CSTS podcast series
Let’s Talk About Your Guns
Episode 4: Doctors and Patients

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NOTES

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AUDIO
DR MARY CAMPAGNOLO: I was new to practice twoyears out of residency and joined a group in southern New
Jersey in a small town there.
I took the practice of a doctor who had retired after
practicing for at least 30 years in the town.

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DR MARY CAMPAGNOLO: It's an area that had a little bit
more of a farming culture. And also it's a location that'sclose to the military base.
So many people do seem to have guns.

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transition to newbeat
DR MARY CAMPAGNOLO: One day, a man arrived in theoffice for the afternoon session.
He seemed like a very calm, somewhat quiet gentleman.
He was about 76 years old. And he lived by himself in the
town.

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DR MARY CAMPAGNOLO: He came in because he had
injured himself that day while he was opening a box with abox cutter and unfortunately sliced his leg.

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DR MARY CAMPAGNOLO: I met him briefly, went over his
records from the prior physician.

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DR MARY CAMPAGNOLO: I sutured his wound and hadsome pleasantries and then I advised him for a follow up.

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DR MARY CAMPAGNOLO: The following week he cameback for suture check and removal and the wound wasdoing well.

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DR MARY CAMPAGNOLO: I expected that if I treated him
properly and with good compassion that he would continue
to be my patient and I would continue to see him in the
future.

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DR MARY CAMPAGNOLO: Two weeks later, my nurse
came and said, oh, you know that man you saw last week?
Do you know what I just heard? He had shot himself in his
driveway.

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DR MARY CAMPAGNOLO: I was totally floored.
It just really struck me that I felt like I had had theseopportunities to talk with this individual who must have hadsome deep-seated trouble at that time.
So I felt a kind of a lost opportunity. Could I have done
something different?

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DR WEST: Dr Mary Campagnolo’s experience isn’t unique.
Nearly a third of the people who die by suicide visit a
primary care provider in the month before their death 1…
leaving many physicians to wonder if they could have done
something more.

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DR MARY CAMPAGNOLO: In retrospect, I wondered why
did he even have that injury in the first place? Maybe it had
some other meaning other than just accident.
As a new doctor it made me think more about the fact thatpeople have guns and they could be having troubling
circumstances. And that if they do start to have someemotional upset that we need to kind of talk about that andwhat to do with their gun.

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DR WEST: I’m Curt West: Associate Professor of
Psychiatry and Scientist at the Center for the Study ofTraumatic Stress at the Uniformed Services University.
Today, in Let’s Talk about Your Guns we'll learn how thisencounter inspired Dr. Mary Campagnolo to incorporate
conversations about guns and safe storage with herpatients.

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DR WEST: We’ll also talk to Dr Joseph Simonetti, a clinicalpsychologist who studies the relationship between firearms,
safety, and suicide.

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https://afsp.org/story/more-than-referrals-the-role-of-primary-care-in-suicide-prevention
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DR WEST: He’ll share what he believes are best practices
for physicians who want to broach the topic of firearm safetywith their patients.

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DR WEST: Firearm safety in the home is built around fiveprinciples. Weapons should be stored unloaded. They
should be taken apart or stored with a disabling device
engaged. They should be stored in locked containers, andammunition should be stored in a separate locked
container. Finally, firearm safety in the home involves
having a plan for storing guns in an alternate location during
times of crisis.

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DR WEST: In the last part of today’s podcast, we’ll discuss
some strategies for how physicians can talk with patients
who may be at risk of using their guns for self-harm.

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DR WEST: Because this podcast isn’t about whether you
are for or against firearms. It’s about how to have open andhonest conversations about safe storage. Conversations
that may save a life.
So now… Let’s Talk about Your Guns.

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DR WEST: Dr. Campagnolo, at that point in your life did
you know anything about guns?

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DR MARY CAMPAGNOLO: No, I knew nothing at the time.
There was not any in my medical school training that I

4recall. I did do public health service in the National HealthService Corps in somewhat of a rural area in Maryland. And
it was a little more of a gun culture that I was exposed tothere, but that was pretty much the limit.
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DR WEST: So what has changed between the way you
approach that patient and how you would approach him
now?

