COMMENTARY

Should Physicians Have a Role in Gun Safety Counseling?

Arthur L. Caplan, PhD

| Disclosures | January 13, 2016
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Arthur L. Caplan, PhD: Physicians are involved with many types of public health issues these days: helmet safety, obesity, and smoking. But one issue that deeply, deeply divides them is gun safety.

Hi. I'm Art Caplan from the NYU Langone Medical Center, where I direct the Division of Medical Ethics. This is Both Sides Now, a new Medscape program that will discuss controversial issues that physicians must face day-to-day in their practice.

Today's topic isn't about guns, as you'll see. It's about the role that physicians should or should not have in counseling patients about gun safety. Is gun safety really a public health issue that falls into the medical domain? Should physicians be talking to their patients about gun safety at all? This is a subject that many people have very strong feelings about. In a few minutes, we'll be talking to some notable people from both sides of the issue, some who are strongly in favor of physicians counseling patients regarding gun ownership and some who are strongly against it.

The Current Status of Gun Counseling in the United States

Dr Caplan: Here is the current status of gun counseling in this country today. Vivek Murthy, our Surgeon General, says that gun ownership is indeed a public health issue.[1] The American Academy of Pediatrics[2] says that it's a physician's duty and role to counsel about gun safety, just as a doctor would talk to patients about the dangers of lead paint, seatbelt safety, and other problems that doctors could end up treating their patients for some day. However, a huge percentage of physicians are against any type of gun counseling. They say that they don't have time for gun discussions. They barely have time to deal with all of the necessary medical issues. It's an invasion of privacy and it could harm the doctor-patient relationship if they get into the topic.

We reached out to the Medscape community, and this is what our poll numbers tell us: 47% of physician respondents said that, yes, doctors should be talking to patients about gun safety. But 39% told us no and 14% said maybe. You can see that there are a lot of strong emotions out there, pro and con.

On the one hand, there are 32,000 gun deaths annually, more than 78,000 nonfatal gun wounds, and gun-related homicides and suicides outnumber the next nine combined leading causes of death.[3,4] On the other hand, there are about 760,000 gun uses per year for people who are defending themselves.[5] Many guns that are used in homicides are illegally obtained. Some say that gun discussions with patients are useless. Guns may save thousands of people from burglars in home invasions and people have the right to own guns.

Pro: It's Our Responsibility to Promote Public Health

Dr Caplan: We're going to talk to a cross-section of the medical community to get their points of view. First, we're going to hear from Dr Bart Kummer, a gastroenterologist and clinical assistant professor at NYU Langone Medical Center. He is strongly in favor of educating patients regarding gun safety.

Thank you for coming. Tell me your position on whether physicians should talk about gun safety with their patients.

Bart A. Kummer, MD: I think that it's within our purview to talk to our patients about guns because it's an important health issue, particularly in America. As part of an annual or comprehensive visit, it's something that should come up, just like how we ask patients about smoking, alcohol, whether they wear a helmet when they ride a bike, and whether they practice safe sex. Do they have any hazardous hobbies? Some patients use molten metal when they're working with glass or they're exposed to a number of toxins or occupational hazards. I think it falls under the same rubric. It's health. It's maintaining health.

If you're going to store a gun, children are going to find it no matter where you put it unless it's in a safe. They should be locked. The ammunition and the gun should be kept separately. The gun itself can be locked. The gun can be put in a gun safe.

Dr Caplan: [Speaking as a clinician] I don't have a ton of time. I can talk to people about their weight. I can talk to people about whether they should exercise more. I can talk to people about helmets. I can ask people if they have a fire extinguisher in the house. Where do guns fit into all of this? Is it a priority?

Dr Kummer: A gun is something that's potentially lethal or disabling to the person who is on the wrong end of that implement. In our country, where we have the right to bear arms, many people do possess guns. They should know how to use them and use them safely.

It's not hard to ask this question because it's a simple question. Is there a gun in your home? If the answer is no, you go on. A patient who comes into my office is not just a gastrointestinal tract that ambles in on two legs. There are a couple of other organs, some more important than others. I also need to get to know that patient, the context in which he lives, both medically and socially.

Dr Caplan: You think having that context is crucial even to managing an area like gastroenterology?

