Ask Your Patients About Guns, ACP Says

Ricki Lewis, PhD

October 30, 2018

In light of the escalating public health crisis of firearm violence in the United States, the American College of Physicians (ACP) has added four position statements and recommendations to the six their board approved in 2014. An editorial, published along with the statement, addresses what a physician can do to help prevent firearm injury.

"Firearms violence and hate crimes, including those stemming from anti-Semitism, are public health issues that physicians confront all too often," said Ana María López, MD, MPH, MACP, president of the ACP, in response to the murder of 11 worshipers at the Tree of Life synagogue in Pittsburgh on October 27.

The updated policy statement was published online October 29 in Annals of Internal Medicine, just 2 days after the latest mass shooting, but was initially approved by the board on July 21.

The ACP has advocated for better controls of guns use for more than 20 years, emphasizing that gun violence is a public health problem that directly affects physicians and their patients.

The Health and Public Policy Committee "identified gaps in policy and existing positions that needed to be strengthened, clarified, or expanded on the basis of emerging research and new initiatives on which the ACP did not have clear policy," write Renee Butkus, BA, from the ACP, and colleagues. The committee members reviewed reports and studies using Google Scholar, PubMed, the news media, policy documents and other sources and provided details in an appendix of evidence for the new statements.

In the four new statements, the ACP expresses support for the following:

  • Appropriate regulation of the purchase of legal firearms to reduce firearms-related injuries and deaths. The statement from the ACP specifies who should and should not be allowed to purchase a firearm. It also covers waiting periods and concealed-carry laws.

  • Best practices to reduce the risk for accidental or intentional injuries or deaths from firearms. The ACP discusses access to firearms by "children, adolescents, people with dementia, people with substance use disorders, and the subset of people with serious mental illnesses."

  • Enacting legislation to ban the manufacture, sale, transfer, and civilian ownership of semiautomatic firearms, also known as assault weapons.

  • "Extreme risk protection order" laws that enable family members and law enforcement officers to petition courts to temporarily remove firearms from people shown to be "at imminent risk" of harming themselves or others.

What Can I Do?

"The updated policy paper and its appendix provide a mountain of evidence on the serious, epidemic-level crisis of firearm violence," writes James S. Kahn, MD, from Stanford Medicine, California, in an accompanying editorial.

Kahn's "aha!" moment wasn't in the context of a disturbed person shooting up a school or a synagogue but rather meeting a new patient who seemed sad and confused. Alerted, Kahn asked about guns, and the patient indeed had them.

Fortunately, further questioning ruled out intent to harm himself or others and revealed that the guns were properly stored. Kahn realized that making questions such as, "Do you have guns?" and "Do you feel safe in your home?" a standard part of intake might head off tragedy.

Kahn relates a second anecdote that involved a patient who did not lock up his guns yet had children at home. "We looked at each other, and he quickly realized that nothing is ever out of children's reach and understood that changes were needed to create a safe home. I did not have to say anything else to him, and it started when I asked, 'Do you have guns in the home?' " Kahn writes.

Asking about guns while taking a medical history, Kahn argues, is similar to asking about substance use and HIV prevention, areas that meld behavior and medicine. "It would be so easy to normalize this line of inquiry and add these questions to an electronic medical record along with questions about alcohol consumption, drug use, and sexual practices," he writes.

Khan lists practical suggestions, such as teaching children what to do if they encounter a gun: "Stop what they are doing, never touch the gun, leave the area, and tell an adult right away."

It's also important to spell out the steps for making a safe environment when a firearm is included: "remove the ammunition from the gun, lock the gun in a secure location, lock the ammunition in a separate location from the gun, store the keys in a different area from household keys, keep the keys out of reach of children, lock up gun-cleaning supplies, and never leave the gun unattended when handling it or cleaning it," Kahn writes.

As reported previously by Medscape Medical News, the ACP is making an ongoing effort to have physicians make a public pledge to engage in this type of discussion with their patients. Thus far, more than 1300 physicians have joined the effort.

The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online October 28, 2018. Full text, Editorial

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