Gun violence: Use public health approach in the exam room
Counseling patients on proper firearm safety and storage comes with cultural, societal and political barriers. But when physicians focus on the well-being of their patients, risk factors and research, and use an empathetic and knowledge-driven approach, firearm safety can improve. It’s not about politics. It’s about keeping patients safe and healthy.
Marian Betz, MD, MPH, an emergency physician and associate professor of emergency medicine at the University of Colorado School of Medicine, has found herself “on the front lines” of firearm violence prevention through treating victims of violence in the ED.
“I’m often frustrated by what feel like really senseless acts of violence that we should be able to prevent, and people’s lives shouldn’t be ruined,” Dr. Betz said to a crowd of physician advocates at the 2017 AMA State Legislative Strategy Conference in Amelia Island, Fla.
Dr. Betz and her colleague, Megan Ranney, MD, MPH, associate professor of emergency medicine at Warren Alpert Medical School of Brown University, provided physicians at the conference with real-world information on how to talk to patients about firearm safety and violence prevention.
“There are patients who truly fear that a physician documenting firearm access is the first step to firearm confiscation,” Dr. Betz said. “So should doctors talk about guns? We would both say, ‘Yes.’”
Physicians have a role to play. “Even things as simple as educating families on safe-storage methods and homes with safe storage, [and] identifying people at risk of suicide can have a real impact,” Dr. Betz said.
Know the numbers
When physicians are talking about firearm safety and violence prevention with patients, they should know the facts of the matter. Firearm ownership and reason for ownership—whether it’s hunting, protection or recreation—can affect how a physician approaches the issue.
“Thinking about your [patients’] and what matters to them and what the firearm culture [in your area] is will be important in how you craft interventions,” Dr. Betz said. The average U.S. gun-related death rate is about 10 per 100,000 people, and the rate varies by state and region, she added
Men account for about 85 percent of firearm-related deaths, according to 2014 data. One-quarter of the gun violence deaths come among people who are black, peaking in early adulthood. Two-thirds of the gun deaths are among white men and this is driven predominantly by suicide. “We hear a lot about accidental deaths, especially in young children, and this is horrifically tragic, but they make up a tiny fraction of all the deaths that we see,” Dr. Betz said.
There were 33,636 firearm deaths in 2013. Of those deaths, just 1.5 percent were “accidental,” while 0.3 percent resulted from mass shootings. Thirty-four percent were homicides and legal interventions, and 63 percent were suicides.
“I’m not trying to imply that suicide deaths are more important,” Dr. Betz said. “[But] in the national conversation about gun violence, suicide is often left out.”
Among at-risk groups, access to firearms is 30 percent for children, 33 percent for teens seen in the emergency department with assault injuries, and 30 percent for women who experience domestic abuse.
Safe storage of firearms could significantly reduce the number of firearm deaths because these are theoretically preventable, Dr. Betz said.
“We know that of all people with suicidal thoughts and even attempts, only 10 percent actually die by suicide,” she added. “We know when people attempt suicide with a gun, about 90 percent of them die … and that final decision is often impulsive.”
Knowing as much as possible about guns and the evidence on firearm violence will add credibility to the conversation and keep it grounded in patient safety.
The right questions to ask
“We talk about smoking. We talk about family history. We talk about diet. We talk about blood pressure management,” said Brown’s Dr. Ranney. All of which have risk factors that lead to those discussions. There are risk factors that indicate someone has an increased risk of experiencing a firearm-related injury and they can be addressed through interventions that could potentially stop a shooting from happening.
“Unfortunately, due to the lack of research our knowledge of what those risk factors are is still very broad,” Dr. Ranney said. For example, citing the recent violence in Chicago over the holidays, Dr. Ranney said, it’s known that interpersonal violence is contagious. “After there’s one shooting there’s more likely to be another,” she said. Another recent JAMA Internal Medicine study found that “social contagion” accounted for 63.1 percent of 11,000-plus Chicago acts of gun violence analyzed between 2006 and 2014.
When speaking with patients and their families, physician counseling should be individualized and routine, Dr. Ranney said, “so that they’re not feeling singled out … but, rather, that you’re taking into account the reasons for owning a firearm” and how to keep them safe.
Examples of the right questions when patients are at risk:
- “What do you think about storing your guns offsite until the situation improves?”
- “Have you thought about how to keep your kids safe around your guns?”
- “Let’s talk about how to lower the risk of your boyfriend hurting or killing you.”
- “I’m not saying you have to give up or dispose of your gun; we’re talking about safety.”
Having the conversations in an individualized, empathetic, but orderly spirit actually does work, Dr. Ranney said. Research has found that families given brief counseling and a trigger lock by a pediatrician are significantly more likely to use them. Emergency department and trauma service interventions can lower the risk of future fights and weapon carriage. Families of suicidal teens may lock up their guns if counseled appropriately.
Safe-storage counseling is an important tool for physicians and it is a long-term practice. Drs. Betz and Ranney offered one final recommendation: Advise, don’t lecture. It’s not about confiscation of firearms; it’s about saving lives.
Inspired by prior successes
In discussing the need for frank patient-physician conversations about gun safety, Dr. Betz sees a parallel to an earlier public health crisis—HIV/AIDS—that made for difficult discussions. The dramatic decrease in HIV/AIDS deaths that begin in the late 1990s was largely the result of the development of antiretroviral medications, but policy issues and patient education contributed, she said.
“Physicians had to work with patients. They had to learn about, and then talk about, things they may not know much about, may not have been comfortable talking about. But they had to make their clinical spaces safe, judgment-free places to educate patients” and helping them to avoid transmission,” Dr. Betz said. With gun violence, “we haven’t seen the same meaningful decreases because we haven’t applied this comprehensive framework to it,” she said.
The framework for action must be a public health model. Drs. Betz and Ranney recommend a four-step process, the same method used to attack many public health issues, including the HIV/AIDS epidemic.
- Surveillance: What’s the scope of the problem? Who is dying? Why are they dying?
- Identify risk and protective factors: What are the causes? Once surveillance and risk factors are understood, effective interventions can follow.
- Develop and evaluate interventions: Types of interventions include education, informing firearm owners about risk factors for suicide and safe-storage in the same way that you educate them about nutrition and exercise. Try out the intervention that fits your specific patients and groups and evaluate its effectiveness.
- Implementation: Scale up effective interventions.
“We know this kind of evidence-based approach works,” Dr. Betz said, citing again the work on reducing mortality in the HIV/AIDS epidemic. In June 2016, the AMA House of Delegates adopted policy declaring gun violence a “public health crisis” that demands a comprehensive response.
Another example of a successful public health approach is the steady decline of car crash deaths since the 1970s. Dr. Betz pointed to a quote from former Arkansas Congressman Jay Dickey His “Dickey amendment” restricted funding for advocacy but has resulted in a perceived ban on federal funding research on gun violence altogether.
“Research could have been continued on gun violence without infringing on the rights of gun owners in the same fashion that the highway industry continued its research without eliminating the automobile,” Dickey wrote in a December 2015 public letter.
Research published in the Jan. 3 JAMA Internal Medicine found that gun violence research was “substantially underfunded” between 2004 and 2015 given how the annual death toll linked to guns. Based on firearms-related mortality rate, researchers said, “gun violence had 1.6 percent of the funding predicted” when compared with the top 30 causes of death in the U.S.
Without the safety measures introduced in automobiles since the 1970s, thanks to critical research and implementation, we would not have seen those decreases in the number of deaths from car accidents, Dr. Betz argued.