Talking About Guns: Website Helps Physicians Follow Through on Pledge

Marcia Frellick

July 13, 2021

In the 3 years since more than 1000 physicians signed a pledge to talk with patients about the guns in their homes, a team of clinicians and data analysts at the University of California, Davis (UC Davis), has been helping them make good on their promises.

The group has developed a national resource for clinicians who wish to address the problem of gun violence deaths in the United States, which continue to mount by the day.

Signatures came quickly in 2018 after the Annals of Internal Medicine asked physicians to sign a formal pledge in which they commit to talking with their patients about firearms. To date, the list has grown to more than 3600, and it remains open for additional signatories.

The effort built on data showing that before people commit violence with firearms, they often have notable risk factors that prompt them to see a physician.

At the time the pledge campaign was launched, frustration and despair had hit new highs after the school shooting of February 14, 2018, in Parkland, Florida, in which 17 people were killed. That occurred just 4 months after the mass shooting in Las Vegas, Nevada, on October 1, 2017, in which 58 people were gunned down.

An editorial by Garen J. Wintemute, MD, MPH, helped kick off the drive.

More Deaths Than WWII Combat Fatalities

Wintemute cited some grim statistics, writing that "nationwide in 2016, there was an average of 97 deaths from firearm violence per day: 35,476 altogether. In the 10 years ending with 2016, deaths of U.S. civilians from firearm violence exceeded American combat fatalities in World War II."

Dr Amy Barnhorst

Amy Barnhorst, MD, vice chair of psychiatry at UC Davis, who was one of the early signers of the pledge, told Medscape Medical News that data analyst Rocco Pallin, MPH, with the UC Davis Violence Prevention Research Program (VPRP), quickly started managing commitments to the pledge and developed a "What You Can Do" intervention for physicians looking for help on how to prevent firearm injury and death.

Those efforts snowballed, and a need arose for a centralized public resource. In 2019, the state of California gave $3.8 million to the VPRP, which helped launch the BulletPoints Project, which Barnhorst now directs.

The website provides clinicians with evidence-based direction on how to have the conversations with patients. It walks them through various scenarios and details what can be done if what they learn during a patient interview requires action.

Barnhorst said the team is working on formalized online educational courses for mental health professionals and medical clinicians that will be hosted through various national organizations.

Dr Christine Laine

Christine Laine, MD, editor-in-chief of the Annals of Internal Medicine, told Medscape Medical News that although almost 4000 persons have made the pledge, that number should be higher. She notes that the American College of Physicians has about 165,000 members, and even that is only a fraction of all physicians and clinicians.

"Signing the pledge helps raise awareness that this is a public health issue, and within the realm of healthcare providers, that they should be counseling patients about reducing risk, the same way we counsel people to wear bike helmets and use seat belts," she said.

Barnhorst says those who don't want to sign the pledge usually cite time considerations and that they already talk with patients about a list of public health issues. They also say they don't know how to have the conversations or what they should do if what they hear in the interviews requires action.

"We can't do anything about the time, but we can do something about the resources," Barnhorst said.

Some clinicians, she said, worry that patients will get angry if physicians ask about guns, or they believe it's illegal to ask.

"But there's no law preventing physicians from asking these questions," she said.

Wintemute told Medscape Medical News he is not discouraged that only about 4000 have signed the pledge. Rather, he was encouraged that the signatures came so quickly. He also notes that the number of persons who are interested far exceeds the number who have made the pledge.

Boosting the pledge numbers will likely take a new push in the form of published articles, he added, and those are in the works.

Among the next steps is conducting pre- and post-tests to see whether BulletPoints is effectively conveying the information for users, he said.

Another is pushing for advances in petitioning for "extreme risk protection orders," which would require a gun owner to temporarily relinquish any firearms and ammunition and not purchase additional firearms.

Wintemute said that currently, Maryland is the only state in which healthcare professionals can petition for extreme risk protection orders. In any state that has the law, a healthcare professional can contact law enforcement about "a person who is at very high risk for violence in the very near future" but who has not committed a crime and is not mentally ill and so cannot be legally detained.

For physicians to include gun counseling as a routine part of patient care will likely require hearing from peers who are finding the time to do this effectively and that it matters, he said.

"It's going to take that on-the-ground diffusion of information, just as it has with vaccine hesitancy," he said.

He notes that data on how to stop firearm violence are sparse and approaches so far have extrapolated from information on how to stop other health threats, such as smoking and drinking.

But that is changing rapidly, he said: "There's funding from the CDC [Centers for Disease Control and Prevention] for research into the kind of work we're doing."

Measuring the success of those efforts is difficult.

One sign of change in the past 3 years, Wintemute says, is that there's recognition among healthcare professionals and the public that this fits into clinicians' "lane."

Mass Shootings Not the Largest Source of Gun Violence

Mass shootings continue to dominate news about fatal shootings, but Barnhorst notes that such shootings represent a very small part ― reportedly 1% to 2% ― of the firearm deaths in the United States. Almost two thirds of the deaths are suicides. Domestic violence deaths make up another large sector.

But it's the mass shootings that stick in the collective US consciousness, and the rising and unrelenting numbers can lead to a sense of futility.

Barnhorst, Laine, and Wintemute acknowledge they don't know to what degree physicians' talking to patients about firearms can help. But they do not doubt it's worth of the effort.

Laine said that during the past year, COVID-19 overshadowed the focus on the pledge, but he notes the signup for the pledge remains open. Information on firearm injury is collected on the Annals website.

Barnhorst says there is no good answer to the question of how many lives need to be saved before talking with patients about firearms becomes worth the effort. "For me," she said, "that number is very, very low."

Laine puts the number at one.

"If a physician talking to their patients about firearms prevents one suicide, then the intervention is a success," she said.

Laine, Barnhorst, and Wintemute report no relevant financial relationships.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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