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Curbing Firearm Violence: Identifying a Specific Target for Physician ActionCurbing Firearm Violence: Identifying a Target for Physician Action FREE

Steven E. Weinberger, MD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 17 May 2016.


From American College of Physicians, Philadelphia, Pennsylvania.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0968.

Requests for Single Reprints: Steven E. Weinberger, MD, Executive Vice President and Chief Executive Officer, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, sweinberger@acponline.org.


Ann Intern Med. 2016;165(3):221-222. doi:10.7326/M16-0968
© 2016 American College of Physicians
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17 52016.

Physicians not only have a responsibility to their patients to diagnose and treat illness; they also have a broader societal obligation to improve population health. The latter can be discharged in part through activities and conversations with patients and families aimed at primary prevention of illness and injury. We have witnessed many examples of successful public health efforts focused on preventing illness and injury, such as immunization, use of seat belts, and smoking cessation initiatives. In each case, physicians and other health care providers have used various methods to inform and educate their patients and the public at large to effect changes in behavior and adoption of important preventive measures.

Many in the medical and public health communities have been attempting to raise consciousness about firearm-related violence as a similar public health problem that deserves action by health care professionals to reduce its magnitude and impact (14). Seven large and influential medical professional societies—the American College of Physicians (ACP), the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Surgeons, the American College of Obstetricians and Gynecologists, the American Psychiatric Association, and the American College of Emergency Physicians—have joined with the American Public Health Association to issue a “call to action” to address firearm-related violence as a major public health problem (5). The American Bar Association (ABA) also partnered in this effort, noting that none of the recommendations presented by these health professional organizations violated the Second Amendment, as established by Supreme Court decisions. Among these recommendations is a halt to physician gag laws that are intended to forbid physicians from discussing a patient's gun ownership and attempting to mitigate the associated risk. More than 50 organizations have now endorsed the positions and recommendations espoused in this call-to-action paper (6).

Unfortunately, despite more than 33 000 firearm-related deaths each year in the United States, there have been efforts to silence those who have particular responsibility to protect public health. The test gag law is in Florida, where legislators are trying to strip health care professionals of their opportunity and ability to address firearm-related violence as a major public health problem (7). This type of interference by legislators with the patient–physician relationship has been described as “overstepping the proper limits of their role in the health care of Americans to dictate the nature and content of patients' interactions with their physicians” (8). Because of publicity about the Florida “Docs versus Glocks” law, physicians have often been unsure about what they can, cannot, should, and should not address with their patients about firearm risks and safety.

In their article in this week's Annals, Wintemute and colleagues make 3 important points to health care professionals: First, there are only rare occasions when physicians cannot ask a patient about firearms; second, physicians may counsel patients about firearms; and third, physicians may disclose information to other parties as necessary (9). The authors focus on the particular importance of addressing firearms with patients when there is information, behavior, or individual factors suggesting a risk for violence to self or others. In primary care and other clinical settings, these principles become particularly applicable when there is a risk for suicide or when there are children in the home. Nevertheless, as both ACP and the ABA have stated in amicus briefs for the U.S. Court of Appeals for the Eleventh Circuit, the Florida statute is broad and vague, leaves physicians uncertain about when they can bring up the issue with patients, puts the burden on physicians to justify or defend raising the subject, and is generally meant to scare physicians and threaten them with sanctions if they broach the topic.

Physicians need to recognize that regardless of the ultimate outcome of legislation in Florida and other states, neither that law nor any others currently in effect prohibit physicians from discussing firearms and firearm safety when there is concern about the risk to self or others. Therefore, they should not shirk their responsibility to seek information about gun ownership when appropriate or to counsel, educate, and take other actions if necessary to mitigate the risk for firearm-related injury or death.

To date, physicians typically have not been trained about how to address issues of firearm-related violence with patients and their families. As a result, their concern about what they are permitted to do is compounded by feeling ill-equipped to address firearm safety with patients. The article by Wintemute and colleagues addresses both of these issues, informing physicians and other health care professionals about their rights and obligations relating to firearm safety while simultaneously educating them about specific guidance to present to patients.

