Pediatricians Reluctant to Discuss Guns With Patients Even With EHR Prompts

Tara Haelle

October 28, 2019

Pediatricians talk to patients about gun safety considerably less often than working fire alarms, even when prompts for both questions appear on an electronic encounter form, according to a study published online today in JAMA Pediatrics.

"We need to develop curricula to teach pediatricians about how to discuss gun safety while preserving trust in the parent–pediatrician relationship," lead author Carole H. Stipelman, MD, MPH, of the University of Utah School of Medicine in Salt Lake City, told Medscape Medical News. "The development of these curricula should be guided by the opinions of physicians and gun-owning parents about how to have effective conversations about gun safety in the home."

An estimated 7% of US children — 4.6 million — live in households with at least one gun that's loaded and unlocked, the authors note. And a consensus of research has shown that the risk of firearm injury and death is greater for children living in a home with firearms, especially those not locked up and accessible to children.

Despite some states introducing gag law bills regarding physicians' discussion of gun safety, multiple medical organizations recommend that doctors talk to patients about the risks of firearms. Yet research reveals that few doctors actually do so. Stipelman and her colleagues tested an intervention to see how it affected that trend.

The researchers programmed questions about gun storage and smoke alarms into an electronic health record (EHR) encounter form for well-child visits at a university health care system's pediatric primary care clinic. The form included options for the presence of guns in the home (yes or no), safety of guns in the home (gun safe, locked cabinet, trigger lock) and working smoke alarms (yes, no, or I don't know).

The researchers tracked doctors' responses to the questions from January 2017 to June 2018. Although the physicians were required to use the form, they did not receive training on the questions and were not required to ask all questions on the form.

A total of 16,576 well-child visits were recorded by 77 residents and 26 faculty. The researchers compared these over time in three periods: from the start of the study until the mass shooting at the Las Vegas concert shooting on October 1, 2017; between that mass shooting and the one at Parkland High School on February 14, 2018, and then until the end of the study June 30, 2018.

Across the board, residents and faculty both did not record data about guns as often as they did about smoke alarms. Residents were 29% and faculty were 32% less likely to ask about guns than about smoke alarms (P < .001).

Overall,  physician faculty documented asking about firearms in 40% to 60% of well-child visits, with the proportion varying by week of the study. Residents documented asking in 45% to 80% of appointments. In the 1 to 2 months after each of the mass shootings, faculty's record of responses to the smoke alarm question exceeded those about guns by at least three standard deviations for three different weeks. However, residents' queries about guns dropped more after the mass shootings than did the faculty's queries.

"We were surprised to see how much more difficult it was for residents to continue to discuss gun safety in the aftermath of a mass shooting," Stipelman said. "With experience, physicians learn to buffer themselves from secondary trauma to be able to continue to treat patients. This may account for the faculty continuing to talk about preventing gun deaths at the same frequency after the mass shootings."

The authors also reported that "faculty but not residents had an increased likelihood of documenting queries in well-child visits for older patients than infants for smoke alarms (preschool to adolescent patients) and guns (preschool and adolescent patients)."

Patients' race/ethnicity and the physicians' sex and clinical experience were not associated with which queries the doctors documented.

The lower frequency of asking about guns vs smoke alarms was not surprising at all to Garen Wintemute, MD, MPH, an emergency medicine physician at the University of California Davis Medical Center.

"Quite a few studies have shown that while physicians view firearm violence as a health problem and believe they should ask about firearms in the home, they're not very good at doing it," said Wintemute, who was not involved in this research but has studied gun violence and doctors' attitudes and practices regarding talking to patients about guns. One of his recent articles explicitly describes doctors' legal rights in talking with patients about gun safety.  

Among the reasons doctors give for not discussing guns at patient visits are lack of knowledge about the issue, not having enough time during visits, and a belief that patients don't want their doctor to ask, which is "not true, with relatively few exceptions, as we and others have documented," said Wintemute, who is also director of the Violence Prevention Research Program at UC Davis.

Training is definitely part of it, agreed Eric Fleegler, MD, MPH, a pediatric emergency physician and health services researcher at Boston Children's Hospital. He also noted the research showing that a majority of parents, included those who own guns, feel it's appropriate for doctors to have conversations about safe gun storage and overall gun safety with patient families. The question is how.

"There's not very good data or information about the best way to discuss guns with families," Fleegler told Medscape Medical News. He noted that about 22 million children live in households with any gun, regardless of how it's stored.

"We know there's a huge exposure of children to guns, we know that guns claim children's lives every day, and yet we don't know the best way to talk to parents," he said. Questions about smoke alarms are rather innocuous, he added, "whereas with guns, we know there are parents with whom this can be a very difficult question."

Though the current study did not address the reasons doctors don't ask about firearm safety, doctors may be concerned "about damaging the parent–pediatrician relationship by asking intrusive or judgmental questions," Stipelman told Medscape Medical News based on her clinical experience. "Effective well-child checkups require building an enduring bond of trust with the family. Some clinicians may not be confident about their ability to talk about keeping children safe from guns without weakening this trust."

The drop in queries following the mass shooting did not make an impression on Wintemute. They were small, he said, and even though he would expect greater attention paid to gun safety in general after mass shootings, "that wouldn't necessarily result in an increased frequency of asking about firearms."

Stipelman attributed this avoidance of discussion to a normal response to trauma, especially given that avoidance is a criterion for posttraumatic stress syndrome.

"A mass shooting is a shared community traumatic event," she said. "The residents may be protecting themselves and their patients' families from retraumatization by avoiding discussing the risk of gun deaths soon after a mass shooting."

That said, neither Wintemute nor Fleegler was surprised to see that residents asked about guns more often than faculty.

"It's my experience that younger physicians are generally more willing than older ones to incorporate this into their practices," Wintemute told Medscape Medical News.

Fleegler agreed that younger physicians tend to be more open to asking about guns, in part because they have grown up with greater awareness of the gun violence problems in the United States.

Wintemute felt inclusion of questions about gun storage on EHRs is a potentially worthwhile intervention for increasing asking. His research group, which recently received $3.85 million in funding in California to educate and train health professionals about firearm violence and firearm prevention practices, will be testing a variety of methods to see which intervention most increases physicians' discussions with patients about gun safety. 

Fleegler, who acknowledged the problems with EHRs and the excessive time that doctors can end up spending on the computer rather than talking to patients, said including the question is an excellent way to prompt doctors to begin the conversation if EHRs are already an integrated aspect of their practice. He was impressed by the high proportion of physicians asking about guns in this study compared to other research findings.

But simply asking the question is just the first step, he said.

"The most important part is not the idea of whether someone has a gun or not but the conversation that comes after that," he said. "We need messages to give our patients. We need to actually empower people so they can take the actions to protect their families with low-risk activation strategies."

The study authors have disclosed no relevant financial relationships and did not report any external funding. Wintemute and Fleegler have no disclosures.

JAMA Pediatrics. Published online October 28, 2019. Full text

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