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Standing AFFIRM: Cognitive errors prevent solutions to fire… : Emergency Medicine News


gun violence, mass shootings, violence prevention


A summer mass of shootings on top of rampant daily violence reaffirms that the United States still lacks a pragmatic health strategy to reduce gun-related harm. Our traditional political approach that pits gun rights and gun control factions against each other, despite its popularity, has yet to contribute to solutions.

However, applying heuristics and standards of practice in emergency medicine to the state of firearm injuries shows us that the national gun violence prevention strategy is tainted with cognitive errors, including understand prejudice. We apply our training, experience, and artistry to initiate a treatment plan for every patient we see in the practice of emergency medicine. We adapt, seek help and design alternative treatment if the patient does not respond to our initial interventions. Persisting with a flawed plan of care for a sick patient invariably leads to poor outcomes, but that’s exactly what we do with gunshot wounds in America.

Fortunately, it is not too late to save our patients, but we must recognize when we make mistakes. The real cure for mistakes is to refrain from making them.

Mistake 1: We trust inadequate data and use it to validate our biases.

Two divergent and deeply held beliefs are at the heart of our assertion about guns in the United States: guns make you safer and therefore “good” vs. guns make you less safe and therefore “bad”. “. Both factions use data to support their beliefs, but none of the existing data is sufficient to explain the depth or complexity of the problem.

“Pro-gun” factions rely on data suggesting that the defensive use of firearms prevents thousands of criminal acts and physical injuries each year. This claim is supported by countless testimonials published in various media. This information, coupled with the simple statistic that all gun injuries are perpetrated by less than 0.1% of gun owners (45,037 deaths and 40,587 injuries in 2021, according to Gun Violence Archive []and about 81.4 million gun owners, according to the 2021 National Firearms Survey [July 16, 2021;]), infers that the remaining 99.9% are “safe” (“good guys”) and add a protective benefit to society. More guns and gun owners therefore means more security.

“Anti-gun” factions report data demonstrating an association between access to guns and negative health outcomes: femicide, suicide, and unintentional injury, to name a few. This assertion is supported by countless headlines in the media and by our own personal experiences caring for patients with gunshot wounds. This information is coupled with data showing an ever-increasing number of gunshot wounds, and it is inferred that firearms are inherently harmful and harm social health. More guns and gun owners mean more gunshot wounds and less safety.

Because the experts representing each faction dismiss their opponents’ data, it’s impossible to have an evidence-based conversation. The obvious answer to the question “Do guns make you more or less safe?” is…both. Discerning nuances and stratifying priorities requires a new collaborative agenda for research and education. Medical professionals who are also gun owners live in the reality of this vast and murky common ground. They are the most qualified people to help develop this program. Please contact us if you are such a person; there is a project for you.

Mistake 2: We assume that policy approaches are the same as health approaches.

Policy approaches claim to reduce gun risk by restricting access to the gun, confiscating it, and removing the person at risk from society by pursuing a related threat or crime. This approach requires knowledge of the laws and the application of disqualifying conditions as well as a high threshold of confidence to prove criminal motive. The “imminent” danger is commonly essential in these cases, which induces foreseeable violent acts, a difficult threshold of proof. It is difficult to involve non-law enforcement personnel in this process due to the risk of personal harm or stigma.

Rather, health approaches reduce gun risk by understanding that acts of violence often follow an escalating pattern based on a balance of risk and protective factors and are propelled by acute stressors. Addressing the health factors that contribute to a person’s ability to commit acts of violence, anticipating when and how access to firearms may destabilize them, and deterring access to firearms through voluntary means can all prevent negative results.

Health interventions are already performed by doctors, nurses and paramedics who counsel patients at risk on lethal means. They are also practiced by committed and conscientious members of the firearms community who are the real good guys and gals with a gun. Retailers use discretion to deny sales to people who seem unstable, gun clubs and social networks deter and discipline members who exhibit disturbing behavior, and gun stores stock guns for families in crisis.

Health at scale approaches require collaboration between invested health and firearms experts who can visualize such a future and develop a strategy to get there. Eliminating biases and opening lines of communication between key stakeholders will create health strategies to empower everyone to prevent gun-related harms.

Dr. Barsottiis the director of the AFFIRM program at the Aspen Institute, a program dedicated to reducing firearm injuries in the United States through nonpartisan health-based approaches. He is also a community practice emergency physician at Berkshire Medical Center in Pittsfield, MA, and a certified 4-H Youth Rifle Safety Instructor. Read his past columns on, and follow him on Twitter@ChrisBarsottiMD. Find more information about AFFIRM on, and follow the foundation on Twitter@ResearchAFFIRM.