Everybody, we're going to go ahead and get started. We have a lot to get to today. By way of very brief introduction I will introduce our five speakers today. We have Dr. Dan Carey who's the secretary of health and human resources for the Commonwealth of Virginia, Dr. William Fox who's the governor of the Virginia chapter of ACP, Dr. Katie Jaffe, an assistant professor of medicine here at UVA, Dr. Mo Nadkarni, professor of medicine EPA, and Dr. Peggy Plews-Ogan, professor of medicine at UVA. They're going to be talking about, This is Your Lane, the public health response to gun violence. So join me in welcoming them and we'll get started. [APPLAUSE] So, many of us are touched by gun violence in the United States. These are our stories. I'm Peggy Plews-Ogab, my father committed suicide with a gun. I'm Michael Williams a trauma surgeon, I have witnessed eight gunshot wounds occurring in hospitals. I'm Katie Jaffe, standing in for Sharon Diamond-Myrsten from family medicine who couldn't be here today. When she was in high school her friend and fellow cheerleader died of a gunshot wound while eating lunch at McDonald's. She was 18 years old and an innocent bystander. I'm Jim Plews-Ogan from pediatrics. A friend of mine, Dr. Kevin Granada, a brilliant surgeon who was a pioneer in robotics for the treatment of cerebral palsy in adults and children, was a neighbor and a friend. His kids played with our kids. He was killed protecting his students at Virginia Tech. I'm John Schorling. My father who was a physician killed himself with a gun. And many of us here knew Carlos Gomez, who was a resident and attending who also killed himself with a gun. I was threatened by a patient with a gun at University of Medical Associates, our training continuity clinic for our residents. These are just a few of the stories that touch our lives as physicians. There are many more. During this grand rounds, every 4 and a half minutes you're going to hear a bell, a gong. And that is in reference to the fact that every four minutes someone is killed or injured in the United States by a gun. Secretary Carey. Thank you and thank you for having me to this very important forum and a very important topic. I just want to continue to get it started that I hope, from my perspective, that you leave here today as physicians, as physicians in training, as other health care professionals, acknowledging our role that we have in influencing gun violence in the commonwealth and in the country. We're a trusted source of information and risk factors, whether it be for suicide or domestic violence, having a gun in the home is one of those social determinants of health, just like access to transportation, access to nutrition, access to shelter. It's something we need to be aware of, we need to ask about in our clinical roles. And also because of its great toll, we need to be spokespeople in the public square as well. So I look forward to participating in today's discussion. Thank you for your interest and thank you for all the other speakers. Thank you for having me. Thank you. Hi, can people hear me, with the mic? I think most of you know, I'm Mo Nadkarni, one of the general internists. And I'm really happy to be here and see so many people turn out. So thanks for coming. To just quote, no disclosures except that Dr. Fox is the governor of the Virginia ACP, and Dr. Carey of course is the secretary of health for the state of Virginia. I'm here to help begin the conversation of gun violence as a public health problem, as opposed to just a gun problem. And to do that I'm going to take you through some of the epidemiology that we have. So as you've just heard, some very poignant stories. 58% of American adults or someone they care for have experienced gun violence in their lifetime. And every day, 100 Americans are killed with guns. So let's start by talking about gun ownership. So across the world there are 857 million guns owned by civilians worldwide. The USA has 4% of the US civilian population and they own 46% of all the guns in the world, that's 393 million guns. USA civilians own more guns than the top 25 next highest countries in terms of gun ownership. And that 393 million number calculates out to about 1.2 guns for every man, woman, and child in the United States. In fact, in April and May of 2018 US civilians bought 4.7 million guns. 4.7 million is a big number. That's sort of like Peggy's salary for two months. But in fact, it's actually more than all that are stockpiled for US military weapons in the United States. We know that higher rates of gun ownership are associated with higher suicide rates, which we'll talk about later, and higher accidental gun death rates. So let's talk about gun deaths in terms of rates of deaths. So if you look at the United States, we have a 10.2 per 100,000 population rate of death or mortality related to guns each year. And that of course dwarfs that of the rest of the world. If you look nationally, and thank you to Secretary Carey for some of the Virginia data, we almost exactly mimic the national data here in Virginia, about 10.2. And remember that 10.2 number for me. So let's talk a little bit about public health threats. Let's see if this will work. But if you look at lung cancer, about 50,000 people per year die. Opioids, which of course are getting a lot of publicity, rightfully so, 47,000. You look at breast cancer, 41,000 people die per year. You look at gun-related violence, 39,776. So we're right in the ballpark. More than prostate cancer at 31,000, HIV at 15,000. And I think it's important to recognize that in 1990 the death rate for HIV was actually 10.2. And over the last 30 years the cause, HIV, has been looked at as a public health problem and treated not just as a medical problem. We've seen a drop down to 1.6 or 15,000 per year. So what does that mean? That means public education was used. We had IV drug needle exchanges that were put into place, public condom availability was increased. So it wasn't just treated with increased medications that made the difference. It was improved because there was a public health response. And then if you look a little further down, we've got vaping, which there was making the rounds just a few weeks ago. That number has now jumped up to a massive 39 per year, and we'll talk about that in a second. And then we have lettuce-related E. coli at five. So we'll talk about that for a second. So vaping deaths, 39, not 33. And you've just heard this week that Juul has decided to suspend sale of flavored e-cigarettes, which are the most dangerous because they're the most attractive to children. And the FDA under Trump it's expected to ban all e-cigarette flavors except tobacco and menthol in the coming weeks. And I think that's an interesting parallel, because we have lots of guns, but then there are especially dangerous types of guns. We ban dangerous e-cigarettes, but we haven't banned the most dangerous types of guns, called assault weapons. Now let's talk