Dr Kummer: Yes. I think that we have a role as physicians not just to be plumbers or electricians. Yes, it's important to diagnose a particular problem, but we have a responsibility to promote public health. I think that gun safety is a simple—perhaps even one-time—nontoxic, nonprescription intervention that can have very profound outcomes for health.

Dr Caplan: I can hear some of my friends in the National Rifle Association (NRA) and other gun settings saying, "Safety's great. Do it at the gun club. Do it when the person purchases a weapon. Teach them about gun safety. There are a zillion other settings. I don't go to the doctor for lifestyle lecturing."

Dr Kummer: I'm not going to give you gun counseling in detail. If you go to the NRA webpage about gun safety, they have a long list of do's and don'ts, sort of the 10 commandments. I don't go through that with my patients. I will ask them if they know about gun safety. I can point them to organizations that can help them. It's a quick, simple, and generally nontoxic intervention.

Pro: It's Our Responsibility to Prevent Injury

Dr Caplan: Dr Kummer made some compelling points about counseling for gun safety. Before we hear from those who are strongly against it, let's talk to Dr Bill Jordan, who also feels that gun counseling is within a doctor's responsibilities. Dr Jordan is the director of Preventive Medicine Residency at Montefiore Medical Center, and President of the National Physicians Alliance.

What is your view on the role of doctors in talking to patients about gun safety?

William B. Jordan, MD, MPH: I think guns are like any other issue where patients are at risk for injury. It's important for doctors to talk about it with patients, especially patients who are at higher risk. We counsel about safe sex. I think it's very important that we get this training as physicians so that we can provide good counseling, even when we're not experts, so that we can improve the safety of our patients. We want to prevent sexually transmitted infections. We also want to give other safety advice, like wearing seatbelts when you're in a car or using a crib when you have a new baby.

Dr Caplan: Right. You don't have to be in possession of a new baby to give advice about a crib.

Dr Jordan: Exactly.

Dr Caplan: Some people are going to say, "Look, I don't want to get into this topic because I think it's going to raise a barrier in my relationship with my patients. They're going to wonder why I'm asking this." Some patients might get turned off or say, "That's a personal issue. Are you going to turn that information over to the police or government agencies?" How do you respond to the challenge that it might corrode trust?

Dr Jordan: I think it's a valid concern. On the other hand, we ask about sensitive information all the time. We usually preface it by saying, "I know this is something that's pretty sensitive. You may be a little bit uncomfortable talking about it, but I talk to all of my patients about this when it's appropriate. I hope it's okay that we talk about it."

Dr Caplan: Tell me, what do you think about efforts to pass laws? I think the State of Florida did this to gag doctors so that you cannot raise this subject with your patient.

Dr Jordan: I'm very opposed to gag laws on the state level that prohibit doctors from talking to patients about medically relevant issues.

Dr Caplan: Do you think that, whatever position you hold about guns, you ought to be opposed to the government interfering in the doctor-patient relationship?

Dr Jordan: I think that states definitely have a role to play in regulating doctors' practices in terms of safety as far as patients are concerned.

Dr Caplan: Do you put information out in your waiting room? Is this something that we could handle without doctor-patient interaction, or is it important to have that human interaction on an issue like this?

Dr Jordan: I think that it is important to have different approaches, but when something comes from a doctor who says it out loud to a patient, it's often much more meaningful than when they just read it in the waiting room in a pamphlet.

Dr Caplan: Let me ask you this: If you're going to counsel about guns, should you have to undergo at least some form of mandatory, if limited, training? You don't want to talk about guns and give the wrong facts.

Dr Jordan: I think that's a fair point. In fact, I'm in favor of it being introduced into medical school training as a standard training module. We get trained in how to talk to patients about safe sex. We get trained in how to talk to patients about quitting smoking. I think it makes sense to get trained in talking about gun safety.

Con: Our Job Is to Treat Disease

Dr Caplan: As you can see, there are many tough issues here. Let's hear from physicians who are against gun safety counseling and see what they have to say.

Let's talk to Dr Connie Uribe, a surgeon from Yuma, Arizona, who left clinical practice to run for the Arizona State Senate. I'm going to dive right into this issue of the role that doctors ought to play. I'm going to do that by asking you to tell us what role, if any, you think doctors should play in counseling patients about guns.

