Garen J. Wintemute, MD, MPH; Marian E. Betz, MD, MPH; Megan L. Ranney, MD, MPH
Acknowledgment: The authors thank Vanessa McHenry of the Violence Prevention Research Program for her expert assistance with the manuscript.
Grant Support: Dr. Wintemute's work on this project was supported in part by grant 2014-255 from The California Wellness Foundation.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2905.
Requests for Single Reprints: Garen J. Wintemute, MD, MPH, Violence Prevention Research Program, UC Davis Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Wintemute: Violence Prevention Research Program, UC Davis Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817.
Dr. Betz: University of Colorado School of Medicine, 12401 East 17th Avenue, B-215, Aurora, CO 80045.
Dr. Ranney: Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Claverick 2, Providence, RI 02903.
Author Contributions: Conception and design: G.J. Wintemute, M.L. Ranney.
Analysis and interpretation of the data: G.J. Wintemute, M.E. Betz, M.L. Ranney.
Drafting of the article: G.J. Wintemute, M.E. Betz, M.L. Ranney.
Critical revision of the article for important intellectual content: G.J. Wintemute, M.E. Betz, M.L. Ranney.
Final approval of the article: G.J. Wintemute, M.E. Betz, M.L. Ranney.
Obtaining of funding: G.J. Wintemute.
Collection and assembly of data: G.J. Wintemute, M.E. Betz, M.L. Ranney.
Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med. 2016;165:205-213. doi: 10.7326/M15-2905
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Published: Ann Intern Med. 2016;165(3):205-213.
Published at www.annals.org on 17 May 2016
Physicians have unique opportunities to help prevent firearm violence. Concern has developed that federal and state laws or regulations prohibit physicians from asking or counseling patients about firearms and disclosing patient information about firearms to others, even when threats to health and safety may be involved. This is not the case. In this article, the authors explain the statutes in question, emphasizing that physicians may ask about firearms (with rare exceptions), may counsel about firearms as they do about other health matters, and may disclose information to third parties when necessary. The authors then review circumstances under which questions about firearms might be most appropriate if they are not asked routinely. Such circumstances include instances when the patient provides information or exhibits behavior suggesting an acutely increased risk for violence, whether to himself or others, or when the patient possesses other individual-level risk factors for violence, such as alcohol abuse. The article summarizes the literature on current physician practices in asking and counseling about firearms, which are done far less commonly than recommended. Barriers to engaging in those practices, the effectiveness of clinical efforts to prevent firearm-related injuries, and what patients think about such efforts and physicians who engage in them are discussed. Proceeding from the limited available evidence, the authors make specific recommendations on how physicians might counsel their patients to reduce their risk for firearm-related death or serious injury. Finally, the authors review the circumstances under which disclosure of patient information about firearms to third parties is supported by regulations implementing the Health Insurance Portability and Accountability Act.
Table 1. Language From Relevant Federal and State Statutes*
Table 2. Conditions When Firearm Information Might Be Particularly Relevant to the Health of a Patient and Potentially to Others
Table 3. Materials for Distribution to Patients
Table 4. Firearm Safe Storage Options*
Table 5. Additional Resources
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Robert B. Sklaroff, M.D.
Nazareth Hospital, Philadelphia PA
August 6, 2016
The Privacy of Physician History-Taking Mustn’t Be Violated, at Gun-Point
Just as was the case two years ago (1), because “public health research predictably guides generation of public policy, it is necessary to scrutinize the political science underlying the paired systematic review (2) and editorial on gun control.” Inasmuch as litigation pends before the SCOTUS, the focus is properly trained on slippery-slope rhetoric subtly embedded in (and omitted from) discussion of what is portrayed as inherent in the patient-physician relationship.It is suggested that an initial query “might simply be, ‘Are there any firearms kept in or around your home?’ (2).” No, the topic should be gently introduced just as is accomplished with other concerns such as tobacco-use, namely, “Would you like to discuss….?” Non-pejorative phrasing is welcoming without being intrusive; the more aggressive approach “simply” may trigger communication cessation and, thus, preclude invoking the presumed motivations for such questioning, education and counseling.In addition, “profiling” of demographic groups allegedly carrying increased-risk for violence includes citation of a generic CDC-website to support the claim that middle-aged and older white men are “at high risk for firearm-related suicide (up to 5 times higher than black men of the same age).” Yet, the specific article addressing this topic included a graph that depicts a three-fold increase (3) and another article covering the same decade (1999-2008) reported a datum that was ignored: “Among racial/ethnic groups, the greatest increases in