Yes, You Can: Physicians, Patients, and Firearms

In 2014, a total of 33599 Americans died of gunshot wounds (1). Although the risk for firearm-related homicide is highest among young African American men, most firearm-related deaths are suicides, for which older white men are at highest risk (2). Public mass shootings account for a small percentage of firearm-related deaths but are occurring more frequently and could affect the character of public life in the United States (3). In early 2013, more than 40% of Americans worried that they could fall victim to firearm-related homicide or assault (4). Physicians seek to prevent important health problems at the individual and population levels. They inquire and counselroutinely in some cases, selectively in othersabout a wide range of health-related behaviors and conditions. In certain circumstances, they disclose otherwise confidential information to third parties to limit the risk an affected person poses to others. Physicians generally do not do well at firearm-related injury prevention, however. They ask infrequently about firearms and counsel poorly, if at all, although they are aware that the high lethality of firearms makes prevention efforts particularly important. In this article, we examine several commonly cited barriers to practicing preventive medicine for firearm-related injuries. Some physicians believe that it is against the law to discuss firearms; we show that this belief is unfounded. We then discuss the circumstances in which prevention efforts might be most appropriate. We briefly review other barriers to their more widespread adoption, patients' opinions about physicians addressing firearms, and the effectiveness of such prevention practices; more extensive information is available elsewhere (5, 6). We offer specific recommendations, based on the limited evidence available, for how physicians can incorporate firearm-related injury prevention into the care of their patients. You Can Ask No federal or state statute prohibits physicians from asking about firearms when such information is relevant to the health of the patient or others. Federal Statute The Patient Protection and Affordable Care Act (ACA) regulates the collection of firearm information, but the scope of these provisions is narrow (Table 1). Most important, the ACA prohibits required collection of firearm information by wellness and health promotion programs. The Obama administration's position was reflected in a January 2013 White House announcement that, to protect the rights of health care providers to talk to their patients about gun safety, it would issue guidance clarifying that the ACA does not regulate communication between physicians and patients about firearms (7). The U.S. Department of Labor repeated this clarification (8); to our knowledge, this guidance has not been issued. Table 1. Language From Relevant Federal and State Statutes* State Statutes Florida The only existing gag law is Florida's medical privacy act concerning firearms (Table 1), enacted in 2011 after a series of inflammatory incidents occurred during clinicianpatient interactions. In one widely publicized incident, a pediatrician in Ocala discharged from care 3 children whose mother declined to answer questions about firearms (9, 10). Florida's law is seen as intruding on the patientphysician relationship (11). Its key provisions hold that health practitioners should refrain from asking about firearms and may not intentionally enter firearm information into medical records. There are broad exceptions, however. A practitioner who in good faith believes that this information is relevant to the patient's medical care or safety, or the safety of others may ask about firearms, and only information that is not relevant to the patient's medical care or safety, or the safety of others is excluded from medical records (12). Physicians and medical professional organizations challenged the law in U.S. District Court, contending that it unduly restricted their First Amendment rights. They were successful (9), but that decision was overturned by a divided 3-judge panel in the U.S. Court of Appeals for the Eleventh Circuit (10, 13). In February 2016, the full court vacated its panel's decision and agreed to rehear the case (14). The District Court decision remains in effect. Other States Three statesMontana, Missouri, and Minnesotahave statutes addressing firearm information acquired by health practitioners or agencies. None includes a gag provision. Montana prohibits requiring patients to provide firearm information as a condition of receiving health care (15). Missouri prohibits requiring that health professionals collect or record firearm information, but with an exception if such inquiry or documentation is necessitated or medically indicated by the health care professional's judgment (16). Minnesota prohibits collection of firearm information by its state health commissioner and MNsure, the agency administering its health insurance exchange (17, 18). More restrictive proposals have been considered elsewhere. In 2015, North Carolina's legislature debated prohibiting the collection of firearm information in any written form and the disclosure of responses to firearm-related questions unless the patient has been adjudicated incompetent due to mental illness (19). A true gag law proposal was introduced in Ohio in June 2015: A physician shall not ask a patient or prospective patient [any] question related to the ownership or possession of a firearm (20). As of April 2016, no action had been taken on this bill. When to Ask Firearm information would be directly relevant to the health of an individual patient and that patient's close contacts under 3 general conditions (Table 2). Where physician preference or simple lack of time precludes routine screening for firearm access, physicians could identify patients for whom these conditions apply and proceed selectively. Table 2. Conditions When Firearm Information Might Be Particularly Relevant to the Health of a Patient and Potentially to Others The first arises when a patient provides information or exhibits behavior suggesting an acutely increased risk for violence, such as explicit or implicit endorsement of suicidal or homicidal intent or ideation. This is an emergency; the need to determine access to lethal means for such patients is self-evident. The second involves patients who possess other individual-level risk factors for future violence. A history of violence perpetration is a strong predictor of future violence in the general population (21) and among firearm owners (22). Similarly, patients hospitalized or treated in emergency departments for violent victimization are at high risk for committing violence (23, 24). Alcohol abuse is common in the general population and among firearm owners (25) and is a well-established risk factor for interpersonal and self-directed firearm violence (26). Drug abuse is another risk factor, but the magnitude of the risk may be drug-specific (27). Serious mental illness is a relatively minor risk factor for violence to others, and risk depends on the nature of the illness (28, 29). Alcohol and drug abuse, prior violence, and violent victimization account for much of the risk popularly ascribed to mental illness (30, 31). Self-directed violence is very strongly linked to mental illness, however. Suicide risk is increased by a factor of at least 10 across a range of psychiatric diagnoses, and an estimated 47% to 74% of suicides are directly attributable to mental disorders (30). Violence risk is particularly high among patients seen for mental illness in emergency departments, recently discharged psychiatric inpatients, and persons experiencing a first psychotic episode (30). Brain disorders associated with impaired cognition and judgment, such as Alzheimer disease, are associated with an increased risk for aggression and violence (32). Third, questions about firearms would be relevant for patients in demographic groups that are at increased risk for firearm-related injury. 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), and young African American men are 20 times as likely as young white men to die of firearm-related homicide (1). Children and adolescents may engage in risk behaviors with firearms because their judgment and cognitive skills are not fully developed (33). Persons with risk factors, including substance abuse disorders, diagnosed mental illness, impulsive anger, suicidal ideation, and dementia, report access to firearms at levels similar to those in the general population (3439). Persons with multiple risk factors are a high-priority group, because risk is likely more than additive in such cases (22, 40). Questions about firearms may be appropriate when the patient is not a firearm owner, given that risk for victimization may extend to all household members if one is at risk for violence and firearms are present. For example, firearm-related questions would be appropriate if a patient's intimate partner exhibited violence and abused alcohol. Barriers High proportions of physicians (66% to 84%) believe they have the right to counsel patients about firearms (41) and a responsibility to engage in efforts to prevent firearm-related injuries (42, 43). The American Academy of Pediatrics has long recommended that physicians provide counseling (44); since the passage of the Florida law, many other medical specialty societies have made similar recommendations (45). Actual practice is another matter. Screening and counseling about firearms is uncommon, whether as anticipatory guidance (46) or a selective intervention (4749). For example, in a study of veterans who screened positive for suicidal thoughts, only 15% of providers documented whether patients had access to firearms (50). Many barriers exist. Perhaps the most important is clinician unfamiliarity with the benefits and risks of firearm