To reduce the unacceptable magnitude of firearm-related injury and death, it is essential that individual physicians and other health care providers, the organizations that represent them, and the legal community band together to ensure that clinicians understand what they can and should do to assess and mitigate the risk for firearm-related injury and death. Collaboration on this specific issue of such public health importance provides an unprecedented opportunity for the health care and legal professions to apply their expertise in complementary areas and ultimately have a major effect on the health and well-being of the American public.

References

Lewiecki EM, Miller SA. Suicide, guns, and public policy. Am J Public Health. 2013; 103:27-31.
PubMed
CrossRef
 
Butkus R, Doherty R, Daniel H, Health and Public Policy Committee of the American College of Physicians. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014; 160:858-60.
CrossRef
 
Dowd MD, Sege RD, Council on Injury, Violence, and Poison Prevention Executive Committee. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012; 130:e1416-23.
PubMed
CrossRef
 
Pinals DA, Appelbaum PS, Bonnie R, Fisher CE, Gold LH, Lee LW. American Psychiatric Association: position statement on firearm access, acts of violence and the relationship to mental illness and mental health services. Behav Sci Law. 2015; 33:195-8.
PubMed
CrossRef
 
Weinberger SE, Hoyt DB, Lawrence HC 3rd, Levin S, Henley DE, Alden ER, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015; 162:513-6.
CrossRef
 
Weinberger SE.  Updated list of endorsers of call to action paper on firearms violence. Accessed at http://annals.org/article.aspx?articleid=2151828&resultClick=3 on 9 April 2016.
 
Parmet W.  The curious case of the docs versus the Glocks: firearms, the First Amendment, and physician speech. Health Affairs Blog. 9 March 2016. Accessed at http://healthaffairs.org/blog/2016/03/09/the-curious-case-of-the-docs-versus-the-glocks-firearms-the-first-amendment-and-physician-speech on 9 April 2016.
 
Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med. 2012; 367:1557-9.
PubMed
CrossRef
 
Wintemute GJ, Betz ME, Ranney ML. Yes, you can: physicians, patients, and firearms. Ann Intern Med. 2016; 165:205-13.
 

Figures

Tables

References

Lewiecki EM, Miller SA. Suicide, guns, and public policy. Am J Public Health. 2013; 103:27-31.
PubMed
CrossRef
 
Butkus R, Doherty R, Daniel H, Health and Public Policy Committee of the American College of Physicians. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014; 160:858-60.
CrossRef
 
Dowd MD, Sege RD, Council on Injury, Violence, and Poison Prevention Executive Committee. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012; 130:e1416-23.
PubMed
CrossRef
 
Pinals DA, Appelbaum PS, Bonnie R, Fisher CE, Gold LH, Lee LW. American Psychiatric Association: position statement on firearm access, acts of violence and the relationship to mental illness and mental health services. Behav Sci Law. 2015; 33:195-8.
PubMed
CrossRef
 
Weinberger SE, Hoyt DB, Lawrence HC 3rd, Levin S, Henley DE, Alden ER, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015; 162:513-6.
CrossRef
 
Weinberger SE.  Updated list of endorsers of call to action paper on firearms violence. Accessed at http://annals.org/article.aspx?articleid=2151828&resultClick=3 on 9 April 2016.
 
Parmet W.  The curious case of the docs versus the Glocks: firearms, the First Amendment, and physician speech. Health Affairs Blog. 9 March 2016. Accessed at http://healthaffairs.org/blog/2016/03/09/the-curious-case-of-the-docs-versus-the-glocks-firearms-the-first-amendment-and-physician-speech on 9 April 2016.
 
Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med. 2012; 367:1557-9.
PubMed
CrossRef
 
Wintemute GJ, Betz ME, Ranney ML. Yes, you can: physicians, patients, and firearms. Ann Intern Med. 2016; 165:205-13.
 

Letters

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Comments

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Curbing Firearm Violence: Tempering Physician Action
Posted on August 6, 2016
Robert B. Sklaroff, M.D.
Nazareth Hospital, Philadelphia, PA
Conflict of Interest: None Declared
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 and editorial (2) on gun control.” Inasmuch as the term “gun control” carries divergent meanings to liberals [restricting firearm access] and conservatives [aiming firearm properly], it is necessary to recognize that editorialization—particularly in a scientific journal—is most effective when it is devoid of proselytizing.