suicide rates were among white non-Hispanics (40 percent) and American Indian and Alaska Natives (65 percent)” (4). Targeting millions of Caucasian males is unjustified.Not surprisingly, an article published last year that conveyed opinions consistent with those being promulgated was cited uncritically, failing to refute the referenced-claim in an accompanying letter that the “onslaught of ‘scientific’ support for gun-control laws is flawed” (5). The abstract even admitted specific recommendations were generated by “proceeding from the limited available evidence.” Such abuse of academic discretion—having bipartisan roots—is more ideological than definitive; it poisons what should be disinterested inquiry devoid of subliminal messaging.Finally, the title (“Yes, you can…”) was overtly reminiscent of the political campaign of the incumbent president, seemingly at-one with the big-government themes that have been emblematic since 2009. Polemics have no place in the composition of scholarly articles; paradoxically, their suasive capacity is diminished as a result.Clinical interactions must uphold patient-physician privacy-rights and be untethered from mandates, both regarding history-taking and how it is recorded. References1. Sklaroff, RB. Guns, Suicide, and Homicide [Letter]. Ann Intern Med. 2014;160(12):876-877. doi:10.7326/L14-5012-2 2. Wintemute GJ, Betz MD, Ranney ML. Yes, you can: physicians, patients and firearms. Ann Intern Med. 2016;165:205-213. Doi:10.7326/M15-29053. Centers for Disease Control and Prevention. QuickStats: Death Rates from Suicide* for Persons Aged 45–64 Years, by Black or White Race and Sex — United States, 1999–2008. Morbidity and Mortality Weekly Report (MMWR) 61(01);21 (January 13, 2012). Atlanta, GA: Centers for Disease Control and Prevention. Accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a6.htm on 5 August 2016.4. Centers for Disease Control and Prevention. CDC finds suicide rates among middle-aged adults increased from 1999-2010. Atlanta, GA: Centers for Disease Control and Prevention; 2014. [Press Release]. Accessed at http://www.cdc.gov/media/releases/2013/p0502-suicide-rates.html on 5 August 2016.5. Sklaroff, RB. Onslaught of "Scientific" Support for Gun-Control Laws is Flawed [Letter]. Ann Intern Med. 2015;162(7):513-516. doi:10.7326/M15-0337. Accessed at http://annals.org/article.aspx?articleid=2151828 on 5 August 2016.
Garen J. Wintemute, MD, MPH; Marian E. Betz, MD, MPH; Megan L. Ranney, MD, MPH
University of California, Davis; University of Colorado; Brown University
September 30, 2016
Physicians, Patients, and Firearms: In Response to Dr. Sklaroff
September 29, 2016To the Editor: Dr. Sklaroff (1) suggests that we advocate asking about firearms without any prior effort to establish either the need for such questions from the physician’s perspective or their reasonableness from point of view of the patient. He is incorrect. We discuss these preliminaries in our article (2) and elsewhere (3) and use that approach in our clinical work. We wholeheartedly agree with the importance of non-pejorative phrasing—again, a point we have made repeatedly. Perhaps he sees something pejorative in “Are there any firearms kept in or around your home?” We do not. We take issue with his use of the loaded term “profiling” to describe making an initial and tentative assessment of an individual patient’s risk for an adverse health event based in part on characteristics that patient shares with others. Physicians adopt this approach all the time—of necessity—are aware of its limitations, and ask questions precisely to refine and individualize those initial assessments. Middle-aged and older white, non-Hispanic males are a prime example. Firearm suicide risk in that large group is high and increasing; to a surprising extent, firearm violence is now an old white guy problem (4). Does that high risk apply to every member of the group? Of course it doesn’t. Does it provide sufficient basis for further inquiry, particularly when other risk factors are involved? We believe it does. Our choice of a title came from the circumstances that led to the writing of the article itself. In recent years we have given presentations on firearm violence at national meetings of medical professional societies and have repeatedly been asked whether it was even permissible under the law for physicians to ask patients about firearms. The first draft of the article focused primarily on a discussion of state and federal laws on this matter, and the title was chosen to summarize our answer to that repeated question. As both our article and this response to Dr. Sklaroff should make clear, we agree entirely with him that physician-patient relationships should be “untethered from mandates.” This includes mandates that would restrict the free exchange of ideas and information about firearms.REFERENCES1. Sklaroff RB. The privacy of physician history-taking mustn’t be violated, at gun-point. Ann Int Med. 2016 Aug 6. Available at annals.org/article.aspx?articleid=2522436.2. Wintemute GJ, Betz MD, Ranney ML. Yes, you can: physicians, patients and firearms. Ann Intern Med. 2016;165:205-213.3. Betz ME, Wintemute GJ. Physician counseling on firearm safety: a new kind of cultural competence. JAMA. 2015;314:449-450.4. Wintemute GJ. The epidemiology of firearm violence in the twenty-first century United States. Ann Rev Public Health. 2015;36:5-19.
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