about food safety versus gun safety. So in 2018, we had a epidemic of E. Coli. Related deaths, there were five. And there was immediately put into effect a temporary ban based on the five deaths. And in fact, just last week, the FDA released a new tracking program for all agricultural products in the United States, which basically registers and can track each of the lots that come out. So we haven't had a big backlash from the American Lettuce Association about registering romaine. We haven't had a big backlash from the American Artichoke Association about background checks for artichokes. But we seem to have a lot of backlash about gun control. In fact, how many of you know what a Kinder Egg is? Anybody been to Europe? The little chocolate eggs, they have little toys inside them. Well, this was thought to be a huge risk and they were banned until 2017. But assault weapons have not. So let's talk about numbers. Gun related deaths in the United States, about 36,000 in 2017, now up to 39,000 as I mentioned. About 22,000 of them are related to suicide each year, 12,000 to homicide, unintentional about 500, law enforcement about 500 although that's felt to be underestimated by a factor of 10 by the Washington Post, and undetermined 300. If you look at these numbers in Virginia, you can see that it's exactly the same, two-thirds are related to suicide, one-third are related to homicide. And then if you move from deaths to injuries, 100,000 injuries per year. About 75% of them are related to assaults, 18,000 or 18% are related to unintentional injuries. Self-harm or suicide-related injuries, 4,000. And then shootings by law enforcement about 1.3%. And then if you talk about cost of injuries, between 2003 and 2013, about 30,000 hospital admissions for firearm injuries occurred. That's about 20,000 per handgun, or 32,000 per admission per assault weapon. And if you take the lifetime cost for one year's worth of gun injuries, it's $2.3 billion, that's billion not million. So let's talk a little bit about suicide then, gun-related suicide. 22,000 Americans die of firearm suicide every year, or two-thirds of all firearm deaths. And typically these are actually committed by white men in rural areas, which are about 75% of all firearm suicide victims in the United States. Suicides using guns are far more deadly than other means. 85% of all suicide attempts by guns are successful compared to all other methods of suicide, where it's a less than 5% success rate, if you will. And if you look at the Virginia data, once again white men are victims of gun related suicide at a rate of 5.6 that of white women, and about three times that of black men. So switching from suicide to homicide, in the United States homicides account for about one-third of gun deaths, 13,000 per year. And if you're black you have a 10 times more likely chance of being killed in a homicide than white Americans. And particularly if you're a young black man you have a 19 times more likely likelihood of dying in a gun homicide than if you were a young white man. So from there we'll go to causes of death in children and teens. In 2017 firearm deaths were number two, just slightly less than motor vehicle accidents, 3,400 instead of 3,600. And it doubled the rate of cancer death for children and teens in the United States. So gun violence does affect children in the United States. Over a period of nine years in the United States 75,000 youths were sent to the emergency room as a result of firearm injuries. That's about 8,000 kids per year. And each of those admissions cost about $45,000. Now if we move to domestic violence, approximately 4.5 million women alive today have been threatened by a gun by an intimate partner. And the references are a little hard to read, but they're down low. 1 million US women have actually been shot or shot at by their partner. And in an average year about 600 women will be killed and shot to death by an intimate partner, and many more of course are injured. And I don't have to tell you, the things that get the most publicity are mass shootings in the United States. So between January 1st and September 30th of this year, there were 20 mass shootings, meaning more than four people exclusive of the gun man or gun woman that have occurred in the United States. And you can see there's no one region that necessarily is higher than another. And then when we talk about subsets of mass shootings, we've got school shootings, events like the Marjory Stoneman Douglas High School shooting in Parkland which everybody's familiar with. There was a study that showed that 75% of high school students cited mass shootings as a primary source of stress. In a Washington Post analysis of the 31 largest cities in 2017 and 2018 that $4.1 million American students, including 1 million elementary school students, had been in lockdown. Despite that, just this week it was reported that the NRA foundation is raising money by auctioning off of guns at schools to the dismay of some parents. So I thought I would share with you-- let's see if we can get this-- just one ad, let's see. Can you help me? Just click on the ad there. Oops, go back. I think we have to switch it over to that screen, and to roll over it on that screen. There you go. This year my mom got me the perfect bag for back to school. These colorful binders helped me stay organized. These headphones are just what I need for studying. These new sneakers or just what I need for the new year. [SCREAMING] This jacket is a real must-have. My parents got me the skateboard I wanted. It's pretty cool. [SCREAMING] These scissors really come in handy in art class. [GUN FIRING] These colored pencils too. The new socks, they can be a real lifesaver. I finally got my own phone to stay in touch with my mom. [DOOR OPENING] [FOOT STEPS] [SOBBING] That was produced by the Sandy Hook Promise, which is trying to end gun violence in America. So in closing I think it's just really important for us to realize that this is a public health threat. We need to approach it as a public health threat. And to talk about how the ACP is going to handle that. I'll hand it over to Dr. Fox. Thank you. I need a little help here. So thank you guys so much for having me. I really appreciate this opportunity. It's so great to be back at UVA. Keep going. My day job, by the way, my name is Bill Fox, again. And my day job is I'm an outpatient internist in a small, independent practice here in Charlottesville. So those independent practices, they still exist. But I'm going to be speaking to the ACP perspective on gun violence. And I want to start with this story. Because it has a cool local connection, I think. So I would be really surprised if anyone knew who this gentleman is. But in the 1970s and 1980s he worked about 20 miles up the road at the Insurance Institute for Highway Safety, if you've ever passed that on the road. He was the president there. His name is Dr. William Hadden. He is-- or he was a Harvard trained physician, and