Constance G. Uribe, MD: I don't believe that they have a role in counseling patients about guns. The role of a physician is to treat the sick and injured. Our role is to treat disease. That's what we're trained to do. Gun safety is not our bailiwick. We're not supposed to be doing that. There are organizations to do that. The NRA has courses on gun safety. The police have courses on gun safety. Young Guns for America teaches gun safety.

The problem is that many government agencies try to keep these organizations out. They try to keep them out of the schools. They try to keep them out of some of the other groups around the country so that our young people are not exposed to gun safety courses. This is where the problem is. It is not for the physicians to teach gun safety. That's not what we're supposed to do.

Dr Caplan: There is an issue about accidents. Some people would say, "Look, it's not just mental health. We see almost weekly a child who has gotten hold of a gun. It was left out or the ammunition wasn't stored properly." What do you say to those who say that it is a mental health issue, but that's only a part of it? What about accidents and mishandling of weapons, particularly when they get into the hands of kids?

Dr Uribe: There are all kinds of accidents that happen. There's no question about this. But it isn't the physician's job to teach people how to prevent accidents.

Dr Caplan: What do you think about efforts to pass laws? Florida has one that says to take guns off the table. Don't talk about it. We'll make it illegal and it's something that we would punish for if a doctor gets into that.

Dr Uribe: I think the government needs to stay out of people's rights and stay out of people's freedoms. There are too many laws on the book, period. It's just that simple. A physician has the right to talk to a patient about whatever he wants to talk about. The point is that society is safer when no one knows who's armed.

One of my professors was thrown into the trunk of a car and kidnapped. The plan was to make him write prescriptions for drugs and then kill him. When they got him out to the desert, what the killers didn't realize was that he had a rifle in the trunk of his car. When they opened the trunk, he came out shooting. He was vindicated.

Con: Refer Patients to Gun Safety Experts

Dr Caplan: Those are some excellent points. Now I'd like to bring another physician's perspective into the discussion. Dr Timothy Wheeler is a surgeon in Upland, California. He's the founder and director of Doctors for Responsible Gun Ownership. I know that he has testified in the House of Representatives and a couple of states about this issue. Dr Wheeler, thanks for joining us.

Timothy W. Wheeler, MD: Thank you for having me, Dr Caplan.

Dr Caplan: Let me ask you to tell us a little bit about your point of view on the role that physicians should play vis-à-vis gun safety in terms of talking with patients. What do you think?

Dr Wheeler: What I would like to see is for doctors to refer their patients to the real gun safety education experts: the National Rifle Association, the National Shooting Sports Foundation, the NRA's state affiliates, and countless local gun clubs around the country. These groups have spent tens of millions of dollars and countless volunteer hours teaching gun safety in every community across America.

If the American Medical Association, the American Academy of Pediatrics, and the American College of Physicians were to agree to work with these true gun safety experts, they could save lives.

Dr Caplan: Let me ask the challenging question in a different way. What if we trained doctors? Forget about the agendas of the American Academy of Pediatrics and other groups. What if we said, "Look, we've got to do more training. We've got to introduce information about gun safety into medical school and reinforce it in continuing education." If it were properly vetted, if it had the message that you think would really achieve gun safety, would you have any objection to that kind of training?

Dr Wheeler: In theory, I would have no objection to that kind of training, but I just don't see how it would work out on a practical level. Doctors are already overloaded with the medical tasks that they have. You probably know as well the enormous extra load of administrative tasks that we have. Doctors are just not equipped to teach gun safety any more than my gun safety instructors are qualified to treat people for a medical problem. Let's get patients to the right people from the get-go and have them properly trained in gun safety. We really can save lives by doing that.

Dr Caplan: Let me ask you this. Some physicians that I talk to say, "Look, I'm not interested in taking away anybody's guns, but I do have patients and it concerns me if I think that they might be suicidal. I'm not trying to teach gun safety. I want to know if there is a gun in the house in case there is someone who is depressed, mentally disturbed, or has some sort of psychological/psychiatric issue." How do you respond to that?

Dr Wheeler: That is a different issue entirely. Certainly, doctors have the right and the responsibility to intervene in a situation where a patient shows signs of being willing to or capable of harming himself or another person. That's when a doctor should intervene and that is altogether proper.

Dr Caplan: Do you think that patients might be less likely to engage their doctor in a discussion of guns because they don't trust the position of organized medicine?

