuaded a generation of scientists — afraid of being black-balled — from entering the field. Without an adequate number of researchers, we will never succeed in solving the large variety of issues that contribute to firearm injury. A number of researchers have attempted to close this gap on their own, with private or state funds. But these researchers are not, in themselves, sufficient for the size of the problem. Imagine if I told you that there were only 16 federally-funded researchers in the field of sepsis?! Firearm injury prevention needs more bright minds.

One final point is worth emphasizing. Firearm injury prevention research is not the same thing as gun control. Advocates on both sides of the political aisle seem to think that researchers are pulling a fast one — that we want to do research simply so that we’ll have proof to take away guns. This is not the point. As a nation, we have reduced deaths and injuries from a multitude of injury mechanisms — ranging from cars to childhood poisonings to pools — through well-done, unbiased research. We have reduced these death rates without getting rid of these entities. Instead, we have designed safer cars, pill bottles, and pools. We have educated people about how to use them more safely. We have provided physicians with evidence-based tools to provide anticipatory guidance and to counsel at-risk patients about each of these types of injury.

As our patients continue to die from gunshot wounds, the time is long overdue for us to do the same for firearm injury.

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