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DR MARY CAMPAGNOLO: Family physicians in general, I
think now feel that it is our responsibility to help to protect
our patients and their families. And so it has become moreroutine that we have on our intake forms to screen for gunsin the home. So I think we're doing a lot more to try to
screen and counsel than we were doing back in the time
when this incident happened.

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DR WEST: So it sounds like the medical culture has begun
to make conversations like this a bit more common. But
what makes it hard for physicians to talk to patients about
guns in the first place?

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DR MARY CAMPAGNOLO: I think there's a sense that wemight be treading on areas that patients feel might not be
our business. And I think perhaps physicians feel they don't
want to have to deal within a potential degradation of therelationship with their patient. And also dealing with thecircumstance where a patient might be angry.
You don't want to make somebody feel like you are judging
them or attacking their behavior or their family's values.

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DR WEST: Dr. Joseph Simonetti studies how primary careproviders can discuss firearm safety with their patients. He's
heard these concerns before.

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DR. JOSEPH SIMONETTI: We're talking about guns in
America. And this is a very passionate and a somewhat
sensitive topic. And if you've never had these discussions
with patients, you're not sure how they're going to react.
None of us want to upset our patients. We don't want todamage our relationships. We need those relationships tohelp patients navigate health related issues. So initiating
sensitive conversations feels like a little bit of a threat.
If they don't feel at ease with us, or even worse, they feelthreatened by us or the conversation we're having, then
we're simply less effective.

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DR WEST: Are physicians trained on how to have theseconversations about firearm safety when they're in medical
school?

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DR. JOSEPH SIMONETTI: Most of us have never been
trained to ask about firearms or to initiate firearm
discussions with our patients. It has not been a componentof traditional medical training across a lot of different clinicalspectrums and certainly not in primary care.
That is obviously changing in contemporary medical
training. But that's still not commonplace. And so most of6us just don't know to do it. Most of us just don't know to do itor haven't known to do it.
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DR WEST: Are there cultural or social impediments out insociety against medical personnel talking to patients about
their firearms?

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DR. JOSEPH SIMONETTI: I think there are a lot of culturaland social impediments to having these discussions.
Having these conversations means that we have to address
our personal biases about firearms and in some cases,
completely set them aside so that we can deliver highquality evidence-based care. And that's an uncomfortabletask for some people to do, especially, I think, those who
don't have a good understanding of why people value gunsin the first place.

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DR WEST: Can you elaborate on that?

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DR. JOSEPH SIMONETTI: When we ask someone totemporarily stop using their firearms or keep firearms out of
their home while they're at risk of suicide, it just can't be
understated what a huge ask this is that we're making ofour patients. If you didn't grow up around guns orexperience guns, you probably don't understand what thismeans. That's okay. But I often ask clinicians when we're
when we're doing trainings, what's your thing? You know,what is it that you care very much about? And maybe it's
biking or riding motorcycles or book club, yoga,
snowboarding, brewing your own beer.

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Imagine if I asked you to stop doing that even temporarily
for a clinical reason. I think most of us would say, wow, if I
had to give up the thing I cared very much about this thingthat my identity is tied to, even for a short time period, I
would really struggle to do that. And so if if you don't
understand what guns mean to people, you can certainly
relate to what something means to you. And that's thechallenge we're asking people to navigate here.
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DR WEST: What would you suggest for a provider to do tobetter understand what firearms mean to their patients who
own firearms?

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DR. JOSEPH SIMONETTI: That is a great question. There
are a number of different trainings available right now on
firearm cultural competency, trying to understand how
people and why people attach value to both having
firearms, using firearms and also their constitutional right todo so. I think that's an important thing that you can do.
Some would encourage clinicians to go to firearm ranges. I
don't think that's necessary, but that is one particular option.
I think the best way is to start asking patients and try andunderstand what it is people have their firearms for what
they do with them and why it means something to them. We
can learn a lot from our patients. We know this and we cando the same when it comes to guns.

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DR WEST: Is there any specific language that can be
helpful in these conversations about firearms and safety?

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DR. JOSEPH SIMONETTI: Being mindful of language isprobably one of the most important things that clinicians
have to learn how to do, not just in firearms, but everywhereacross all of clinical medicine. Language is critical. Having ashared language is a fundamental. It's necessary to have ashared dialog. And I think few things probably demonstrate
the cultural divide we're navigating on this topic more sothan the lack of that shared language that we just haven't
developed yet.