Dr Wheeler: There's no question about it anymore. When doctors bring a political agenda of gun control into the exam room, they're stepping into dangerous territory. They're committing an ethical boundary violation. They're going where they should not go in a patient's private affairs for political reasons, not for the health of the patient. Patients aren't dumb. They understand that. They sense that something is wrong.

Summary and Closing Statements

Dr Caplan: Where is this all headed? Here are the key points that we've heard in today's program. On the pro side, guns are a public health and safety issue. Physicians have the right to care about patient safety. Asking about guns is easy and need not create problems. Physicians can save lives, and many medical organizations are in favor of gun discussions.

On the con side, doctors have little enough time to discuss medical issues, much less guns. Gun questions could erode the doctor-patient relationship by infringing on trust. Gun discussion invades the patient's privacy. Patients are worried about gun ownership information in their medical record. Possibly, asking about guns is just a disguised political agenda to get rid of guns.

Now let me give you my personal slant on this subject. I tend to agree with the Surgeon General. I think that gun safety is a legitimate topic to bring up with patients. It seems especially true to me when it's pediatricians. There may be kids in the household who need to know what to do if they see a gun, find a gun, or might be exposed to a gun in a different environment. It also seems to me that counseling about guns makes sense if you're concerned that someone has a mental health issue or might be suicidal. You certainly want to detect that problem and ask about guns.

On the other hand, it is true that you need to be educated. Either you know what to tell the patient if they have questions or you know where to send them if they have questions. It isn't enough just to say that it's on your checklist if the patient asks you something and you can't answer in an intelligent, informed manner.

The issue of gun safety and counseling is clearly going to remain a divisive topic for the foreseeable future, but I hope that this program has given you some further insight and information so that you can make up your own mind. I'm Art Caplan from the NYU Langone Medical Center. I hope to see you next time on Both Sides Now.

 

References

  1. Murthy V. [Twitter comment]. October 16, 2012. January 7, 2016. https://twitter.com/vivek_murthy/status/258393687871074304 Accessed

  2. American Academy of Pediatrics Gun Violence Policy Recommendations. https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/documents/aapgunviolencepreventionpolicyrecommendations_jan2013.pdf Accessed January 7, 2016.

  3. Centers for Disease Control and Prevention. Fast Stats: All injuries. http://www.cdc.gov/nchs/fastats/injury.htm Accessed January 7, 2016.

  4. GunPolicy.org. United States -- Gun Facts, Figures and the Law. http://www.gunpolicy.org/firearms/region/united-states Accessed January 7, 2016.

  5. Kleck G. Degrading scientific standards to get the defensive gun use estimate down. https://www.saf.org/wp-content/uploads/journals/JFPP11.pdf Accessed January 7, 2016.

Authors and Disclosures

Authors

Arthur Caplan, PhD

Director, Division of Medical Ethics, New York University Langone Medical Center, New York, New York

Disclosure: Arthur L. Caplan, PhD, has disclosed the following relevant financial relationships:
Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Johnson & Johnson's Panel for Compassionate Drug Use (unpaid position)
Serves as a contributing author and advisor for: Medscape

Bart A. Kummer, MD

Clinical Assistant Professor, Department of Medicine, Division of Gastroenterology, New York University School of Medicine; Staff Physician, New York University, Langone at Trinity Center, New York, New York

Disclosure: Bart A. Kummer, MD, has disclosed no relevant financial relationships.

William B. Jordan, MD, MPH

Board President, National Physicians Alliance, Washington DC; Assistant Professor, Family and Social Medicine; Co-director of Medical Student Education; Director of Preventive Medicine Residency, Albert Einstein College of Medicine; Attending Physician, Montefiore Medical Center, Bronx, New York

Disclosure: William B. Jordan, MD, MPH, has disclosed no relevant financial relationships.

Constance G. Uribe, MD

Clinical Professor, Department of Surgery, University of Arizona College of Medicine; Honorary Staff, Cancer Consultant, Yuma Regional Medical Center, Yuma, Arizona

Disclosure: Constance G. Uribe, MD, has disclosed no relevant financial relationships.

Timothy W. Wheeler, MD

Retired Surgeon; Director, Doctors for Responsible Gun Ownership, A Project of the Second Amendment Foundation, Upland, California

Disclosure: Timothy W. Wheeler, MD, has disclosed no relevant financial relationships.

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