also a master of public health. And before he had that job in Charlottesville-- can everyone hear me? Before he had that job, he was the first director of the National Highway Traffic Safety Administration. So you're probably asking, well, why is that germane to a talk on gun safety? So in 1925 when automobile travel was just taking off in this country, there were 21,000 deaths on the roads. That translates to a rate of 18 deaths per 100 million miles driven. Today that number has plummeted to two. So how we got from 18 to two was not by chance. It was a concerted and broad-based effort, led by people like Dr. Hadden and others, who first researched what it is that cause motor vehicle fatalities. And then safety improvements, which at the time included things like three point seatbelts, guardrails, infant car seats, and a concerted effort to combat DUI. In his own words, Dr. Hadden said this, the understanding and prevention of disease and injuries should be the first strategy of medicine. And that no treatment, no matter how necessary, is not the logical first line of attack. Nothing better in my mind encapsulates the rationale for a public health approach to firearms injuries than that statement. The ACP has an almost 25 year history of advocating for sensible gun safety. We published our first evidence-based position statement in 2015. That was updated recently, October 2018. There are a total of 34 position statements and recommendations in the paper. I don't have a lot of time so I've only picked out five. But I do encourage you to read the entire paper when you get a chance. First, and I'm standing in a room full of educators, and some of you probably play a role in curriculum development for the medical students or the residents. Physicians should become informed. Medical schools, residency programs, and CME programs should incorporate firearms violence prevention into their curricula. Now, this seems self-evident to me. But it is not evident to everybody, including the former assistant dean of my medical school alma mater, University of Pennsylvania Dr. Stanley Goldfarb. In this Wall Street Journal editorial Take Two Aspirin and Call Me By My Pronouns, which by the way, was published just six weeks ago, Dr. Goldfarb argued that teaching medical students and residents about issues like fire arms injuries or even climate change or other quote, unquote social issues interfered with what he would consider a rigorous and classic scientific education. I and the ACP respectfully disagree with that. Number two, ACP supports a universal background check system, including sales by gun dealers, sales at gun shows, and private sales to keep guns out of the hands of felons, persons with mental illnesses that put them at greater risk of inflicting harm to themselves or others, and that's an important emphasis, persons with substance use disorders, and domestic violence offenders. For some perspective, in 2018 greater than 26 million gun purchasers submitted to background checks. 100,000 were denied purchase. But 22% of gun acquisitions take place without a background check. And that translates to 8 million guns transferring hands without any background check. States addressing gun show loopholes export fewer guns later used in crimes. And we have known for many years now that there is strong public support for universal background checks. Here are references on that section. Number three, ACP supports strengthening and enforcing state and federal laws to prohibit convicted domestic violence offenders from purchasing or possessing firearms. The important point here, domestic violence offenders should include dating partners, cohabitants, stalkers, and those who victimize a family member other than a partner or child. Individuals subject to domestic violence restraining orders, including temporary orders, should be prohibited from purchasing and possessing firearms. Now, federal laws prohibiting domestic abusers from accessing guns apply only to spouses, parents, guardians, and not dating partners, not stalkers, and not other relatives. But half of intimate partner cases involve dating partners. In addition, federal law does not restrict an abuser's access to firearms until the restraining order is permanent. States with laws which cover emergency protective orders in addition to final protective orders experience a 16% reduction in intimate partner gun homicides and references for that. Number four, ACP favors enactment of legislation to ban the manufacture, sale, transfer, and subsequent ownership of semi-automatic firearms that are designed to increase rapid killing, AKA, assault weapons and large capacity magazines. Now, we've been down this road once before, the federal assault weapons ban of '94. And the results of that have been somewhat debated because there was a grandfathering stipulation during that law. And it made it difficult to judge the overall effect of the law or to tease out the differences between the assault weapon ban and the large capacity magazine ban. But we do know that crime data from six major cities after the ban took effect found that crimes involving the most common types of assault weapons did decrease by 17% to 72%. Finally, ACP supports the enactment of extreme risk protection orders, which allow family members and law enforcement to petition a court to temporarily remove firearms from individuals who are determined to be an at imminent risk of harming themselves or others. Although most of the ERPO laws have been enacted recently, data from the earliest adopter state Connecticut suggests that they have been somewhat effective in reducing the suicide rate at least. An analysis of population level data for self injury determined that about 72 suicides were averted due to the law since its inception, 1999 through 2013. Now, in response to our paper in October 2018 the NRA tweeted, someone should tell self-important doctors stay in your lane. Well, we physicians were not going to have any of that. We were quick to respond, first the ACP leadership, and then the Annals of Internal Medicine. Tell the NRA to stay in its own lane and out of the exam room. Take a stand today. And then the public response. Doctors say bullets in their patients are very much their business. We are not anti-gun, we are anti-bullet-holes-in-our-patients. And then from Joseph Sakran, the trauma surgeon at Hopkins, very influential in this field, where are you when I'm having to tell those families their loved one has died? And then it went viral. This is our lane, this is my lane. First patient, first and very personal. First patient, first day of residency, gunshot wound, he didn't make it. Can't post a patient photo, this is a selfie. And then more and more graphic. I think the paper, and the NRA response, and then your response to that NRA tweet has really touched a nerve. I'm just going to leave things as I conclude, again, with the words of Dr. Hadden. And then I will turn things over to