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DR WEST: What do you mean by shared language?

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DR. JOSEPH SIMONETTI: First of all, the term safety,
which we all use in some way, even the term lethal means
safety can be problematic as a clinician. And many of us
would say, well, firearm safety within the context of suicide
prevention is keeping your gun unloaded or locked or out ofyour house. And while it's not unreasonable to think thatthose are safety behaviors for suicide prevention, that might
be very different from what the person sitting in the exam
room with us thinks about in terms of gun safety.
Gun safety has been taught for generations in this country
far longer than I or we have been thinking about it asdoctors and safety means a lot of things don't shoot at
something if you don't know what's behind it carry your gun
down. Don't climb a tree stand with a loaded rifle. It mightmean to some people keeping your gun loaded and readyfor use in case somebody invades your home. So we reallyneed to think hard about whether safety is the term we

9should be using it in what scenarios we should actually beusing it.
There are other things that firearm specific terms which canbe problematic to assault weapon gun violence using theterm clip instead of a magazine. Now, I think a lot ofclinicians will hear this and say, this feels a little bit silly tome. Why should I have to learn new language to have aconversation about keeping my patients safe? And while I
think that's a valid point in some ways, we unfortunately
don't get to pick the things that go in to whether our patientsdeem us as credible or not. I had to learn a lot of new words
to discuss heart conditions and drug use before mypatients, before I could effectively engage them in treating
their heart conditions and their drug use disorders. This
really is no different.
DR WEST: So let's focus perhaps on patients that keep
their guns for self-protection. Does that present any uniquechallenges in the conversation with them about safety andsafe storage?
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DR. JOSEPH SIMONETTI: Yeah… When we talk toclinicians in the field, one of the biggest challenges thatthey're trying to navigate is when they're having a firearm
related discussion with a patient who keeps their firearms
for protection and feels strongly about doing so.
If you talk to an individual who owns a gun and keeps thegun for protection and is concerned that somebody's goingto break into their home in the middle of the night, and you

10say, what is it you're doing to protect yourself? Well, theiranswer is very commonly, well, I have a gun and I need tokeep it very close to me in case somebody were to attack
me or I would have need that gun in the middle of the night.
But what we know in firearm suicide prevention is that time
matters. For individuals in crisis the ability to very quickly
access a means of harming oneself, such as a firearm thathas a lethality of greater than 90% that is what leads toelevated suicide risk.
And so it's really a challenging conversation to talk to
somebody who thinks they need to reduce their time inaccessing a gun and motivate them to increase their time inaccessing that gun.
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DR WEST: What would you suggest?

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DR. JOSEPH SIMONETTI: Often times I said to patients in
the inpatient setting, I know why you keep that gun. I knowthat you feel safer with that gun next to you at night. But you
were just in my emergency department because you had a
gun to your head the night before. You know, what's most
likely to happen over the next couple of weeks is thatsomebody for the first time ever is going to break into yourhouse or is that your suicide risk - the reason you're herewith me in the hospital - is going to be the bigger problem.
Can we think about making some changes, at least until
you're feeling better? Removing, reducing access tofirearms, at least during that short time period is what we
focus on.

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DR WEST: Are there specific steps that you counsel yourpatients on to increase the safety of firearms in their home?

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DR. JOSEPH SIMONETTI: There are specificrecommendations we do make. First and foremost, weknow across a number of studies now that the safest thingis likely to have a gun outside of the home. That's the thingthat puts the most time between a person and their accessto a firearm when they're in crisis. And so it's a personal
policy of mine as a clinician that with each patient, I will at
least mention what I think is the safest thing. And I will doso cautiously. And I will do so with the understanding thatmost patients aren't ready to remove their firearms fromtheir household, even temporarily. And many may never go
about doing that. But I think it's important to be honest
about what I think the evidence says, and I think it's
important to make that recommendation because somepatients go and do that. And for those patients, I haveachieved what I think is the greatest suicide risk reduction.
So that's important. But again, many people aren't going todo that, and that's perfectly okay. As I said before, thiswhole conversation, we're just navigating a couple of thingsand it's trying to find the intersection between what theevidence tells us so far and what is acceptable to patients
and what's achievable to patients. If we don't findsomething that works for our patients, then we're wasting
our time.

