Annals This Week: Physicians, Patients and Firearms

Last December, I wrote about ACP activity to counteract firearm violence.  This week, the Annals of Internal Medicine published a review on physician practice regarding asking about firearms. It is striking that 40% of Americans are worried they could be victims of firearm violence.  That doesn’t sound like the domestic tranquility envisioned by our founding fathers.

We are hopefully beyond the discussion of whether or not gun violence is a public health issue.  You’ll recall that the nomination of the current Surgeon General, Vivek Murthy, was contested because he dared to publicly state that it is an important issue of public health.  But physicians could do better at preventing firearm violence.  The article summarizes barriers and makes suggestions for implementing a preventive approach.

Legislative action such as Florida’s so-called “Docs versus Glocks” law have led some clinicians to be, um, gun-shy about asking questions related to firearms.  The authors point out that existing laws, even the Florida gag rule, do not prohibit the clinician from asking about firearms when that information is relevant to the care of the patient or the patient’s safety, or the safety of others.  It is the routine collection and documentation of information about gun ownership that is prohibited.  The three other states with firearm/health statutes also do not outlaw collection or recording of information about firearm ownership when it is medically necessary. More proscriptive bills have come up in North Carolina and Ohio but have not been passed as laws.

The authors then outline three conditions for which, even if a physician was having difficulty incorporating firearm discussions as a matter of routine, there should be selective implementation.  First, when a patient is at acute risk for harm to self or others: suicidal or homicidal ideation or intent.  Second is the presence of individual risk factors for engaging in future violence, including a history of violence; certain phases of mental illness such as recent discharge from an ED or inpatient facility, or experiencing a first psychotic episode; and cognitive disorders.  Third, there are high risk groups: for suicide, middle-aged or older white men; for homicide, young African-American men.

The authors identified lack of familiarity with the benefits and risks of firearm ownership, with how to counsel about firearm and with firearms themselves as the most significant barriers.  Little has been done to assess specific interventions.  But there is advice about how to counsel.  They advocate for respectful conversations recognizing the cultural aspect of gun ownership, best occurring in the setting of an existing patient-physician relationship.  They give other suggestions for the content of such conversations.  Finally, they remind us that disclosure of protected health information to authorities is permissible when harm to self or others is imminent.

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