Katie Jaffe so that she can instruct us in what we can do in the office to help our patients. Thank you. So can you hear me? So I'm going to talk in this segment about clinical interventions for preventing firearm violence. This photo was taken of my uncle not long before he ended his life with a self-inflicted gunshot wound. And this is my grandmother, she was the one who found him. You can imagine the grief and the trauma she felt as his mother. Suicide is the most common form of firearm death. And we know that nearly half of all patients who commit suicide will present to their physician in the 30 days prior to committing suicide. I believe we can play a role in curbing this form of firearm violence among our patients and also instances of homicide and accidental death. The most common reasons cited for gun ownership is self-protection. And yet the evidence shows having access to firearms increases the likelihood of homicide victimization and completed suicide. And individuals with access to loaded firearms and or unlocked firearms have increased risk of suicide, relative to individuals with unloaded locked guns. Dr. Nadkarni outlined some of the demographic data that you might take into account when you're determining who to counsel on firearm violence. We frankly may not have time to talk to everybody about this issue. But we know from the epidemiology that older Caucasian men are at higher risk for suicide. And younger African-American males are at higher risk for homicide victimization. There are other risk factors that we can take into account as well. These include prior exposure to violent behavior, either as a victim or a perpetrator. A history of severe mental illness, which primarily increases risk for suicide. A history of substance abuse, especially alcohol use disorder. Dementia or other forms of impaired cognition and judgment. And finally children in the homes where firearms are present are at increased risk. So how do you talk to your patients about firearms? You don't want to be judgmental, you want to focus on patient safety and well-being. And you want to educate. In some cases the focus will be on educating your patients on safe storage, so patients should be using a locked gun cabinet for storage. And they should store the guns unloaded. They should keep ammunition separate from the firearm and use trigger locks. In other cases, those of elevated risk, you're going to be educating patients on the potential dangers of having a firearm in their home and options for transferring the firearm off site. So this might be the kind of conversation, you'd have with someone who's severely depressed, or has a history of suicidal ideation, or is a victim of domestic abuse. And finally if you feel the patient is actively suicidal or homicidal then you want to take immediate action to maintain the safety of the patient and others. I'm going to transition to going over a few cases loosely based on patients I've seen in my clinic. And I might ask for your participation in answering these. So 50-year-old businessman comes into your clinic, he's with his wife, he's been having suicidal thoughts since losing this job. He endorses owning a firearm, and he's been having thoughts of using it to end his life. His wife asks if the firearm can be given to his friends to help keep him safe. So what is your next step? Do you A, start an SSRI, refer for counseling, and tell him he should give the gun to his friend for safekeeping, and ask his wife to help make sure this happens? Or do you B, send them to the emergency room via medic 5 for inpatient management of acute suicidal ideation? If he refuses inpatient evaluation, contact the magistrate to initiate a TDO. Or do you C, discuss with him and his wife the legal options for transferring the firearm in the state of Virginia due to a loophole in background check legislation, he could give his firearm to his friend. Encourage them to consider transferring the firearm to the police as an alternative. Or is the answer D, which is both B and C? So a show of hands for A? for B, C, or D? Yeah, in this case he's the acutely suicidal. He needs to be treated immediately and he can't be left alone until he's treated. But it's still an opportunity to talk about the firearm in his home. Because probably even when he's feeling a little better he's not the kind of person you'd want to keep a firearm. And he's asking about how he might transfer it to someone else. And so you have an opportunity to talk to him about those options. And while I think we would all be safer with universal background checks, that's not what we have in the state of Virginia currently. And it is legal for him to give his firearm to a friend, a family member, or a neighbor. But I would encourage him to turn it over to the police. So our next case, this is an 89-year-old farmer who's brought in by his wife. She's concerned about his memory and worried he's developing dementia. His SLUMS score it 19, which is consistent with a diagnosis of dementia. So which of the following is important to address during this visit? A, you want to counsel the patient about not driving, B, investigate for the underlying etiology of his cognitive impairment, C, ask about firearms and if president counsel on the importance of keeping the firearms lock and unloaded or transferring them out of the home, D, verify if the patient has previously completed an advance directive and that you have this on file, or E, all of the above. So I'm just going to go ahead and give you the answer. You want to talk about all of these things. If you're worried about someone driving, you should also be worried about their access to firearms. This is not the kind of person who you want to have easy access. Something accidental and dangerous could happen. Final case, this is a 42-year-old female coming in for a routine follow up. She's a smoker and you want to talk about smoking cessation. But she reports she's got too much stress going on in her life to talk about quitting smoking now. And you find out that her live-in boyfriend is abusive. And he has a history of a domestic violence misdemeanor. What should you do next? Do you A, provide contact information for the local shelter, a support group, and counseling services, or B, encouraged patient to obtain a firearm for protection? C, ask about firearms in the home and counsel her that she's at increased risk of being the victim of firearm violence. Explain that legally her partner does not have the right to possess a firearm given his history of a domestic violence misdemeanor. So anybody, a show of hands for A? And B, C? So the answer is actually A. This partner of hers has this domestic violence misdemeanor history. But in the state of Virginia currently, that does not prohibit him from possessing a firearm. She is at increased risk and you do want to get her out of that situation. And that's why you want to help her to get to a local shelter. We all know that doesn't always