An empirical scientific viewpoint about gun control

For just a moment, let’s take a scientific viewpoint about gun control here and try to leave emotions (and the Constitutional argument) out.

The best type of study to determine whether gun control and/or regulation would be a Randomized Trial:

  • Randomizing a state or country to regulation or not.

Since that’s not going to happen, the next best type of evidence we have to go by is observational, either case-control or cohort studies:

The exposure is: gun control regulation.

  • This could be considered dichotomously (Yes/No) or continuous (level of regulation from strict to lenient/none)

The outcome is: death by guns.

  • This could be considered in numerous ways: absolute numbers of gun deaths annually; relative numbers of gun deaths adjusting for size of population; number of gun massacres, etc.  We could even consider any violent deaths, if you want to be more general.

In a case-cohort study, we’d look at the outcome first (let’s say, massacres) and look backward for the exposure, then calculate an odds ratio that the outcome was significantly associated with the exposure.

In a cohort study, we’d look at the exposure first, looking at level of gun control as a continuous variable.  This could be done retrospectively or prospectively.  As of now, we could only do this retrospectively.  Then look for the outcomes (deaths, massacres, etc.), and determine a risk ratio that the outcome was associated with the exposure.

Either way, the data would indicate that countries with increased exposure (increasing regulation) is associated with a decreased odds/risk of the outcome (fewer deaths, massacres).

Please NOTE that I did NOT say that increasing regulation CAUSED fewer deaths, just that it was ASSOCIATED WITH fewer deaths.

Now, I do not have numerical data, so I am only going on what I understand to be true, the empirical data.  For those who would not believe this to be true, the best way to deal with this is to show data that decreasing the exposure to gun regulation (i.e., increasing the populace’s ability to acquire firearms legally) is associated with fewer gun deaths.

Therefore, my preference is the following: until evidence (not raw emotions, beliefs, or Constitutional Amendments) that decreased regulation (including eliminating gun zones) results in decreased odds/risk for the outcome (gun death) is found in other countries, then there is no reason to accept the notion that we need to stop advocating for strict gun control.  For that matter, stricter gun control has evidential support (even if not emotional support among some) and should be advanced.

If you choose to comment on this in the opposite direction, please think before you do. The anecdotal evidence currently being provided by those who would oppose stricter regulations is purely speculative.  I am open to hearing the data to refute the above contention, but it needs to be at least as strong methodologically.  In other words, “case reports” (testimonials by individuals) or “case series” (testimonials by groups, including lobbyists) are weaker forms of evidence scientifically, and I will not consider them as valid as the comparative empirical data I have put forward as an argument.


Update: July 20, 2016

A large study with sound methodology has been published in JAMA this week with data backing up this blog post.

Posted in public health | Tagged , , , , | 4 Comments

A Rapid Rescue for a New Mnemonic in BLS

In reviewing for my upcoming ACLS recertification through the American Heart Association‘s HeartCode ACLS program, I learned that the classic mnemonic for the Basic Life Support (BLS) primary survey, the “ABCs”, which stood for Airway, Breathing (including Look, Listen, and Feel) and Circulation, had recently been modified.  The purpose of the change was to decrease time until chest compressions and defibrillation.

However the change leaves us without a simple mnemonic for easy recall for the primary BLS survey.

Thus I introduce my mnemonic for the primary BLS survey, and how much more appropriate could it be:


  • R (Response): Assess the patient’s responsiveness. This includes scanning the chest for movement.
  • A (Activate/AED): Activate the Emergency Response System & get an AED (if available)
  • P (Pulse): Check for a pulse
  • I (Initiate): If there is no pulse, initiate high-quality CPR
  • D (Defibrillate): Check rhythm (via AED) and deliver a shock if indicated

You could also remember “RAPID Rescue”.  The addition of “Rescue” should help you remember that if you are successful in restoring spontaneous circulation, give Rescue Breaths.

Please disseminate…RAPID-ly!

Posted in medical education, patient care | Leave a comment

Are Twitter-savvy students “privileged”?

At this week’s AAMC meeting, Alex Djuricich (@MedPedsDoctor), Terry Kind (@Kind4Kids), and I presented a workshop that dealt with using Social Media/Twitter in our roles as medical educators.  During a breakout session within the workshop, I heard an interesting concern that I had not previously considered.

One participant’s administration was concerned that students who are not using Twitter, Facebook, or other social media venues would be excluded from the information provided by the faculty on these sources.  Their concern is that the students who are involved on social media would thus have an advantage over those who do not use the sites.

Although I understand the worry, I am not concerned. Social media is simply a different way that faculty and students can communicate.  After classes, students often come up ask questions or clarify areas of uncertainty with their teachers.  Many professors hold office hours, sometimes even with groups of students.  On a personal note, for years I have been answering students’ emails on a one-to-one basis.