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DR WEST: What about patients who are not willing to
remove guns from their household?
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DR. JOSEPH SIMONETTI: For those that aren't ready toremove their firearms from the household, even temporarily,
we talk about other things. And those typically are related tolocking behaviors and secure locking behaviors within thehousehold. There's dozens of ways to do this, you know,
using external locking devices like a cable lock or aclamshell, using a gun safe or a gun cabinet, removing theammunition, storing the ammunition elsewhere.
There are other things that I think are really important when
they're going to keep their gun in the home and lock it up.
And those can include things like, Hey, can your spouse or
your neighbor come over and hold on to the keys while that.

gun's in the safe? Will your brother come over and justchange the number combination and do it for seven days
while you're going through this time period? Those areimportant steps that will increase the time necessary forsomebody to access their firearm if they go into their crisis.
Again, it's a conversation. It's navigating those different
options to figure out what works for them, because if it
doesn't work for them, they're simply just not going to do it.

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DR WEST: You’ve been involved with the Lethal Means
Safety program with the Veterans Health Administration.
Can you tell me about that?

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DR. JOSEPH SIMONETTI: The VA has been clear about
its priorities for quite a long time now, and suicide
prevention basically leads them. I think there's a realization

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that if you're not talking about firearm suicide prevention,
you're not doing everything you can to prevent suicides.
So what we started was an educational program that is
aimed at encouraging our clinical workforce to engage at
risk veterans in adopting different firearm behaviors to
reduce their own suicide risk. It's based on education,
training, real time to support to clinicians and consultation toboth VA clinicians and community non-VA providers who
might be caring for veterans.
One of the things that we have traditionally lacked is what
do we do when somebody is reluctant or ambivalent or not
ready to make behavior change? Are there ways that we
can have conversations with them which help them explore
some of their ambivalence maybe, or some of the conflict inthe things that they value to help encourage, motivate or
motivate changes in their firearm storage behaviors.
We're now in the VA developing a competency-based
training program, which is just in the early days of doing thisright now. But it's largely going to be centered on
motivational interviewing work. And my colleague Francis
Hannon, who's at VA Connecticut and the Yale School of
Medicine, is developing at least the first I've seen a firearm
specific motivational interviewing manual that will help
empower clinicians to have patient centered discussions
about their firearms.
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DR WEST: What do you know about whether or not thistraining works?

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DR. JOSEPH SIMONETTI: That's a hard one to answer.
We have first survey data which shows that clinicians arelearning. They're learning the basic content and theevidence and the skills that are necessary to have theseconversations. We can look into the clinical record and seethat these conversations are happening so that that's
incredibly important. Ultimately, we'd love to see changes insuicide rates. That's what everybody wants. But from ameasurement perspective, isolating the impact of any single
intervention, like firearm related conversations on
something as broad as population level suicide rates is justan extraordinary challenge. I think the evidence in theencouragement is just more subtle than that.
In my opinion, the conversation around firearms change inthe past five years. It's slowly changing, I think, nationally,
within the context of firearm suicide prevention. And I thinkin health care systems, the conversation is changing as
well.
Five years ago we were answering questions to clinicians
about, well, what's the evidence and what's the percentage
of suicides that are related to guns? Today we're answeringmuch higher-level questions, which is, well, my patient has
this really specific firearm scenario and I'm just having
trouble navigating through the conversation to identify
something that would specifically work for her. Can you help
me think through this a little bit? And that's evidence to me.
We just know that they're engaging on this topic, andobviously that's not entirely because of the VA's work.

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There are a lot of great groups across health care systems,
community partners and academic settings that are working
on firearm suicide prevention are helping us move theneedle.
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DR WEST: So it sounds like as a result of this training,these conversations are happening more often.

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DR. JOSEPH SIMONETTI: That's correct. These
conversations are happening more often.
I think we're more and more finding that not only is it
acceptable, it's almost an expected part of clinical care, atleast within the context of suicide prevention. We justcompleted a study, a study which was among a nationally
representative sample of adults who live in households with
firearms. And 80% of gun owners nationally said that asking
about firearms should be part of routine clinical care whensomebody is at risk of suicide. And 90% of those who lived
in households with guns but didn't identify as the gunowners themselves, they said the same thing.
That's a really tremendously high level of acceptability forthese interventions. So I think we know more and more that
this this is an acceptable thing to do in clinical settings.