happen. If the firearm in the home belongs to her, you want to help her find a way to get it out of the home. If it's out of her control and belongs to the dangerous partner, you want to get her out of the home, which is always your goal. But you also want to talk to her about avoiding the rooms in the house where the guns are in periods escalation and tension between the two individuals. But unfortunately, this history of a domestic violence misdemeanor does not prohibit the perpetrator from having a firearm. So I'm just going to, in summary, I want us all to be thinking about talking to our patients about firearm violence. We want to identify risk factors and counsel on transfer out of the hands of those at risk, and counsel on safe storage. And as physicians, we also want to be promoting legislation that promotes gun safety. And so up next we have Dr. Dan Carey who's going to talk to us about legislative initiatives in Richmond currently for meeting that goal. All right, good afternoon again. And thank you for the quality of discussion. I hope I can live up to that high standard. And I do want to give-- just a couple of things. First, a little add on to the some of the metrics in gun violence, just a little bit in Virginia. I don't think I-- slides are advanced here, right? Oh, here we go. so here's a list of the actual eight legislative suggestions that were put through by the governor in response to-- really, these were in play in last year's legislative session. But we're also reintroduced. And I'll get to those in a moment. First, just a word about me. I'm a clinical cardiologist. I had the pleasure of practicing, I see Chris Cramer in the back. We shared patients along the way. I was the head of the heart center down in Lynchburg and practiced cardiology and vascular medicine. And I'm thrilled to be in this role. It's an incredible opportunity to serve, to bring a clinician's perspective on both prevention, and treatment, and diagnosis, but also data-driven solutions. And I realize in public policy it's not always possible to have data-driven solutions. We heard a little bit about what's effective. But in such large levers, in complex situations it's hard always to see the exact cause and effect. We don't have a randomized controlled trials of these interventions like we do with a new drug or a new therapy. But that doesn't mean we can't gather evidence. And it doesn't mean we can't act for what this really is, which his gun violence is indeed a public health emergency in Virginia and across the country. We know that Virginians are confronting the threat of gun violence every day in their homes, in our schools, our workplaces, and in our communities. In 2017, there were 1,028 lives lost in Virginia due to gun violence. And this number of rose in 2018. Our children think that a lock down and active shooter drills are normal. And the most recent Virginia youth survey showed that over 21% of high school girls and over 10% of high school boys have seriously considered suicide in the last year. And each year we lose almost 200 veterans to suicide from gun violence. So unfortunately our public health data tells us that the majority of family and intimate partner homicides occurred with the use of a firearm. We can and we must do better to protect our families, our communities. Because we can't expect our communities to be healthy and thrive when such violence is prevalent. And it's time to stop focusing on the aftermath of gun violence and focus instead on prevention and intervention. And it's also time that we clinicians lead the way in this very, very important topic. Earlier this year our office hosted and participated in a number-- and I think I've got a picture here. Oh, the very front. We had it in the very front. So there is a picture. I, as the secretary of health and human resources, coming from a public health perspective, along with Secretary Brian Moran, the secretary of public safety and homeland security hosted a number of listening sessions across the commonwealth after the Virginia Beach event. And after the governor had called for a special session to deal with gun violence prevention. And it was quite educational. I mean, we had many of the folks at the perspectives that have been represented in this room. Trauma surgeons, teachers, victims, especially intimate partner victims of violence, telling us their stories firsthand like you've heard today. But there is another side of the story. And this is a highly emotional issue. And the more that we as clinicians can bring data and also focus on the fact of those 1,000 gun deaths in Virginia, 60% as you indicated, are suicides. And again, 200 of those are suicide of veterans. And if you add the additional homicides that are intimate partner violence, and often identifiable based on history and risk factors, an exacerbation of non-gun-related violence. And as we see has been mentioned with the red flag laws and the like, there's an opportunity indeed to intervene. So legislatively at the state level since taking office, Governor Northam has consistently advanced and supported legislation that will prevent gun violence in the Commonwealth. While it is still early to discuss legislative packages for 2020 at the General Assembly, the northern administration has previously introduced several pieces of legislation. I'll go over those one by one. They were in the special session that the governor called the-- I think you know the story. And again, I see this issue a lot like expansion of Medicaid. That there is an 85% in favor across the commonwealth, a 60% amongst Republicans. And I think this has become an issue that again, folks came out because you're coming for your hunting rifle. You're coming for your deer rifle. If you look at the interventions that are proposed, and again, we'll likely learn over the years if we pass this package of eight things, we learn in five years looking at our statistics just like the example of the National Highway Safety Institute or something like that. I think I had it about right. We will learn and we can iterate and if something is not successful. I do think as a start, we need a culture of safety around guns. Because indeed, they are unsafe and causing harm in the commonwealth. So these legislative proposals include legislation requiring universal background checks on all firearm sales and transactions and eliminating the loophole. Virginia has a great distinction of being the source of guns for violent crimes in New York City. What a shame. Legislation banning dangerous weapons, including bans on assault weapons, high capacity magazines, bump stocks and silencers. It's hard to argue against that. Again, these are common sense of which there is broad support in surveys across Virginia. Legislation to reinstate Virginia's successful law allowing only one handgun purchased within a 30 day period. And legislation requiring that lost and stolen firearms be reported to law enforcement within 24 hours so they