If a significant area of concern arises, it surely is the faculty member’s responsibility to make sure the problem or misunderstanding is not a systemic issue that all students are having.  Social media simply expands the ability for students to communicate efficiently with their faculty.  The faculty members’ responsibilities to clarify information for all their students doesn’t change.  Social media simply helps break the barrier between the two groups, not increase it.

Posted in medical education, Social Media | 2 Comments

My Med 2.0 (#med2) Experience

This weekend I attended my first “med-tech” conference (Medicine 2.0). What an eye-opening experience it was for me!

I got to meet some phenomenal people whom I never would have otherwise met just by staying in my silo of gastroenterology and esophageal diseases over the last decade.  Many of these people I’d previously “met” online through Twitter. For the most part, that was the extent of our relationship. Nonetheless our interactions on Twitter made the real-life meeting seem completely natural, as if we’d known each other for years.

I also got a rejuvenated exhilaration about advancing my work at the intersection of medicine, technology, and the digital space. It has been somewhat difficult as a junior faculty member at a medical school to get the sense that working at this crossroads could be considered “scholarly” and productive by traditional medical academic standards.

At Med 2.0, I encountered a phenomenal group of innovative physicians, nurses, scientists, informational technologists, and communications experts (among others) who have made this field a major part of their life’s work. Creators of digital apps for medical and educational uses have figured out how to get scholarly production our of their work.

Since medical training and research tends to focus on epidemiology, risk factor modification, and patient care interventions like medications and surgery, Medicine 2.0 helped me realize that there is a lot of valuable scholarly work to be done dealing with the intersection of medicine and digital technology. The collaborations that have emerged as a result of Twitter and Medicine 2.0 will be priceless.

Thank you for letting me be a panelist this weekend and asking me to share my experience over the last 2 years. And thank you for welcoming me into this great community.

Posted in medical education, Social Media | Tagged , , , , , , | 7 Comments

The internist as a puzzle solver: my (a)vocation

I’ve been getting GAMES magazine for years. Decades, actually, on and off.  I remember doing logic games way back in elementary school, and I still do them first in my GAMES magazines.  When I was a kid, my grandmother and I would do jigsaw puzzles together, and I now find myself doing them with my own children.
During a lunchtime panel of the Internal Medicine (IM) Interest Group at UNC today, I was drawn to something that one of my colleagues on the panel said. He noted that if you separate the “medical” specialists (internists, pediatricians, etc.) from the “surgical” specialists (orthopedic surgery, urology, etc.), there is often a difference in the type of intellectual arguments the two groups have.  Paraphrasing, he said:
Medical specialists argue more about what diagnosis the patient has over what the treatment of the diagnosis is.
Surgical specialists argue more about what the treatment should be, often whether or not to operate, over what the diagnosis is.
Of course, this is an overly broad generalization.  He did not mean to say that internists don’t argue over treatment plans or that surgeons don’t argue over diagnosis.  Clearly both do.  He pointed out that some medical specialists, like oncologists, tend to keep their discussions more focused on the latter type (e.g. “Should this patient with breast cancer receive chemotherapy?”), and surgeons similarly have to make sure the diagnosis is correct before they operate.
Nonetheless at general internal medicine “morning report”, residents often focus on creating a broad differential diagnosis and then figuring out what data they’d need to get the right answer.  In other words, using their logic to solve the puzzle the patient is presenting to them.
Thinking back now, I find it interesting that I made a conscious decision in the latter half of medical school to change my career path from surgery to medicine. Puzzle solving has occupied a good portion of my recreational time since childhood.  Maybe my choice during medical school to go into IM was my subconscious way of making sure I would enjoy my career.  I’m certainly glad I made that choice!
Posted in medical education | 2 Comments

Introducing #medsm, a new unifying hashtag for the intersection of Medicine & Social Media

As you read this, you might be asking yourself why Twitter needs this new hashtag. The reason is simple: to permit anyone to follow a single unified stream of medical content.

Currently, many people use #hcsm to disseminate medical tweets, but also since it may seem to stand for “healthcare in social media”.  However the actual definition of #hcsm is “healthcare communications and social media,” really meant to discuss the practice of communication of healthcare information, not the actual healthcare information itself.

Even though #hcsm tends to be one of the most widely used healthcare hashtags and subsequently a way to get one’s tweets noticed, it can be quite difficult to filter through the #hcsm stream to find medical information, especially as Twitter grows in popularity.

Therefore, #medsm is being introduced as a new umbrella hashtag for posts related specifically to healthcare and medicine topics.  The #medsm hashtag could be include content with links to studies, stories about patient care, etc.  The more broadly it becomes used, the more likely Twitter users will be able to identify your healthcare-specific content.

