Physicians Uneasy Vetting Conceal-and-Carry Gun Applicants

June 25, 2014

Physicians are engaged in the gun control debate whether they like it or not.

Some medical societies have inserted themselves into the fray by declaring gun violence a public health threat, particularly in light of mass shootings such as that at Sandy Hook Elementary School in Newtown, Connecticut, in 2012. In addition, pediatricians have aroused opposition from the National Rifle Association and some lawmakers by attempting to counsel parents about gun safety.

Now a study published in the June 19 issue of the New England Journal of Medicine reports that physicians — in North Carolina, at least — are uneasy about being asked to decide whether someone is fit to carry a concealed firearm. The lead author surmises that their apprehension stems more from lack of guidance and liability worries than any antigun bias.

Every state allows its citizens to legally carry a concealed handgun, although 10 states restrict this right, requiring a person to demonstrate need or exercising discretion in issuing permits, according to the National Conference of State Legislatures. North Carolina is 1 of 40 "shall-issue" states that are far more lenient about concealed gun permits (none are needed in Alaska, Arizona, Arkansas, Vermont, and Wyoming).

In North Carolina, individuals wanting to exercise their concealed-weapon right must apply to their county sheriff for a permit. One prerequisite under state law is not suffering "from a physical or mental infirmity that prevents the safe handling of a gun." Sheriffs sometimes ask an applicant's physician whether the person satisfies this criterion.

The study showed that North Carolina physicians, by and large, feel uncomfortable and not so capable in this role of judging firearm competency.

The authors surveyed 600 physicians last fall on this subject and received 222 responses: 62% from family physicians and internists, and another 38% from psychiatrists. Thirty-six percent of the physicians said they owned a gun.

Roughly 1 in 5 of the 222 physicians reported they had been asked to sign competency permits for concealed weapons in the prior year. Of these physicians, 79% agreed to certify competency.

However, among the 222 physicians surveyed, roughly 2 in 3 disagreed with the statement that this vetting job belongs to a patient's primary care physician, and 84% agreed that medical assessments of permit applicants should be the domain of physicians trained for this task.

The study also found that:

  • 60% of physicians said they were not knowledgeable about state and federal laws on concealed weapons and permits;

  • 59% said they could not adequately assess whether their patient was physically capable of safely using a concealed weapon, whereas 47% said the same about determining mental capability; and

  • 59% worry that refusing to sign a statement vouching for a patient's competency could damage the physician–patient relationship.

What Constitutes Competence to Carry?

In an interview with Medscape Medical News, study coauthor Adam Goldstein, MD, MPH, said what prompted his interest in the competency question was not any animus toward gun ownership or concealed weapons but the lack of training and objective guidelines to help physicians arrive at a recommendation.

Dr. Goldstein, a family physician, and several colleagues ruminated on this fuzziness in another article published in the New England Journal of Medicine in 2013. Clinicians, they wrote, receive detailed guidance from the North Carolina transportation department on what to assess and disclose when it comes to giving "transportation physicals" for drivers' licenses. In contrast, such detail is lacking on concealed-weapon applications, which vary widely from county to county.

In particular, North Carolina does not spell out what constitutes mental or physical competence to carry a concealed weapon. Without such a definition, physicians might reasonably disagree on whether Parkinson's disease or a history of depression disqualifies someone from strapping on a Glock 26.

Physicians also face legal uncertainty when they are asked to certify an applicant, Dr. Goldstein and his coauthors said. Do they risk a lawsuit for violating the Health Insurance Portability and Accountability Act when they disclose a person's health information to a county sheriff? Could they be sued if a person they declared competent later committed a murder with a state-sanctioned concealed weapon?

Resolve all these issues, and he and many other physicians would feel more comfortable assessing competence, Dr. Goldstein told Medscape Medical News.

"We would agree that there is a stronger role for physicians in this issue," said Dr. Goldstein, a professor at the University of North Carolina School of Medicine. "Instead of shirking away from it, we should find ways to engage it."

"We Need to Be Proactively Involved"

Sharing Dr. Goldstein's views on engagement is Bernd Wollschlaeger, MD, a family physician in Miami, Florida, who is embroiled in a legal battle over a physician's role in preventing gun violence. Physicians ought to help vet applicants for concealed weapons, provided there is "guidance and a legal framework," said Dr. Wollschlaeger, a gun owner who possesses a Florida concealed-weapon permit himself.

"We need to be proactively involved and use our expertise in identifying those who may pose a risk with a weapon," he said. "Who else should do this but doctors?"

Similar to many other physicians, Dr. Wollschlaeger also believes he is obliged to counsel parents of young children about safe gun storage in the same way that he warns about other household hazards, such as electrical outlets and backyard swimming pools. This professional stance is at the center of a federal court battle pitting the state of Florida against a group of Florida medical societies, along with Dr. Wollschlaeger and several other physicians.

In 2011, this medical phalanx sued the state of Florida in a federal district court in Miami after the legislature there passed a law that effectively prohibited clinicians from asking patients about gun ownership. What was at stake, lawmakers contended, was the Second Amendment right to bear arms. The federal court overturned the so-called gun-gag law — staunchly supported by the National Rifle Association — as an unconstitutional infringement on physicians' First Amendment right to free speech. In August 2012, the state of Florida asked a federal appeals court in Atlanta to reverse the lower court decision. The appellate case is still pending almost 2 years later.

The authors have disclosed no relevant financial relationships.

N Engl J Med. 2014;370:2453-2454. Full article

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