Counsel Patients on Gun Safety? Over 700 Doctors Weigh In

Neil Chesanow

Disclosures

March 16, 2016

Should Physicians Have a Role in Gun Safety Counseling?

Whether physicians are ethically obliged and professionally mandated as healthcare professionals to counsel patients on gun safety continues to be an extremely contentious issue.

In January 2016, bioethicist Art Caplan, PhD, director of the Division of Medical Ethics at New York University's (NYU's) Langone Medical Center, explored the subject in a Medscape video, "Should Physicians Have a Role in Gun Safety Counseling?" Dr Caplan asked, "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 2014 Medscape video, Dr Caplan argued that, "Docs Should Promote Gun Safety With Patients." It sparked hundreds of impassioned comments, both pro and con.

A month later, Medscape contributor Greg A. Hood, MD, an internist in Lexington, Kentucky, penned a thoughtful rebuttal, "It's Not a Doctor's Duty to Discuss Gun Safety With Patients," which also received scores of comments from doctors on both sides of the issue, most of whom agreed with Dr Hood.

In the 2016 Both Sides Now video program, Dr Caplan spoke with "some notable people from both sides of the issue, some whom are strongly in favor of physicians counseling patients regarding gun ownership and some whom are strongly against it." The video was widely viewed, and it reignited the debate among Medscape members.

Making the case for physician involvement was Bart A. Kummer, MD, a gastroenterologist and clinical assistant professor at NYU's Langone Medical Center. "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," Dr Kummer said. "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."

William B. Jordan, MD, MPH, director of Preventive Medicine Residency at Montefiore Medical Center in New York, also believes it is a physician's duty to offer counseling on gun safety. "I think guns are like any other issue where patients are at risk for injury," Dr Jordan opined. "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."

But two other doctors whom Dr Caplan interviewed on camera strongly disagreed. Constance G. Uribe, MD, clinical professor in the Department of Surgery at the University of Arizona College of Medicine in Yuma, said: "I don't believe that doctors 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."

Dr Uribe noted that the National Rifle Association (NRA), police departments in many cities and towns, and other organizations offer courses on gun safety to the general public, and their instructors are far more expert than the typical doctor.

Timothy W. Wheeler, MD, a retired surgeon in Upland, California, and director of Doctors for Responsible Gun Ownership, a gun rights organization, agreed with Dr Uribe, adding that taking on an additional responsibility wasn't practical for busy physicians. "Doctors are already overloaded with the medical tasks that they have," he said.

"Now let me give you my personal slant on the subject," Dr Caplan concluded. "I think that gun safety is a legitimate topic to bring up with patients. It seems especially true to me when it's pediatricians.... 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."

Over 700 physicians and other healthcare providers have added their own viewpoints to this exchange, in which a variety of perspectives were voiced.

Whether gun safety was a bona fide healthcare issue—as the American Academy of Pediatrics and the American Medical Association, among other physician organizations, insist it is—was a topic of heated debate among the doctors who offered comments. If it is, many wrote, where do you draw the line?

"Should physicians ask all patients about marital infidelity/promiscuity, whether they engage in oral or anal sex, and whether they would consider an abortion if pregnant?" one doctor asked. "These too may be perceived as 'health-related' issues. Let's face it, the push to get physicians involved in the issue of gun control is largely politically motivated and, with rare exceptions, inappropriate."

An oft-voiced related issue was that putting the onus on physicians to educate patients on gun safety blurs the lines on a doctor's responsibility to those patients. "Where does a doctor's role begin and end?" a doctor wanted to know. "Should we tutor patients about hazardous driving techniques and how to prevent them, risks of electrocution and how to prevent it, and risks of slipping in their bathroom and how to prevent it?"

Another widely voiced sticking point concerned entering a conversation about gun safety in an electronic health record (EHR), which was perceived as being the first step along the road to a nationwide confiscation of firearms. "The problem, in my opinion, isn't talking about the guns, it's putting it in the chart," a doctor wrote in a typical comment. "If a doctor checks a blank in your EHR to the effect that you have guns, be sure that someday someone is going to find you in an EHR records search and tell people you don't want to know."

