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Tuesday Dec 15, 2015

Can Physicians Save Patients From Violent Deaths?

"Do you have a family history of sudden death?"

In medical school, I learned to ask my patients this standard prompt during sports physicals, in search of possible hypertrophic cardiomyopathy. Their answers often surprised me.

Many of my patients do have relatives who suffered a "sudden, unexplained death," often the result of a murder or suicide. Which feels, in a way, utterly unexplainable.

Violence certainly isn't unique to any particular country or demographic, although some communities are at higher risk than others. Gun violence, in particular, has commanded recent headlines. Our culture is peppered with violence in many forms: intimate partner violence, bullying, hate crimes, gang violence, sexual assault, elder and child abuse, and others.

The impact of violence, including deliberate self-harm, is overwhelming: According to the CDC, almost 60,000 Americans die each year as the result of homicides (www.cdc.gov) or suicides(www.cdc.gov).

There are nonfatal consequences of violence, as well. In addition to the emotional impact on victims of violence and their families, the CDC estimates medical and productivity costs associated with violence exceed $70 billion(www.cdc.gov) annually.

It is difficult to get through a day without seeing another fatal beating, another shooting, another self-inflicted fatality on the news. But are these deaths preventable?

Advocacy Efforts Decrease Accidental Deaths
In public health terms, deaths from violence technically fall under the broader category of injuries. "Accidental" injuries that result in death include car accidents, burns, poisonings, drowning, falls and so on. There are only two types of "intentional" injuries that result in death: suicides and homicides.

Physicians have historically been leaders in the campaigns and public policy changes that reduce accidental injuries. In 1984, New York was the first state to pass a law requiring drivers and front-seat passengers to wear seat belts, an effort led by physicians(www.nytimes.com) and public health advocacy groups. Since then, the other 49 states followed suit, and seat belt use jumped from 11 percent in 1981 to 85 percent in 2010. Seat belts have saved an estimated 255,000 lives(www.cdc.gov) since 1975.

Although it seems like common sense now, the battle over mandating seat belts was initially contentious in the face of arguments about personal autonomy, coupled with the high cost to car manufactures to meet certain safety standards. However, diverse groups came together -- including auto insurance companies -- to provide research and education on the societal impact of seat belts.

An array of grassroots groups also came together to tackle deaths from fires, including parents, fire chiefs, physicians and politicians. Fire-prevention efforts, including nearly 400 local ordinances requiring residential sprinklers(www.rwjf.org), smoke alarm legislation and fire education, have resulted in a 26.5 percent decrease in fire-related fatalities(www.usfa.fema.gov) in a 10-year period.

Similarly, drowning deaths have dropped significantly(pediatrics.aappublications.org) since 1985 thanks to greater use of pool fencing, water-entry alarms, pool covers, lifeguards and CPR training -- to say nothing of more adult supervision -- according to a the American Academy of Pediatrics.

These public health successes resulted from careful data collection and research into pilot interventions. The evidence led to advocacy and policy changes.

Investing in Mental Health
More than 500,000 Americans call in sick -- or are impaired on the job -- every day because of depression, according to the Harvard Business Review, which recently called for employers to offer free and anonymous screenings(hbr.org).

There is an overwhelming body of evidence that supports screening for depression in adolescents(www.uspreventiveservicestaskforce.org) and adults(www.uspreventiveservicestaskforce.org), including pregnant and postpartum women. New York City's public hospital system recently announced it is making depression screening universal for pregnant women and new moms(www.nydailynews.com). Such screenings can lead to early disease detection and interventions such as counseling and medication. But patients diagnosed with depression need a continued collaborative approach to their care. Roughly 45 percent of people who commit suicide visit their primary care doctor in the month before their death(www.ncbi.nlm.nih.gov). It is prudent for physicians to always ask their patients about thoughts of hopelessness, self-harm and death when screening for depression.

Moving beyond what an individual physician can do to prevent suicide, evidence shows that system-wide changes can be extremely successful. The U.S. Air Force implemented a comprehensive approach to suicide prevention that included education, rapid intervention teams and a buddy system. Followup analysis showed a significant reduction in suicide rates(www.ncbi.nlm.nih.gov) in that branch of the military.

Unfortunately, however, suicide rates are increasing(www.afsp.org) in the general population, and suicide is the 10th leading cause of death in the United States, according to the latest figures. Physician groups should advocate that more research be conducted on prevention strategies, and the country needs to invest more in mental health, because access to these resources is often key to prevention.

Approaching Homicide as a Public Health Problem
Homicides are even more complicated. These deaths often involve interpersonal violence among individuals -- whether known or unknown to the victim -- such as community violence, child/elder abuse, intimate partner violence, bullying and sexual assault. Homicides can also involve collective violence -- which may be social, political or economic in nature -- such as hate crimes, terrorism, gang behavior, war and human trafficking.

Changing the trajectory of intentional causes of deaths is a daunting challenge, but it's not impossible. The responsibility can't simply fall on politicians, religious leaders, physicians or any other group of individuals. To achieve success, society as a whole must tackle this problem.

And just like every other public health issue addressed above, reducing homicides starts with collecting data and studying pilot interventions.

The World Health Organization already has a multifaceted strategy to reduce violence globally(apps.who.int) that includes fostering healthy relationships between parents and children; helping youth develop life skills; reducing access to alcohol, guns, knives, poisons and other lethal means; promoting gender equality to prevent violence against women; changing cultural norms that support violence; and increasing social support programs.

As family physicians, we can have a powerful impact on childhood development. We can ask parents about spanking and have an open conversation with them about discipline. We can promote comprehensive sex education that emphasizes healthy relationships between partners. And in the vast majority of cases, we can inquire about safety and offer support or resources to those in need.

Although the evidence on screening every single patient for violence and abuse is limited, certain populations should be asked.

And, of course, we can continue to be leaders in the community by launching or joining grassroots efforts that are seeking solutions to violence.

Although there isn't any single solution to this issue, violence is a learned behavior and can be changed. We have seen success when we define and truly understand the challenges we are facing.

Mostly importantly, I hope Americans continue to ask themselves, "What else can we do?" And then work to make it happen.

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).

Posted at 03:45PM Dec 15, 2015 by Natasha Bhuyan, M.D.

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