GUN CHECK WITH YOUR CHECKUP
Doctors urged to discuss gun safety with patients and look for risk factors
By now, you are probably used to the probing questions your doctor asks during your annual checkup. How have you been sleeping lately? Any increased stress at work? Problems at home? Have you engaged in any risky sexual activity?
Don’t be surprised if, in the future, the questioning turns to guns.
With gun violence on the rise over the past few years and mass shootings happening more frequently, physicians are making a renewed push to treat the issue as a public health crisis. And part of that begins in your doctor’s office.
Doctors, especially primary care physicians, are in a unique position to know some of the most private details of our lives, including many indicators that could suggest a higher risk of being a victim or perpetrator of gun violence.
The Violence Prevention Research Program at the University of California Davis has launched a new tool kit for doctors and nurses that teaches them how to gently introduce the topic of guns into the conver- sation, with a special emphasis on spotting red flags that could indicate risks for suicide, domestic violence, homicide or children’s access to guns.
While physicians liken the strategy to previous campaigns that involved asking patients about seat belt use or smoking, gun rights advocates see it as intrusive and a way for doctors to leverage their status in society to ultimately reduce ownership of firearms.
The “What You Can Do” initiative was conceptualized after the Las Vegas, Nev., massacre in October, when a lone gunman fired indiscriminately into a crowd of concertgoers from a hotel high-rise, killing 59 and wounding 422. It was the worst mass shooting in U.S. history.
Those who have studied mass shooters say many of them — although not all — showed warning signs before committing their crimes.
The program’s founders acknowledge, however, that violence is much more likely to occur closer to home.
Nearly 23,000 people in the U.S. were killed in firearm suicides in 2016, accounting for 59 percent of all gun deaths that year, according to the Centers for Disease Control and Prevention. A 2017 study published by the American Academy of Pediatrics found nearly 1,300 children die from gunshot wounds each year, and about 6 percent are accidental shootings.
Dr. Kelly Motadel, a pediatrician and chief medical officer at Vista Community Clinic in North County,
said the question of gun access in the home is already a common one in pediatricians’ offices, but that the inquiry should become standard across all age groups.
“People don’t think of their doctor as political. It allows us to be more of a neutral party and come at it from an ‘I care about your health’ issue rather than a gun control issue,” Motadel said. She pointed to research that showed just a doctor mentioning a risk factor makes a patient more likely to reduce that risk factor.
“Even though there’s a lot of doctor-bashing out there, most people still respect their doctor,” she added.
The organizers stress the project is not about restricting people’s rights to firearms, or politicizing the issue.
“Having a gun in the home increases the risk of violence and death for everyone in the home,” said Rocco Pallin, a research data analyst at UC Davis and the project’s director. “It’s about the gun owner being responsible and understanding the risk of having that gun.”
A Florida law in 2011 aimed to restrict doctors from asking about guns, but the “Docs vs. Glocks” law was overturned by a federal appeals court last year. As long as the doctor feels the question is relevant to the patient, then it is legal, the UC Davis program advises.
Doctors are advised in the guidelines to approach the gun conversation with patients respectfully and to realize that many gun owners already take safety very seriously. It also urges doctors to “keep in mind that firearm ownership can be reflective of longstanding beliefs and values.”
Much of the advice to doctors revolves around being able to identify patients who might be at higher risk than others.
That can include someone with a history of violent behavior, domestic violence, drug and alcohol abuse, or mental illness. Special attention should also be paid to demographic groups that include children for accidental shootings, middle-aged and older men for suicide, and adolescent and young men for homicide.
The conversation with the patient should typically begin with asking if the patient owns or has access to a firearm and if anyone else might have access, according to the guidelines. The doctor should take steps to make the conversation specific to the patient’s circumstances, relate to the patient’s well-being, be educational and include follow-up in case conditions change over time.
Recommendations to the patient might include safe gun storage tips, firearms safety classes or how to properly dispose of an unwanted gun.
Doctors can jot down the patient’s answers in the file, but are otherwise prohibited from sharing personal health information due to federal law. However, if the doctor uncovers information that suggests the patient or someone else is in imminent danger, then the doctor can take preventative measures that include contacting family, law enforcement or mental health providers.
Doctors can also suggest that in times of crisis guns be stored temporarily outside the home, such as with a police department or at a local gun range. In California, law enforcement officials or family members, but not doctors, can file a Gun Violence Restraining Order that prohibits certain people from owning guns, such as patients exhibiting homicidal or suicidal intent.
The Annals of Internal Medicine is supporting the project and is urging colleagues to take the pledge to at least commit to talking about firearm safety with their at-risk patients. More than 1,000 physicians have signed up so far.
Some question, however, if it is realistic — or fair — to continue to expect more from doctors with increased patient loads and work requirements.
“I’ve administered health care facilities side by side with physicians for 35 years, and the amount of required information that we have put on them in the last decade is not sustainable long term,” said Fran Butler-Cohen, CEO of Family Heath Centers of San Diego. “Until we address these societal issues more effectively through legislation and policy, it is absolutely unfair and unconscionable to continue to demand more and more of our medical professionals.
“They are not responsible for the nation’s opioid epidemic, they are not responsible for obesity,” she added, “and clearly cannot act in place of good, solid gun control legislation.”