"There should be a law that physicians can't routinely ask about guns unless the information is not entered into the patient's health record," another doctor believed. "Unless all those eager documenters among us can be directed not to document gun possession information, they shouldn't be collecting that information."

Many commenters stood by patients' Second Amendment right to own a gun without intrusion by the federal government—and certainly not by their doctors.

"There are appropriate, very limited situations for asking about guns," a doctor reasoned. "We do need to be aware of, and oppose, efforts by the government to restrict our constitutional rights, including the right to have and use guns. That said, there are situations when it's important to ask—for example, a psychiatrist caring for a potentially suicidal patient."

"I think the trouble comes in with mandates," another doctor added. "I understand that certain states have mandated that physicians NOT ask about guns, which is ridiculous. If I am treating a suicidal patient, I'm going to ask about guns, and I'll deal with any legal consequences later. On the other hand, to mandate that we counsel all patients on guns intrudes on our good judgment about how our time is best spent in a clinical encounter."

Many doctors raised concerns about jeopardizing the fragile bond of trust they had built with long-time patients by sticking their noses where they didn't belong.

"If your practice is too large and you want to prune it, then broach the subject of firearm safety," a physician warned. "Patients tell me that they were alarmed when a doctor did that. They said they were never going back to that doctor. We are already greatly concerned about patient compliance with medication for things like diabetes, hypertension, and weight loss, and with EHRs putting another barrier between doctors and their patients, why erect another barrier to weaken that trust?"

"Physicians in the office need to maintain a professional demeanor at all times," a doctor insisted. "Attempting to inquire/counsel about gun issues crosses the political line, and it places the physician firmly in the middle of the gun/no gun debate—but perceptively, we would be on the side of the 'gun grabbers.' Do we really want to be cast in such a role?"

A substantial minority of commenters, however, made the opposite case: that gun safety is a health issue that physicians shouldn't ignore.

One doctor put it like this: "The role of a physician is not only to treat diseases but also to prevent diseases and their complications. This includes discussions about concussions, vaccinations, preventable gun injuries, etc. Simple statements I make as a pediatrician are: 'For any car rides, please make sure to wear a seat belt'; 'for bike rides, wear a helmet'; 'if you own a gun, make sure it is locked and stored safely'; and 'please be sure to get your vaccinations.' I don't care whether my patients 'own' anything."

"The American Academy of Pediatrics said it all," another doctor asserted. "If you want to be a physician, then you have committed to always practicing in the best interests of your patients. If you can't stand the heat, as Harry Truman said, get out of the kitchen."

A number of doctors felt that concerns about privileged EHR data being read by a federal agency cataloguing people who owned firearms was a red herring.

"Some doctors are just paranoid that encouraging gun safety means taking away guns, and that is not true!" a doctor declared. "Why would a note in the EHR endanger the gun owner? It could just say 'Guns discussed' for brevity, which would include anyone the doctor feels would benefit as part of preventive medicine."

"I am not qualified to discuss gun safety in any detail with my patients, as I am not knowledgeable about the topic," a doctor admitted. "I do, however, ask parents if there are firearms in the house, and if there are, whether they are stored in such a way that their children can't get access to them. I have so far encountered no one who did not recognize these questions as being motivated by a concern for a child's safety, just as my question about wearing a bike helmet is."

"To ignore a (brief) discussion of firearm safety is the equivalent of not discussing 'anticipatory guidance' in pediatrics," a doctor pointed out. "The fact that we are cowed into silence because this is a subject of rage and paranoia in our country makes it a more pressing issue to discuss, equivalent to any other public health issue (or, in this case, crisis). Successful providers have the skills to broach difficult subjects sensitively and nonjudgmentally."

Some doctors felt understandably overwhelmed by the often heated comments on the rightness or wrongness of the physician's role in firearm safety education.

"After reading multiple posts on the discussion of guns in the household," one doctor wrote in exasperation, "I have come to the conclusion that there is not enough time in the day or possibly the week to discuss the various instruments that can cause death and destruction to my patients or their families."

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