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It Is Always “Relevant” to ASK About Guns: A “Call to Action” as Family Physicians

William C. Wadland, MD, MS

(Fam Med 2016;48(9):679-81.)

The Orlando massacre was the worst gun violence in the history of the United States. The shooter was a citizen of the United States and a resident of the state of Florida, where laws make it easy to obtain guns but also very difficult for physicians to have discussions about gun safety with their patients. Firearm injuries cost US health care more than $70 billion annually.1 Gun deaths average over 30,000 annually with 160 non-fatal injuries daily in the United States.2 Eighty-eight Americans die each day from gun violence.3 Though mass shootings get major publicity and often provoke fear and more gun sales, they amount to a small fraction of firearm-related deaths and injuries.2 Those who are most vulnerable to everyday gun violence are children, depressed persons, and partners subject to abuse. Depressed persons are particularly vulnerable. Many suicides are impulsive and are made in conjunction with alcohol or other drugs. Guns greatly raise the risk of a successful suicide attempt.1 “A gun in the home is 43 times more likely to be used to kill a friend or family member than a burglar or other criminal.”4 While mass shootings such as the Orlando massacre invoke a sense of helplessness, especially when our leaders seem to do nothing, our personal “Call to Action,” as family physicians, should be to protect our own patients from the harms of gun violence by engaging them in discussions that enhance gun safety.

Core to Our Mission

 

Core to our mission as physicians, especially family physicians, is having confidential, intimate, and meaningful conversations with patients that relieve suffering from disease and decrease mortality. Having conversations that prevent adverse outcomes and result in positive life changes is perhaps what we do best as family physicians. Engaging the patient in life-changing discussions on gun safety is now particularly difficult in Florida, where the law states that “A health care practitioner...may not intentionally enter any disclosed information concerning firearm ownership into the patient’s record if the practitioner knows that such information is not relevant to the patient’s medical care or safety, or the safety of others. A health care practitioner...shall respect a patient’s right to privacy and should refrain from making a written inquiry or asking questions concerning the ownership of a firearm or ammunition.... Notwithstanding this provision, a health care practitioner or health care facility that in good faith believes that this information is relevant to the patient’s medical care, or safety of others, may make such a verbal or written inquiry.”5

Protect Freedom of Speech Within the Patient-Physician Relationship

 

“Gag” laws, such as the Florida law, are a direct assault both on physicians’ First Amendment right to free speech and the patient-physician relationship.6 For this reason, the American Academy of Family Physicians (AAFP) along with seven other health professional organizations and the American Bar Association issued a “Call for Action” that oppose such “gag” laws and states that “Physicians must be allowed to speak freely to their patients in a nonjudgmental manner about firearms, provide patients with factual information about firearms relevant to their health, and the health of those around them . . . without fear of liability.”7 The American Bar Association has declared that such a position is consistent with the Second Amendment.7 Of note, the Affordable Care Act (ACA) does not prohibit doctors from asking their patients about guns in the home when relevant to patient care. The ACA does state that physicians are not required to ask about gun ownership. Additionally, the ACA does prohibit the collection of data on gun ownership for use by employers and the Department of Health and Human Services (DHHS). Relevant patient information on guns can be recorded in the medical record8 but not collated into a database.

Having Discussions With Patients About Gun Safety Is Now Very “Relevant”

 

The key to these laws is the word “relevant.” Many of the risks for gun violence cluster together with other risk factors such as depression, substance use/abuse, and concerns of physical or sexual abuse. Brief health maintenance intake forms should include questions about gun ownership along with smoking, exercise, sexual activity, drug/alcohol use, symptoms of depression, and fear of personal violence. One may argue that it is only “relevant” to ask about guns in the household if a physician suspects that the patient intends to do harm with a gun. However, most injuries to children are unintentional and due to poor firearm safety measures in the household and are, indeed, preventable. Just as it is relevant to counsel non-smokers on the risks of passive smoke exposure, it is, therefore, relevant to counsel non-gun owners on the value of gun safety while with others who carry guns, with children playing in households with guns, or in the presence of persons consuming alcohol or are actively depressed with guns. Such “relevant” health information can be provided with a simple, brief handout9 listing risks of children accessing guns in a household, unintentional shootings, homicide, and suicide as well as summarizing safe storage measures such as cable locks, trigger locks, lock boxes, or safes. Physicians may have to take specific actions to have guns removed from the household when patients are suicidal or homicidal. All advice on firearm safety “relevant” to the individual patient should then be documented in the medical record. Taking such actions in the “best interest “of the patient may be viewed as civil disobedience by some.

“Call to Action” as Educators and Researchers

 

As educators and researchers, we have been quite successful in developing brief interventions by physicians to promote smoking cessation, decrease risky alcohol use, and even promote physical activity.10-12 Medical students have been able to deliver such interventions using shared decision making with simulated patients with high fidelity and reliability.13 As educators and researchers, we should advocate to stop restrictions on gun violence prevention research and test new models for interventions that promote gun safety.3 Limited studies in primary care have shown that patients will take on safety measures with firearms just after brief counseling.14,15 We should evaluate comparative interventions promoting gun safety using different models such as health belief behavioral change, motivational interviewing, and shared-decision making. We should develop curricula focused on enhancing counseling and communication skills for learners that engage patients in nonjudgmental dialogue concerning gun safety that is tailored to the context and needs of the individual patient.16 A recent national survey reports that “Two-thirds of non-firearm owners and over one half of firearm owners in the US believe that health care provider discussions about firearms are at least sometimes appropriate.”17 As Parker Palmer states in The Courage to Teach on “Divided No More,” we should come together and break “the grid lock and despair” of gun violence by creating successful programs that help physicians have “relevant” conversations with their patients that result in less gun violence and increased safety.18

Do Not Be Afraid to Ask About Guns

 

We should encourage our patients to ask others in their community about gun safety so they can be free of the fear of gun violence while their children or grandchildren play in their neighborhoods. We should not be afraid to ASK about guns and ADVISE our patients on “relevant” safety measures.

 

Acknowledgments: Dr Wadland is a member of the Executive Committee of Physicians for the Prevention of Gun Violence (PPGV).

Correspondence: Address correspondence to Dr Wadland, Professor, Chair, and Senior Associate Dean Emeritus, Department of Family Medicine, College of Human Medicine, PO Box 357, Charlevoix, MI 49720. wadland@msu.edu.

 

References

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  15. Barkin S, et al. Is office-based counseling about media use, timeouts, and firearm storage effictive? Results from a cluster-randomized, controlled trial. Pediatrics 2008 Jul;122 (1):e15-e25. doi: 10;1542/peds.2007-2611.
  16. Betz ME, Wintemute GJ. Physician counseling on firearm safety: a new kind of cultural competence. JAMA 2015;314:449-50.
  17. Betz ME, Asrael D, Baeler C, Miller M. Public opinion regarding whether speaking with patients about firearms is appropriate: results of a national survey. Ann Intern Med 2016. Published online July 26, 2016. doi:10.7326/MI 16-0739.
  18. Palmer P. The courage to teach. Chapter VII, “Divided no more, teaching from the heart of hope.” San Francisco, CA: Jossey-Bass, Inc, 1998.

From the Department of Family Medicine, Michigan State University.


Copyright 2018 by Society of Teachers of Family Medicine