How Docs in Firearm-Friendly States Talk Gun Safety

Samuel Mathis, MD, tries to cover a lot of ground during a wellness exam for his patients. Nutrition, immunizations, dental hygiene, and staying safe at school are a few of the topics on his list. And the Texas family physician asks one more question of children and their parents: "Are there any firearms in the house?"

Dr Samuel Mathis

If the answer is "yes," Mathis discusses safety courses and other ideas with the families. "Rather than ask a bunch of questions, often I will say it's recommended to keep them locked up and don't forget toddlers can climb heights that you never would have envisioned," Mathis, an assistant professor at the University of Texas Medical Branch in Galveston, said.

Mathis said some of his physician colleagues are wary of bringing up the topic of guns in a state that leads the nation with more than 1 million registered firearms. "My discussion is more on firearm responsibility and just making sure they are taking extra steps to keep themselves and everyone around them safe," he said. "That works much better in these discussions."

Gun Safety: Public Health Concern, Not Politics

Conversations about gun safety are becoming more important than ever, not only with parents of pediatric patients but with youth and adults as well. The statistics tell why:

Unintentional shooting deaths by children rose by nearly one third in a 3-month period in 2020 compared to the same period in 2019.
Six of every 10 gun deaths in the United States are by suicide.
As of July 28, 372 mass shootings had occurred.
Firearms now represent the leading cause of death among the nation's youth.

In 2018, the editors of the Annals of Internal Medicine urged physicians in the United States to sign a pledge to talk with their patients about guns in the home. To date, at least 3664 have done so.

In 2019, the American Academy of Family Medicine (AAFP), with other leading physician and public health organizations, issued a "call to action," recommending ways to reduce firearm-related injury and death in the United States. Physicians can and should address the issue, it said, by counseling patients about firearm safety.

Dr Sarah Nosal

"This is just another part of healthcare," said Sarah C. Nosal, MD, a member of the board of directors of the AAFP, who practices at the Urban Horizons Family Health Center, New York City.

Nosal said she asks about firearms during every well-child visit. She also focuses on patients with a history of depression or suicide attempts and those who have experienced domestic violence.

Are Physicians Counseling Patients About Gun Safety?

A 2018 survey of physicians found that 73% of the 71 who responded agreed to discuss gun safety with at-risk patients. But just 5% said they always talk to those at-risk patients, according to Melanie G. Hagen, MD, professor of internal medicine at the University of Florida, Gainesville, who led the study. While the overwhelming majority agreed that gun safety is a public health issue, only 55% said they felt comfortable initiating conversations about firearms with their patients.

Dr Melanie Hagen

Have things changed since then? "Probably not," Hagen told Medscape Medical News. She cites some reasons, at least in her state.

One obstacle is that many people, including physicians, believe that Florida's physician gag law, which prohibited physicians from asking about a patient's firearm ownership, was still in effect. The law, passed in 2011, was overturned in 2017. In her survey, 76% said they were aware it had been overturned. But that awareness appears not to be universal, she said.

In a 2020 report about physician involvement in promoting gun safety, researchers noted four main challenges: lingering fears about the overturned law and potential liability from violating it; feeling unprepared; worry that patients don't want to discuss the topic; and lack of time to talk about it during a rushed office visit.

But recent research suggests that patients are often open to talking about gun safety, and another study found that if physicians are given educational materials on firearm safety, more will counsel patients about gun safety.

Are Patients and Parents Receptive?

Parents welcome discussion from healthcare providers about gun safety, according to a study from the Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Researchers asked roughly 100 parents to watch a short video about a firearm safety program designed to prevent accidents and suicides from guns. The program, still under study, involves a discussion between a parent and a pediatrician, with information given on secure storage of guns and the offering of a free cable lock.

The parents, about equally divided between gun owners and non–gun owners, said they were open to discussion about firearm safety, especially when the conversation involves their child's pediatrician. Among the gun owners, only 1 in 3 said all their firearms were locked, unloaded, and stored properly. But after getting the safety information, 64% said they would change the way they stored their firearms.

A different program that offered pediatricians educational materials on firearm safety, as well as free firearm locks for distribution, increased the likelihood that the physicians would counsel patients on gun safety, other researchers report.

Getting the Conversation Started

Some patients "bristle" when they're asked about guns, Hagen said. Focusing on the "why" of the question can soften their response, she has found. One of her patients, a man in his 80s, had worked as a prison guard. After he was diagnosed with clinical depression, she asked him if he ever thought about ending his life. He said yes.

"And in Florida, I know a lot of people have guns," she said. The state ranks second in the nation, with more than a half million registered weapons.

When Hagen asked him if he had firearms at home, he balked. Why did she need to know? "People do get defensive," she said. "Luckily, I had a good relationship with this man, and he was willing to listen to me. If it's someone I have a good relationship with, and I have this initial bristling, if I say, 'I'm worried about you, I'm worried about your safety,' that changes the entire conversation."

She talked through the best plan for this patient, and he agreed to give his weapons to his son to keep.

Likewise, she talks with family members of dementia patients, urging them to be sure the weapons are stored and locked to prevent tragic accidents.

Nosal said reading the room is key. "Often, we are having the conversation with a parent with a child present," she said. "Perhaps that is not the conversation the parent or guardian wanted to have with the child present." In such a situation, she suggests asking the parent if they would talk about it solo.

"It can be a challenge to know the appropriate way to start the conversation," Mathis said. The topic is not taught in medical school, although many experts think it should be. Hagen recently delivered a lecture to medical students about how to broach the topic with patients. She said she hopes it will become a regular event.

"It really comes down to being willing to be open and just ask that first question in a nonjudgmental way," Mathis said. It helps, too, he said, for physicians to remember what he always tries to keep in mind: "My job isn't politics, my job is health."

Among the points Hagen makes in her lecture about talking to patients about guns are the following:

Every day, more than 110 Americans are killed with guns.
Gun violence accounts for just 1% to 2% of those deaths, but mass shootings serve to shine a light on the issue of gun safety.
110,000 firearm injuries a year require medical or legal attention.
Each year, more than 1200 children in this country die from gun-related injuries.
More than 33,000 people, on average, die in the United States each year from gun violence, including more than 21,000 from suicide.
31% of all US households have firearms; 22% of US adults own one or more.
Guns are 70% less likely to be stored locked and unloaded in homes where suicides or unintentional gun injuries occur.
Action points: Identify risk, counsel patients at risk, act when someone is in imminent danger (such as unsafe practices or suicide threats).
Focus on identifying adults who have a risk of inflicting violence on self or others.
Focus on health and well-being with all; be conversational and educational.
Clinicians should ask five crucial questions, all with an "L," if firearms are in the home: Is it Loaded? Locked? Are Little children present? Is the owner feeling Low? Are they Learned [educated] in gun safety?

Kathleen Doheny is a Los Angeles freelance health and lifestyle journalist. Follow her on Twitter: @DohenyKathleen

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