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DR WEST: What do you suggest for physicians who arelooking to explore this issue more?

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DR. JOSEPH SIMONETTI: There are a lot of different basic
trainings that are available on lethal mean safety andhaving these conversations. The VA is just one of them.
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adopting firearm related discussions as part of their clinicalpractice to start there.
I think other guidance which I typically give people is leave
your bias at the door. And maybe that's someone who hasstrong feelings about having more gun policies in America.
Maybe that's clinicians who feel very strongly about their
Second Amendment rights in their personal gun ownership.
It doesn't matter which side of the bias you're on regardlessto provide, I think effective clinical care, that bias has to beleft at the door in. And really what I would say is to rely on
your expertise and just know your limits. You don't have toknow what a Mossberg is. You don't have to know what a
Glock handgun is to have these conversations, take theseconversations as an opportunity to learn from your patients.
And if your patient's gun owner probably has moreexpertise than you, you can engage their expertise infiguring out what to do about that, if anything. And I thinkmost importantly, and I just can't say this enough, isunderstand what a good outcome is from these discussions.
What we're talking about is behavior change. Behavior
change is hard. It doesn't matter whether it's asking
somebody to change their gun behaviors, promoting weightloss or medication adherence. These are all really hardthings to do. And as human beings were imperfect andadopting some of these things. And so what I tell clinicians
over and over and over again is do not go in to 100 firearm
related conversations expecting 100 of your patients tomake the changes that you suggest right off the bat or even17ever, that that's not the outcome that we should be
expecting with these discussions. A positive outcome issimply to engage on the conversation and ideally, maybe
you plant some ambivalence in someone's head when
they're at risk of suicide. Maybe they make a gun relatedchange. And sometimes we see people make big gun
related changes. But I think the win is simply having theconversation in a way that is that is respectable and patient
centered.
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DR WEST: Dr. Mary Campagnolo agrees. She’s been
having conversations about firearms and safety with herpatients for years.

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DR MARY CAMPAGNOLO: I always couch it as this issomething I ask everybody. This is a normal question. It's
not like I'm targeting your family or your specific situation.
I'm asking everybody when they have their healthmaintenance visit or as a new patient. And so I do tend tofind I've not had any problem responses to those questions.

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DR MARY CAMPAGNOLO: I just feel we do need to ask
these questions as a routine and document answers so thatwhen there might be some circumstance that arises, we cantake the proper action to, again, help our patients that might
be depressed or feeling suicidal intent. And, I think it's soimportant that we all do that.

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beat
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DR WEST: Conversations between health care providers
and their patients about firearms and safety are an
important part of suicide prevention. These conversations
start with meeting patients where they are andunderstanding their reasons for gun ownership and theirsafety practices.
Encouraging safe storage practices is one way of putting
time and distance between an impulsive decision and afatal act.

67.

DR WEST: Thank you to Dr. Mary Campagnolo and Dr.
Joseph Simonetti for participating in this discussion.

68.

DR WEST: You’ve been listening to Let’s Talk about Your
Guns. This podcast is made possible by The Henry M.
Jackson Foundation for the Advancement of Military
Medicine. It’s produced by Podville Media for the Center for
the Study of Traumatic Stress at the Uniformed Services
University.

69.

DR WEST: To learn more about our mission and for
additional resources, please visit cstsonline.org.

70.

DR WEST: Be sure to subscribe to the show on yourfavorite podcast app and leave a five-star review.
Thank you for listening.

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71.

PRESENTER: The views expressed are those of the
speakers and do not necessarily reflect the views, opinions,or policies of the Uniformed Services University, theDepartment of Defense, the US Government, or The Henry
M. Jackson Foundation for the Advancement of Military
Medicine, Inc.

72.

PRESENTER: Mention of trade names, commercial
products, or organizations does not necessarily constituteor imply endorsement by the Uniformed Services University,
the Department of Defense, or the US Government or The
Henry M. Jackson Foundation for the Advancement ofMilitary Medicine, Inc.

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