Here’s an example of a great use of the #medsm hashtag, by Howard Luks (@hjluks):

I hope you’ll use #medsm and find the new hashtag helpful!

Acknowledgements:  Many thanks to @hjluks, @Doctor_V, @FarrisTimimi, @RichmondDoc, @SeattleMamaDoc, @DoctorNatasha, and @drmikesevilla for their feedback and support of the idea for #medsm!

Posted in Social Media | Tagged , , , , , , , | 21 Comments

Twitter 101 for Docs: Twitter Lingo

At the end of my last post, I said we’d discuss some ways to enhance your professional community on Twitter in an upcoming post.  But first, let’s remain in Twitter 101 so you can understand some of the intricacies of Twitter.

If you’ve been on Twitter for even a few days and you’ve started to follow a few people, you might be confused by some of the codes, words, and symbols you see.  Don’t worry.  Anyone who is on Twitter has had to figure it out at some point.  Fortunately it isn’t too difficult to rapidly understand.  Here are the basics you’ll need to more easily navigate the medical Twitter-sphere:

  • “@” (e.g., @RyanMadanickMD): This is a user’s Twitter handle.  Think of it as their username.  The “@” symbol simply defines to the Twitter server that you are speaking directly to or about a particular user.  This has 2 primary uses: a reply or a mention.
    • Reply (aka an @reply): When you reply to a particular user by clicking the Reply button under the tweet, the user’s @username will automatically appear at the beginning of your tweet, and you can then respond, as @otorhinolarydoc would have done in reply to @pbjpaulito in the conversation below.  When you reply to someone, your tweet will then appear in the user’s Mentions section on the Connect page of Twitter.  Be aware, though, that the @username does indeed count against the 140 characters allowed by Twitter.
    • Mention: If you are not replying to a particular user’s tweet, but you’d like to say something to or about him/her, you “mention” them by first typing the “@” symbol followed by his/her username.  For example, I might tweet: “Thank you @DoctorNatasha for helping with this blog!” Similar to an @reply, a mention will also appear in a user’s Mentions section.  You can mention more than one person, but just as above, each user’s name counts against the 140 character limit.


  • “#”: In Twitter-speak, this is known as a hashtag.  Think of it as a keyword or topic of the tweet. It can be used in the middle of the tweet, like this: or tagged on to the tweet, often at the end, to delineate a particular category, such as #meded for medical education, or a topic, such as a medical conference like Digestive Disease Week (#DDW12).  Several years ago, a group of Twitter users established the Healthcare Hashtag Project to help standardize the use of hashtags for healthcare.  This site is quite useful if you’d like to see if a particular hashtag is already in use in the medical Twittersphere.
  • RT: This means “Retweet”, which simply indicates the reposting of another user’s tweet.  On their website, Twitter makes it easy to retweet a post by simply clicking on the “Retweet” link that appears under the original tweet when you hover over it. However, occasionally you will actually see “RT” appear in the tweet, often followed by an @username.  This isn’t officially recognized as a Retweet by Twitter, but often is done to allow you to add something to the original tweet, like this:In this tweet, the user (@rlbates) retweeted (“RT”) the original tweet by @DrJudyStone (who has mentioned @murzee), and added a small comment at the beginning of the tweet (“+1”).  You might now be wondering what “+1” means.  This is a lexicon that many Twitter users employ to indicate their agreement with the particular tweet (some people use other numbers too, to indicate even greater agreement!).
  • MT: This means “modified tweet”. Usually Twitter users employ “MT” to indicate that they are retweeting someone’s post, but in order to fit their own comment into the 140 character limit, they needed to modify the tweet in some way. In these two tweets, @cmaconthehill essentially retweeted the original tweet by @TonyclementCPC, but modified it so that he could comment on @TonyclementCPC’s original tweet.
  • Shortened links: Take a look back at the tweets above by @BetterHealthGov or @rlbates. At the end you will notice some short URLs (or web page addresses): ““, ““, and ““.  Don’t worry too much about the specifics of these, but you should know what they do.  If you click on one of these links in a tweet, they will take you to a pre-specified web page.  It just has shortened the web page’s address to a manner that will more easily fit into a tweet.  As an example, the first link ( takes you to a page with the following address:’s_and_colitis_dietary_considerations. The web page’s address takes up nearly 100 characters by itself!  There are many ways of creating these shortened links, but if you want to start including links in your tweets, Twitter itself will shorten links you enter into your own tweets.

Let me know if there are other semantics you’re having difficulty understanding!

Posted in Social Media | Tagged , , , , | 5 Comments