Physicians should prepare to counsel patients on firearm safety

NEW YORK - Physician counseling can help prevent firearm injury and deaths, and so doctors should be prepared to have effective conversations with their patients on firearm safety, according to a Viewpoints essay today in the Journal of the American Medical Association (JAMA).

The two authors say counseling on firearm safety requires "a new kind of cultural competence."

"(We) are used to the idea that a physician's personal views (be they religious, political, or otherwise) shouldn't impact treatment of individual patients. In the realm of firearm safety, though, I think the larger political debate has hampered our ability to talk with patients in a way that is respectful and effective (in terms of educating patients)," Dr. Marian E. "Emmy" Betz from the University of Colorado School of Medicine in Denver told Reuters Health by email.

Recently proposed or enacted state laws that restrict physicians' conversations with patients about firearms have spurred debates about doctors' roles in preventing firearm injury and death.

Dr. Betz and her coauthor Dr. Garen J. Wintemute from the Violence Prevention Research Program at the University of California, Davis in Sacramento argue that physicians "can - and should - act as leaders in educating the public and advocacy for public health and safety in topics ranging from nutrition to firearm injury prevention."

They should broach the subject with "respectful counseling behaviors that are simultaneously individualized to the patient and routine for certain high-risk patient populations" and should provide "nonjudgmental firearm safety information empathetically without explicit orders to do something," Drs. Betz and Wintemute write.

Doctors who don't own guns, they say, could consider asking one of the 13% to 41% of physicians who do own guns to provide leadership in developing cultural competence in firearm safety counseling.

In some contexts, firearm safety is particularly important to the patient's health, Dr. Betz said, such as "patients at risk of suicide (e.g., those with depression, suicidal thoughts, self-harm behaviors, or prior history of these), at risk of domestic violence (both as perpetrators and victims) and those with cognitive impairment (e.g. diagnosis of dementia)."

"For children, firearm safety would ideally be included in other preventative health guidance," she said. "In the same way that we educate parents on home safety (e.g., locking up toxic medications or household cleaners, using child gates to prevent falls down stairs, using smoke alarms) and outdoor safety (e.g., using seatbelts/child seats and bike helmets), pediatricians could provide information about how to store firearms safely so that kids can't use them."

Still, it's an uphill battle. The National Rifle Association has gotten legislation passed in several states (and supported by US Court of Appeals decisions) that forbids physicians from asking about gun ownership or storage practices. And Congress continues to reject efforts to overturn an NRA-supported ban on Centers for Disease Control and Prevention (CDC) research on gun violence.

"I'd hope that rational dialogue and collaboration would continue to extend beyond individual physician-patient encounters," Dr. Betz said. "There's great promise in ideas like the 'gun shop project,' where suicide prevention materials are distributed in gun shops. To develop these kinds of innovative programs, we need innovative partnerships and we need data -- and organizations like the Center for Disease Control & Prevention and the National Institute of Health need to be allowed (and encouraged) to collect data and fund nonpartisan research about firearm injury and deaths."

Dr. Samir Mehta from The Hospital of the University of Pennsylvania in Philadelphia recently reviewed trends in firearm safety. He told Reuters Health by email, "Guns, in my humble opinion, may not be as household in some parts of the country as others. And, in some ways, discussion about guns in the home likely also differs."

"There are several opportunities at preventive care/injury where general practitioners, pediatricians, and others doing primary care/well care might start this discussion like you would about drinking, drugs, and sex," Dr. Mehta continued. "Oftentimes, by the time they appear at the trauma center with an injury, the preventive aspect has been missed/ignored  but there is still an opportunity for intervention."

Just as with domestic violence, sex, and other social issues, Dr. Mehta said, "Physicians need to consider this as part of the patient interaction process and take it as part of the history - for example, when we take a social history it is almost always - occupation, smoking, drinking, illicit drug use. There are other things that are part of the social environment that can have an effect on patients."

Dr. Kate Prickett of the Population Research Center at the University of Texas at Austin, told Reuters Health by email, "The need for patient-centered care when consulting patients on firearm safety is crucial given that who does and does not own and store their firearms appropriately is not random, and there are ways we can leverage what we know about certain factors that put some families more at risk than others to discuss and nudge parents towards safer storage practices."

"Our findings suggest that parents' gun safety behavior is correlated with other safety behaviors, which might be easier to ask about as a gateway to (and in the context of) safety behaviors more generally," Dr. Pickett said.

"For example," she said, "in our nationally-representative study of families with preschool age children, parents who let their kids ride bikes without a helmet were also more likely to report not storing their firearm in a locked cabinet. Parents who reported using harsh discipline techniques (like spanking) and had higher levels of parental drinking were also more likely to report not storing their firearms appropriately. Again, these might be factors that come up in other contexts that provide both an indicator of risk and gateway to conversation."

"The reasons why parents might own guns and not store them in a safe way are nuanced - knowing the reasons for each individual family, I think, is important for helping nudge parents towards better decisions around gun storage," Dr. Pickett concluded. "For example, parents might not think their young children are physically able to operate a gun, when studies have shown that children as young as two begin to have the tactile strength to discharge a firearm. Or many parents think that teaching their middle-school age children not to touch a gun without adult supervision will stop them - again, studies have shown that a much greater proportion of children report having played with their parents' guns unsupervised or know where they are hidden, compared to the proportion of parents who state otherwise. In this way, it's important to approach gun safety consultation in terms of their children's developmental stage, like other health advice. Guns that are not locked away and inaccessible pose a risk to children at all ages--highlighting that with evidence that is age-appropriate to their children may help parents take action."

Dr. Chad Krueger from San Antonio Military Medical Center, Fort Sam Houston, Texas told Reuters Health, "Just like physicians educate patients about swimming pools, automobiles, and other recreational activities that are potentially deadly, firearm safety should be discussed."

"Most patients are likely uncomfortable discussing (gun safety) with their physician," so the physician needs to bring it up, Dr. Krueger said. "This can easily be done for children by asking the parent(s) a standard question (i.e., are there firearms in your house or where the child is staying) and then providing education from there. For adult patients, it likely takes a physician really knowing their patients and learning that they keep a firearm at home for protection, enjoy activities associated with firearms (i.e., hunting), etc. in order to easily broach the topic."

Dr. Betz has a related TEDxMileHigh talk on "How to Talk about Guns and Suicide" on YouTube (http://bit.ly/1K2talX).

(Disclosure: The reporter, a physician, owns guns and is a member of the NRA. He strongly supports firearm safety and physician counseling on firearm safety. He lives in a state where asking patients about gun ownership is illegal and can result in disciplinary action.)

SOURCE: http://bit.ly/1IEN3hV

JAMA 2015;314:449-450.

References: Reuters Health
comments powered by Disqus