Mass shootings are reshaping the character of American public life. Whoever we are, they happen to people just like us; they happen in places just like our places. We all sense that we are at risk.

Yet even as we focus on the latest tragedy in Las Vegas, we must remember that these horrific mass shootings have accounted for no more than 1% to 2% of deaths from firearm violence in recent years. The 2 mass shootings with the highest fatality counts in modern U.S. history, in Las Vegas on 1 October 2017 and Orlando on 12 June 2016, resulted in 107 deaths. Yet nationwide in 2016, there was an average of 97 deaths from firearm violence per day: 35 476 altogether (1). In the 10 years ending with 2016, deaths of U.S. civilians from firearm violence exceeded American combat fatalities in World War II.

Calls for action in the wake of Las Vegas have been made not just with profound sadness and outrage but with a here-we-go-again sense of futility. This is entirely appropriate if action by Congress and the White House is being called for—those institutions have abdicated their responsibility on this complex and pressing problem as on so many others.

But there is a critically important and beneficial action that we physicians can take, right now and on our own initiative. Fundamentally, it's quite simple. We need to ask our patients about firearms, counsel them on safe firearm behaviors, and take further action when an imminent hazard is present (2).

This can be a focused intervention, because violence is not distributed at random. People who commit firearm violence—whether against others or themselves—and people who sustain it often have well-recognized risk factors. As a result, firearm violence can to some extent be predicted. What's more, these factors often bring high-risk individuals into contact with physicians. They include abuse of alcohol (3) and controlled substances, acute injury (4), a history of violence (including a suicide attempt), poorly controlled severe mental illness (5), an abusive partner, and serious life stressors.

The relationship between fatal violence and recent contact with a health professional is clearest for people who commit suicide: As many as 45% have seen their primary care provider within a month of their deaths (6). Particularly at older ages, these persons frequently disclose their intent to kill themselves, and they are most likely to do so when they have coexisting health problems (7). Unintentional injury is a concern, too; are there children or impaired adults exposed to firearms, creating a risk for unintended harm to themselves or others?

We already acknowledge that we should talk about firearms with patients, and patients agree (8); however, we don't do it (2). There are barriers, to be sure. We may be concerned that we don't know enough about firearms, or about the benefits and risks associated with owning and using them. We may think that we don't have time. We may even believe that such conversations are prohibited by law, which is a myth.

In fact, there is a growing literature on when such conversations are most appropriate, how to ask the questions, and what to do with the answers (9). The key, as always, is to make clear that we are asking because we care about our patients' health and well-being. Materials for both physicians and patients are available (2), and more are in development. Many professional societies, including the American College of Physicians, have agreed that talking about firearms is something a physician should do (10).

With all that in mind, here is what you can do right now to help stop firearm injury and death: Make a commitment to ask your patients about firearms when, in your judgment, it is appropriate, and follow through. If you need to study up in advance, so be it.

As we know, commitments to change health-related behaviors mean more when they are made in public. The Figure is the template to post a comment at http://go.annals.org/commit-now in response to this commentary. Fill it out and post it. If you give us permission to contact you, we will follow up to see how you're doing, let you know what others have done, and provide new resources as they become available. By all means, e-mail this commentary to your colleagues or send the link (http://annals.org/aim/article/doi/10.7326/M17-2672); encourage them to make a commitment similar to yours. The form closes on 16 April 2018.

You won't be acting alone. I frequently hear from physicians who have reached a personal tipping point and decided to stay on the sidelines no longer. For the first time in more than 20 years, a growing group of clinical and basic science researchers is providing new information on the risks and benefits of firearm ownership and the prevention of firearm violence at the individual and societal levels. The Centers for Disease Control and Prevention is still not in the game, but the National Institutes of Health had a formal program of firearm violence research funding from 2013 to 2016 and remains open to proposals. The National Institute of Justice, which has been providing support at least since the 1990s, made 4 grants totaling $2.9 million in early October. California has just established the nation's first publicly funded firearm violence research center, and New York may follow suit.

These activities and others in the background will help create the knowledge base and infrastructure to make your efforts as effective as possible. But in the end, it all comes down to what happens between you and your patient in the office, or the hospital, or the emergency department.

Please make your commitment. There is no better time, and it's the right thing to do.