can be tracked. Legislation creating an extreme risk protective order, we've heard about that from the ACP. An excellent list, actually you see these are well informed by those priorities from the ACP and the AAP that have really led the way in the American College of Trauma Surgeons, American College of Surgery have led the way in encouraging us as clinicians to get involved in this issue. So that extreme risk protective order allowing law enforcement and the courts to temporarily separate a person from his or her firearms when those individuals have demonstrated dangerous behavior or represent an immediate threat to themselves or to others. And three more quick pieces, legislation enhancing the punishment for allowing access to loaded unsecured firearm by a child from a class 3 misdemeanor to a class 6 felony. The bill also raises the age of a child owning a gun from 14 to 18. Legislation enabling localities. And this is very important when you think about Virginia Beach. Localities should be allowed to enact firearm ordinances that are more restrictive than that for the state as a whole. So that different localities, be it Charlottesville, or Lynchburg, or Virginia Beach can make those decisions for themselves. And also finally legislation prohibiting all individuals subjective final protective orders from possessing firearms. So what is our role as clinicians? I think they've been well covered. But I think that the main thing is that we need to own this issue we need to understand that what we do in the exam room or in other counseling opportunities does and can make a very large difference. And in addition to that, we have an opportunity as advocates in the public square to speak out for common sense, gun safety, because people do listen to us if we speak with one voice. So our work doesn't end outside of our practice, outside of the cath lab or outside of our workplace. And we owe it to the people we serve to stay engaged and make our communities safer, healthier, and more equitable. As you saw, there's a significant disparity in the outcomes in different communities, especially in communities of color. So I hope that you will take what you have heard here today and what you have learned and we can use it to take action and to keep the conversation going. So thank you very much. And I think you'll close it out. One last thing, so we had an election this week. I will say, very excited about the outcome. It does portend very good things around these eight laws, these eight bills. They still sit with the Virginia Crime Commission, which was scheduled to meet not next week, but the week before Thanksgiving. I have not heard how that will be organized. It's still in the leadership of the Republicans and we'll see what happens. My own feeling is that were we to pass a package of laws similar to this in 2020 session, we would see really folks across the aisle saying, it's about time. We've gotten over it. It's no longer this red meat issue to rally the base, to activate white fragility, and other things that I think has been far too common. So I'll let you close it out. Thank you very much. OK so just really quickly, we can't end without a little moment of silence for gun research, which has really struggled over the past 20 years. Compared to other causes of major causes of death, gun violence research has really struggled. You can see it's that little yellow dot way down there. I guess falls did a little worse, but not too much worse. And that's left us with a dearth of information about not only what causes gun violence but also what we can do about it. And there's a reason for this, and it's the Dickey Amendment. I don't know how many of you are familiar with this but in the 1990s the CDC actually prioritized gun violence research and started to focus on it as a public health problem. In relation to a number of studies it actually showed some promise in understanding this. As a reaction in 1996 the NRA worked with legislators to propose the Dickey Amendment. And since 1996 the Dickey Amendment has prohibited funding for gun violence research. Every year it's put into the funding bill. And this has been true last year because of all the recent spate of mass shootings in schools. There was a lot of pressure put on the legislature. And there was a little crack in the armor. But basically the same amendment was approved again. But there is actually some light at the end of that tunnel. In 2019 the House passed a budget bill and sent forward to the Senate floor for reconciliation a bill that would put $50 million back into gun violence research. Huge win, but the Senate has not yet taken that up. So pay attention to what's happening in the next few months, I guess, if not few days actually. That this has to be resolved, the Senate actually tried to put forward one that had that taken out again, that $50 million taken out again. But it didn't pass forward. So we still have that to go in the legislature. So it's very possible that if some of these public health measures had been in place that some of the stories you heard about from our standing here in the front talking about our own experiences of gun violence might have been prevented. With an extreme risk protection order with a law banning those with a prior conviction for misdemeanor with legislation enabling localities to enact stricter firearm ordinances and any of these proposals that we talked about might have made it less likely that 18-year-old Tundalayu Alfred would have been killed in crossfire. So I want you to think of where we were 40 years ago with seat belts and smoking. Before I started this grand rounds, frankly I have to say I was a little bit intimidated by all the variety of arguments. In particular the argument that translates roughly into, well, this one law won't prevent X-Y-Z. And that's true, no action, no single action will completely address each possibility but together these actions can be powerful forces in reducing the harm of gun violence. Some people don't use seat belts even still. And some people still smoke, obviously. But the collective public health actions of belts, airbags, speed limits, guardrails, driver's license has had the effect of reducing motor vehicle accident harm? And package warnings, public health education campaigns, banning smoking in restaurants and workplaces, and finally holding tobacco companies responsible for the harm they're false advertising cost has all contributed to reducing harm from cigarettes. So we can do this. We know how to do this. We've done it before. So our hope is that after this grand rounds that when the NRA or anyone else says to you that you have no business as a physician talking about gun violence you can say to them confidently, actually, this is my lane. Thank you very much for coming. [APPLAUSE] We'll take questions until 1:15 just is to be respectful of clinic commitments. And if you would wait for a microphone so all can hear your question or comment. I'm on