It is claimed physicians “have a broader societal obligation to improve population health [and, thus] to inform and educate their patients and the public at large to effect changes in behavior and adoption of important preventive measures.” A broad-brush assertion is invoked to justify deputizing physicians—like it or not—to accumulate behavioral information subject to transfer to a “third-party” [read: “government”]. Such is the nuanced segue from recognition of the noble duty to promote public health, to the elitism inherent in forcing both “ends” of the patient-physician relationship to submit to mandated questioning-and-answering.

In addition, it is claimed physicians “should not shirk their responsibility to seek information about gun ownership when appropriate” based upon an accompanying article that supposedly identified “only rare occasions when physicians cannot ask a patient about firearms.” To the contrary, careful scrutiny of the article by Wintemute and colleagues fails to identify any putative exceptions for, instead, it seeks to justify such querying globally. Such is the lamentable truth-disconnect between false citation of an allegedly-corroborative article and excessive opining.

Not surprisingly, it is also claimed—incompletely—that “The authors focus on the particular importance of addressing firearms with patients when there is information, behavior, or individual factors suggesting a risk for violence to self or others.” Actually, the article uses demographic characterization [a.k.a. “profiling”]—misquoting the literature in the process—to trigger justifying such probes.

Finally, physicians are tasked to band inter alia with the legal community to “mitigate the risk for firearm-related injury and death,” ignoring the societal and political forces-at-play that dwarf allegedly-“medical” considerations. In fact, fear that physicians could become data-fonts for the National Security Agency (3) is ethically linked to how some would justify expanding databases, both made available for background-checks (4) and accrued by questioning students pursuant to Common Core “educational” grants (5).

Clinical interactions must uphold patient-physician privacy-rights and be untethered from mandates, both regarding history-taking and how it is recorded.






References

1. Sklaroff, RB. Guns, Suicide, and Homicide [Letter]. Ann Intern Med. 2014;160(12):876-877. doi:10.7326/L14-5012-2

2. Weinberger SE. Curbing Firearm Violence: Identifying a Specific Target for Physician Action. Ann Intern Med. 2016;165:221-222. doi:10.7326/M16-0968

3. [Anonymous]. National Security and Medical Information. Electronic Frontier Foundation. San Francisco, CA. Accessed at https://www.eff.org/issues/national-security-and-medical-information on 5 August 2016.

4. [Anonymous]. The Role of HIPAA in Gun Control. Scripted. San Francisco, CA. Accessed at https://www.scripted.com/writing-samples/the-role-of-hipaa-in-gun-control on 5 August 2016.

5. American Principles Project. New Changes to National Assessment of Education Progress (NAEP) Are Illegal [Press Release]. American Principles Project (June 27, 2016). Washington, D.C. Accessed at https://americanprinciplesproject.org/education/8385/ on 5 August 2016.


Curbing Firearm Violence
Posted on August 9, 2016
Stephen Strum
Private Practice of Medical Oncology/Internal Medicine
Conflict of Interest: None Declared
Being up-close and personal with patients over a span of four decades provides perspective that is often lost in today's world of rapid-fire conclusions. The era of a patient having significant time during a physician encounter is over. We are immersed, whether we acknowledge it or not, in what I call McMedicine i.e. fast-food medicine. Consultation reports for new patients are more often than not lacking in detail. Follow up office visits are now most commonly copy-paste functions of the so-called electronic health record, whose purpose is often optimal insurance reimbursement. As a medical oncologist who remains consistent in his belief that integrative care is crucial to the best outcomes no matter what the primary illness may be, I rarely see expressions of serious cognitive thinking in consultations and office visits. The primary focus of most physicians is on ordering lab tests and imaging, and not on history, physical examination and diagnosis. Just ask patients. And now we propose to add on to this harsh reality a discussion by the physician relating to the significant problem of firearms.

Why not have those wishing to obtain a firearm obtain a permit just as we do with a driver's license? The risk of death from either is comparable. Motor vehicle accidents accounted for 11.2 deaths per 100,000 population in 2013 in comparison to 10.6 deaths per firearms (CDC,National Vital Statistics System). If anything, such testing would at the very least increase education relating to gun safety and proper gun handling. And isn't it painfully tragic that the source of the quotation below is from a victim of gun violence.

"Our lives begin to end the day that we become silent about things that matter."
-Martin Luther King
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