大规模枪击事件正在重塑美国公共生活的特征。不管我们是谁，他们都会碰到像我们这样的人。它们发生在我们所处的地方。我们都感到自己处于危险之中。

然而，即使我们专注于拉斯维加斯的最新悲剧，我们也必须记住，这些可怕的大规模枪击案占近几年枪支暴力死亡人数的不超过1％至2％。2017年10月1日在拉斯维加斯和2016年6月12日在奥兰多举行的两次枪击案是美国现代历史上死亡人数最高的两次枪击事件，造成107人死亡。然而，全国在2016年，有一个平均的枪支暴力死亡97的每天：35 476共（1）。在截至2016年的10年中，枪支暴力造成的美国平民死亡人数超过了第二次世界大战期间美国的战斗死亡人数。

在拉斯维加斯过后呼吁采取行动不仅​​是带着深深的悲伤和愤怒，而且还有一种我们再也没有用的感觉。如果需要国会和白宫采取行动，这是完全适当的，因为这些机构已经放弃了对这个复杂而紧迫的问题的责任，对其他许多机构也是如此。

但是，我们的医生现在可以根据自己的意愿采取极为重要和有益的行动。从根本上讲，这很简单。我们需要询问患者有关枪支的信息，就安全的枪支行为向他们提供咨询，并在存在迫在眉睫的危险时采取进一步措施（2）。

这可能是有针对性的干预措施，因为暴力不是随机分布的。实施枪支暴力的人（无论是针对他人还是对自己的暴力）和维持枪支暴力的人通常都具有公认的危险因素。结果，可以在一定程度上预测枪支暴力。而且，这些因素通常会使高风险的人与医生接触。其中包括酗酒（3）和管制药物，急性伤害（4），暴力史（包括自杀企图），控制不佳的严重精神疾病（5），虐待对象和严​​重的生活压力。

自杀者最清楚致命的暴力行为与最近与医护人员的接触之间的关系：死亡后一个月内，有多达45％的人曾看过初级保健提供者（6）。这些人尤其是在年纪较大的人时，经常会透露自己要自杀的意图，而当他们并存健康问题时，他们最有可能这样做（7）。意外伤害也是一个问题。是否有儿童或残障成人接触枪支，从而可能对自己或他人造成意外伤害？

我们已经承认，我们应该与患者讨论枪支问题，并且患者同意（8）；但是，我们不这样做（2）。当然，有障碍。我们可能会担心，我们对枪支，或者与拥有和使用枪支有关的收益和风险了解得不够多。我们可能认为我们没有时间。我们甚至可能认为，这种对话是法律所禁止的，这是一个神话。

实际上，关于这种对话何时最合适，如何提出问题以及如何处理答案的文献越来越多（9）。与往常一样，关键是要明确我们要问的原因，因为我们关心患者的健康和福祉。现有可供医师和患者使用的材料（2），并且还在开发中。许多专业学会，包括美国内科医师学会，都同意谈论枪支是医师应做的事情（10）。

考虑到所有这些，您现在可以采取以下措施来帮助防止枪支伤亡：承诺在您认为适当的时候询问患者有关枪支的情况，并继续进行下去。如果您需要提前学习，那就去吧。

众所周知，在公共场合做出改变与健康相关的行为的承诺意味着更多。该图是在http://go.annals.org/commit-now上发布评论以响应此评论的模板。填写并发布。如果您允许我们与您联系，我们将跟踪您的状况，让您知道其他人的所作所为，并在可用时提供新资源。务必通过电子邮件将此评论发送给您的同事或发送链接（http://annals.org/aim/article/doi/10.7326/M17-2672）；鼓励他们做出与您相似的承诺。表格于2018年4月16日截止。

您不会一个人行动。我经常听到已经到达个人引爆点并决定不再待在场上的医生的消息。二十多年来，越来越多的临床和基础科学研究人员正在提供有关枪支所有权的风险和益处以及在个人和社会层面预防枪支暴力的新信息。疾病控制与预防中心仍未参与其中，但美国国立卫生研究院在2013年至2016年拥有正式的枪支暴力研究计划，目前仍在接受提案。至少自1990年代以来一直提供支持的国家司法研究所在10月初提供了4笔赠款，总计290万美元。加利福尼亚刚刚建立了国家

这些活动以及背景中的其他活动将有助于创建知识库和基础架构，以使您的工作尽可能有效。但最终，一切都取决于您与您的患者在办公室，医院或急诊室之间发生的情况。

请做出您的承诺。没有更好的时间，这是正确的事情。