board. But the Constitution might be in the way, right? So the difference between cars, and the lettuce, and guns is there there's no amendment guaranteeing the right to own romaine or drive a Lamborghini. Can we do this without repealing and replacing the Second Amendment? I'll take just one quick stab at that. Can you all hear me? I don't know if my microphone is-- it's on, but I'm not sure how well you can hear me. But when the ACP came out with its first position paper in 2015 it was associated with a call to action from six major medical societies and the American Bar Association. So we all know doctors and lawyers, we don't agree on a lot of things. But the ABA endorsed that none of the recommendations at least that the ACP put forward in that call to action, which granted is not every single recommendation that ACP came up with, but many of them did not run afoul of the Second Amendment and did not run afoul of any Supreme Court precedent that had been set. So there is some thought that it's not necessarily anti-second. And I'll just say it, from the suggestions, those eight bills that are still in play, those were introduced in previous years in some way, shape, or form. None of those were challenged on constitutional means. There are indeed some actions, for example not being a constitutional lawyer it makes sense. But having been a military physician and come from a military family that I thought that the Constitution says militia, not individuals having-- we're not allowed to have howitzers or F-22 fighter planes. Well, I should be allowed to have M-16s. You know, I was trained with M-16s and nine millimeter in Air Force for personal protection. I think that's a separate bucket. That probably is a debate as whether it truly is the militia versus individuals. And the Supreme Court has said it is individuals. But again, Supreme Court rulings do change over time. And I thought originally it was the states versus the federal government, not individuals versus everyone. So I do think, frankly, as time goes on in our electorate changes that discussion will change. But all of the things that have been advocated by the AAP and all of the physician groups are debated not on constitutional grounds, but are debated on public policy grounds. So I think we have a lot of room to go before it becomes a true Second Amendment debate. I mean, it will be a debate but you'll need a constitutional amendment to enact. Are there any studies that show the rates of defensive uses of firearms, in other words the benefit of the private citizenry using that, and the types of injuries and deaths they may prevent? I'll take a stab at this as well. I'm not familiar. I think there is some evidence out there, but I'm not so familiar with it except for the fact that a handgun is much more likely to be a source of injury and death to the person than they would use it to actually protect themselves in a self-defense situation. If I may. Mm-hm. So as a guy who's routinely-- that guy? The answer to your question is you can't do the science to find out. We're not allowed because of the Dickey Amendment. So to echo the secretary's position on this, I think the second amendment will be a challenge. It has to be able to come hopefully in my lifetime, if not my lifetime, your lifetime. We have to keep fighting this second amendment because it's interpreted incorrectly. Vince Gulia, God bless him, himself changed the law of the land in my mind to protect guns and not people. Our job is to advocate that that's crazy. So there is no science, hopefully we can get the CDC to get out of the way. I am also asking that the college, all of our colleges, surgeons, and physicians advocate for conducting research without federal funding to the same question. Because there are other ways to get funded to do this kind of work. We just haven't said, oh, we can't do it because the CDC said so. It's not entirely true. So also recently a number of studies have looked at different localities, so different urban areas with higher versus lower or more restrictive gun laws. And both in urban sites and state to state those with more strict gun laws actually had a reduced homicide rate. So it's hard-- and then there are studies looking at the ownership of a gun. So owning a gun actually across most studies puts you at higher risk for violence with a gun. And that started with Kellerman way back in '92. So I think there is, despite the paucity of evidence in general, there is evidence that points to that ownership of a gun and having looser gun laws does actually point to a higher rate of homicides. We're not even talking about suicides. It's implied. So your piece of that data that Peggy's talking about has to do with the fact that tighter gun laws, they're kind of rising in impersonal crime. Home break-ins went higher, car thefts for higher, stick ups run higher. So there's no correlation that anyone's being able to show that tighter gun laws equals more crime in the general population. I think there's a lot of statements said that are not really necessarily accurate. In 2010 the CDC actually was tasked by the Obama administration to study this exact topic. They published in 2013 the name of the paper they published was the priorities for research to reduce the threat of firearm-related violence. And they published at the National Academies of Science. And they estimated using a pretty wide breadth of data, about 27% of the actual numbers of firearms, injuries, and crimes. That about 500,000 to three million instances of self-defense firearms were happening every year which is anywhere between 50 and 300 times the amount of actual firearm-related injuries that are occurring every year. That number was actually validated by two separate statisticians before that even occurred. And they were able to come to that number kind of conclusively. I also think there's been some pretty decent data that show from a state level that both super strict gun laws and super relaxed gun laws don't seem to have any correlation on crime. I think New Hampshire, for example, has maybe the most lax gun laws around the entire country and they have among the lowest, if not the lowest gun crime. In addition, I think that there's this sort of interesting in assault weapons and banning them. And in reality there's less than 500 rifle deaths per year, not even assault rifles, just rifles deaths per year. To put that in perspective, there's about 8,500 handgun deaths every year. And those are just the homicides, not suicides. So I'm not really sure if we can say that they're truly the most dangerous weapons out there. I'll have a say, tell that to the folks of in Las Vegas. Yeah, but next questioner. Hi, thank you all very much for a great presentation. Question about the red flag laws, it seems like that's something that's going to affect us as clinicians directly. Because we're going to be presumably some of the people that raise the red flag. And the question would be, it seems like that's sort of a gray zone in terms of when does someone reach the criteria of an imminent threat? Do they have to make a direct threat against somebody, a specific person? Or is it going be more they want to kill somebody just generically? And it seems like that's going to be coming down the pike, when do we raise the red flag? Yeah, I mean, I certainly have read the bills. But I think it's still the judgment, just like it is now, is what is that? I think the criteria is very similar to ECEO TDO, that's what it's modeled after, the language is the same. So if you would, as a clinician, because of suicidal ideation or other things are moving towards an ECO or for that matter voluntary commitment, then shifting if that law already passed, shifting to a discussion. By the way, what lethal means you have, including guns is also part of the discussion. And if that were to go forward, one of the things law enforcement says, we don't really have a place to store, catalog. We need funding to store it, catalog guns that folks show up with. So I think there's likely need to be some public financing as well so that local law enforcement has an infrastructure in place to deal with it. So Andy, also, from the ACP perspective at least, we want to be absolutely clear that the vast, vast majority of individuals with a mental health diagnosis do not represent a source of threat to themselves or others. And we want to be clear not to paint all of those with a mental health condition with one broad brush. And that's important. And then I think it's a really good question, and we are seeking some type of clarification as to-- well, I guess I'll take a step back and say, we need to train our clinicians to be able to recognize when a mental health issue rises to the level of where we think there is an imminent threat to that person or another individual. And take a step back and clarify what would be the triggers that would lead to removing guns. So all the answers we don't have, or at least I don't think we have yet. There we go. So as an oncologist I was struck by the numbers of mortalities compared to breast cancer, and lung cancer, et cetera, not so far behind. I think about the incredible efforts we take as physicians, oncologists, public health to do cancer screening prevention, et cetera, et cetera. I'll ask Dr. Jaffe and the Secretary, what can we do as an institution to educate people? And especially in the areas of Virginia where we know there's a lot of vulnerability, more guns, a lot of socioeconomic stress, opioid problems, et cetera. | can we do to try to educate about this risk and try to mitigate it, what is the commonwealth doing across the state? But also in those areas in particular. I'd just be curious to know how we can address it like we do screening and other ways to prevent the problems. I mean, first we have to ask the question. I mean, you need to know in patients that you're worried about whether or not they have access to firearms. And sometimes that can be a touchy subject. But other things we talk about are also touchy, like substance use and sexual partners. But you've got to ask, and people at high risk. I mean, some people are going to be receptive. I've had a patient who was severely depressed who had a handgun for protection in a cabin in a rural area that he had as a vacation home. And we talked about it, and next visit, that gun, he got rid of it. So it's not a crazy thing to bring up. People can be receptive, not everybody will be but we also need to be aware working with students and residents, asking these questions so that they are learning to ask too. A little about broader public health content. Yeah, I'll say two things. The Virginia Department of Health is distributing with, actually, not just hundreds of thousands have a number of millions of dollars that they have access to buy gun locks. And have public health in the health districts, opportunities to give people gun locks so they can keep their gun safe in the home, especially with their children present. That's one initiative. And then through the Department of Veterans Affairs as well as the Department of Behavioral Health and Developmental Services we're implementing the governor's task force on suicide prevention, governors talent, excuse me, in conjunction with the VA Department. And really has to do with this lock and talk program. As you can see that most suicides is a transient thing. And if you're doing overdose of medicines in a home, very rarely successful. But if there is a loaded gun in the house, almost always successful. So the lock and talk program, those would be highlighted. The two things from a public health perspective. And then secondly, advocating for common sense gun laws. And just add on to that, echo Jaffe's comment. I think, like any social determinant of health, we actually have to ask the questions. There's literature that you have to be careful not to hurt people's feelings. That's all true. We have to ask the questions. We have to go and we have to ask all the questions to all people. We get into trouble, I think, when we say, I think Brian might be the person I have to ask that question too. And I need to ask Mike the question. If we say, the room gets asked all the questions, that's how you tend to go down. We've got a history in this country of being very selective who gets asked what. If we start asking all the questions to all the humans, I think the answers will be more forthcoming. But if we're selective we-- I think if we just, by asking have you been traveling to an Ebola infested area, which is what every person come in the emergency room has that question asked. You're probably going to ask, let's talk about your use of seatbelts. Do you have access to food? Do you have access to lethal means? I Think all of those things, we got to ask. And I think the physician needs to indicate, the clinician, but it could be the team, again, that does screening. Screening questionnaires, and if the provider then speaks up and gives the signal, this is important. I think that there's ways to make sure it's not a 40 minute questionnaire in your 20 minute slot. Going to have time for one more breif one. I just wanted to address as an epidemiologist how you associate outcome with risk. And so you don't look at the total number of deaths by handguns, versus the total number of deaths by high-powered weapons. You look at the risk of exposure of that particular item and then what was the likelihood of the outcome. So I don't think that we can argue that if you are sort of injured by a high-powered gun, your risk of death is going to be significantly higher than your risk if you are injured by a handgun. And so you can't just look at the total number of deaths of each side. You have to look up the risk of that exposure. And so I think that you're right in that, the high-powered weapons are clearly more dangerous. Thank you. Thank y'all so much for being here and for your time. All right. Good.